The findings of the kitchen inspection, conducted 1/20/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the 01/02/23 kitchen inspection, conducted 04/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second re-visit to the re-licensure kitchen inspection of 01/20/23, conducted on 07/06/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 1/20/23 at 10:40 am -1:00 pm revealed the following areas.

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;

* Spice shelves;

* Juice dispenser;

* Coffee machine;

* Kitchen drains;

* Trash cans;

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of cabinets and drawers;

* Ceiling fire sprinklers and vents;

* Walls and floors throughout kitchen;

* Open shelving under the steamtable;

* Inside and outside of Rubbermaid drawers storing utensils;

* Interior and exterior of microwave;

* Stove/grill/oven knobs, doors, interior, exterior;

* Area around grill/stove;

* Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers and around the hood;

* Wall behind/underneath hand wash sink ;

* Hand washing sink with large accumulation of food and dirt debris in basin, and on faucet;

* Open shelving throughout kitchen;

* Industrial mixer;

* Large can opener and housing;

* Floors throughout the kitchen had black matter build-up, food and trash debris and grease in corners, under equipment and around perimeter edges;

* Exterior and interior of reach in refrigerators and freezers;

* Rack shelving in dry good storage;

* Rack shelving storing equipment and dishes;

* Under and behind shelving in dry good storage;

* Door thresholds;

* 2 fans;

* Window seal;

* Exterior and Interior of deli refrigerator;

* Interior of cabinets and drawers of beverage station in dining room;

* Dish/Utility carts in kitchen and dining room;

* Bulk dry good bins and lids;

* Mop sink area;

* Exterior of ice machine;

* Exterior of steamer;

* Toaster;

* Baking rack and can good storage rack; and

* Waffle makers.

b. The following areas were found in need of repair:

* Cabinets and laminate countertops of beverage station in dining room with scrapes, chips, gaps/discolored or damaged. Missing/damaged caulking;

* Wall next to beverage station with damage/chipped paint;

* Kitchen entrance door with damage and missing paint in threshold and door;

* Caulking around dish machine area with black substance buildup;

* Cracked/loose tile by wall near stove;

* Corner stripping by mop bucket area separating from wall;

* Multiple light fixtures with cracks;

* Vegetable freezer with large ice/frost buildup;

* Gap in ceiling in a corner above paper product storage;

* Refrigeration fans in stand up coolers/fridges with dust and rust build up;

* Sneeze guard on tray line with areas missing or cracked.

c. Facility was not using small diameter probe thermometers for thin foods.

d. Multiple wire racks for dish/equipment or food storage were found with build up and or rust areas rendering them not a smooth cleanable surface.

e. Cutting boards/surfaces found to be heavily scored and/or stained.

f. Container tabled "random" utensils was observed dirty and had visible contamination of spray/drips splatters on the utensils inside the container.

g. Fridge and freezer storage was cluttered and not organized posing possible air flow concerns.

h. During lunch tray service, kitchen staff was observed touching RTE foods (tomatoes and lettuce for sandwiches) with bare hands. Cook was observed touching ready to eat food items with gloves that were potentially contaminated from prior tasks.

i. Multiple non dietary staff entered the kitchen without washing hands. Not all kitchen staff had their hair restrained as required.

At approximately 12:00 the Memory care unit kitchenette was toured with Staff 1. The stove top was found with food debris on and inside the burners. The microwave was observed to be damaged on the inside of unit. Some of the drawers and cabinets had drips and spills inside. The door way threshold and flooring had areas that needed repair. A leak was found under the sink. Staff 2 acknowledged the areas and indicated they would be addressed.

At approximately 12:30 pm surveyor reviewed above areas with Staff 2 and the need to address the cleanliness of the kitchen.  Staff 2 acknowledged the areas.  At approximately 1:00 pm the areas of concern in the main kitchen were reviewed with Staff 1 who acknowledged the issues and confirmed the kitchen would be cleaned right away. At 1:30 pm surveyor observed additional facility staff members had arrived to assist with the cleaning of the kitchen.

Floor in kitchen was replaced.

Microwave was replaced.

New additional cleaning schedule by activities team, w/ sign off sheets.

MC administrator responsible for monitoring kitchen cleaning logs and report in management stand up meeting.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observation of the kitchen on 04/05/23 revealed the following areas needing cleaning, and repair:

a. An accumulation of food spills, splatters, loose food debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of microwave;

* Industrial mixer;

* Large can opener;

* Under and behind shelving in dry good storage;

* Door thresholds;

* Dish/Utility carts in kitchen;

* Bulk dry good bins and lids;

* Mop sink area;

* Wall above dish sink; and

* Floors throughout the kitchen had black matter build-up, food and trash debris, grease in corners, under equipment, and around perimeter edges.

b. The following areas were found in need of repair:

* Cabinets and laminate countertops of beverage station in dining room with scrapes, chips, gaps/discolored or damaged.  Missing/damaged caulking;

* Wall next to beverage station with damage/chipped paint;

* Kitchen entrance door with damage and missing paint in threshold and door;

* Refrigeration fans in stand up coolers/fridges with rust build up; and

* There was no sneeze guard on the tray line.

The need to ensure the kitchen was maintained clean and good repair was discussed with Staff 3 (Executive Director) and Staff 2 (Restaurant Manager) on 04/05/23. They acknowledged the findings.

To address accumilation of food spills, splatters, loose food debris, grease etc. in all identified areas.

-Implement daily cleaning log for problem areas.

-Weekly cleaning log for identified areas; edge of floor, below and behind shelves, tables, stove.

-Use degreaser and approved sanitizer to hand clean hard to reach areas. Apply to floors and corners, on legs and under equipement.

-Clean food service carts after every meal.

-The areas nedding corrected will be evaluated weekly.

-Executive Chef is responsible to monitor areas for completion.

-Replacing tile and reworking mop sink area.

-New dry goods bins ordered.

-Wall above sinks contracted for replacement.

-Door thresholds, modlings contracted for replacement.

-Repair leaks under sink.   

Items found in disrepair:

-Cabinets and laminate countertops were replaced, reworked and stained.

-Sneeze guard was replaced.

-Refridgerator fans will be replaced.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.  

Refer to C240.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240.

Weekly deep clean team shifts implemented.

New trainings on kitchen cleanliness, changing daily habits when cooking, clean as you go.

Food handler's certificates for all dietary staff completed.

Sweeping and mopping under all shelves & equipment nightly. Added all identified problems areas to daily & weekly cleaning tasks.

Maintenance director working on replacing tiles by baseboard, near steamer.

Calking back wall near dish washing station and addressing drywall gap in ceiling.

Replacing sneeze guard on tray line.

Maintenance responsible for addressing these building repairs or modifications by 3/1/2023.

Must check-in with Executive Chef daily at management stand up meeting.

Shelving under steam table is no longer used to store cookware.

Microwave cleaned every night.

Cleaning grill in between food services.

Hood, vents cleaned weekly.

New beverage station upgrade, contracted and set to be completed by 3/1/2023. Knobs were taken off sink, cleaned entirely as needed and nightly.

Can opener is cleaned after each use. 3/1/2023

Mixer is covered when not in use.

All shelving was cleaned and scheduled weekly.

Walls behind shelves cleaned and scheduled weekly.

Fans were removed from the kitchen.

Deli refrigerator cleaned every night.

Food service carts are wiped down between services and sanitized.

All surfaces are wiped down and sanitized as needed and every night.

Toaster oven is cleaned after each use.

Ordered correct size thermometer for thin foods.

Cleaned off rust and related build up on wire racks.

No longer using cutting board on deli table.

Ordered new cutting boards.

Utensil containers cleaned out and stored in a cleaner area.

Kitchen staff either got haircuts or are waring hairnets.

Executive Chef responsible for daily and weekly monitoring of all required cleaning and related tasks.

Chef presents information daily at manager stand up meeting.

Executive Director responsible for monitoring and coordinating all efforts.

Based on observation, record review, and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240.

Refer to C240.