The findings of the kitchen inspection, conducted 06/25/24, 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 re-visit to the kitchen inspection of 06/25/24, conducted 10/17/24, 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 revisit to the kitchen inspection of 06/25/24, conducted 01/02/25, 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, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 06/25/24 at 11:30 am through 2:00 pm revealed the following deficiencies:

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:

* Ceiling vent as you enter the kitchen;

* Interior of reach in freezer;

* Industrial can opener and housing;

* Interior of microwave;

* Open shelving where pots/pans were stored;

* Interior of ice machine; and

* Open shelving under steam table/service line.

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

* Open shelving under steam table with damage to shelves causing an uncleanable surfaces. Multiple areas were covered by a tin foil like substance that was peeling/cracked and had dirty/debris accumulation;

* Section of caulking in dish machine area had black debris build up;

* Multiple cabinets had white duct tape covering worn areas of cabinets that was also worn and created a non smooth surface.

c. Surface area on tray line and countertops in prep area with scratches and heavy wear, multiple areas on counter tops with chipped or missing surfaces. Some areas covered by black duct tape.

d. Multiple items stored in reach in coolers were not dated when opened. Multiple items did not have prepared or use by dates.

e. Multiple drinks and all fruit cups were not covered for room tray delivery.

f. Kitchen staff member preparing and/or serving food did not have hair effectively restrained as required. Multiple care staff assisting with serving/delivering food did not have on aprons to serve as a protective barrier between care giving tasks and meal service tasks. One caregiver did not have hair restrained while in kitchen serving residents fruit.

g. White cutting board was noted to be heavily stained and scored. Multiple fry/saute pans were found heavily scored and/or heavy carbon/back debris along edges and cooking surfaces.

h. Multiple sanitation cloths/rags were stored on counters and not in sanitation buckets.

The surveyor reviewed above areas with Staff 2 (Dining Services Director) and they acknowledged the identified areas. At 1:45 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Executive Director) who acknowledged areas needing addressed.

1.

a.Kitchen will receive a deep clean to remove all accumulation of food spills, splatters, loose food, trash debris, dirt, dust, black matter and grease including ceiling vent, interior of reach in freezer, can opener, microwave, open shelving, ice machine and dish machine.

b.All food will be labeled appropriately in the kitchen and any unlabeled food will be thrown away.

b.Shelving & cabinets bids will be obtained to replace any damaged cabinets.  Bids for replacement of counter tops will also be obtained if needed.  Bids will be reviewed and work scheduled.  The State will be notified when work is scheduled.

c.Equipment will be inspected and any worn or damaged equipment replaced including cutting boards, pots and pans.

d.Aprons and hair covering requirements were discussed with staff and and implemented immediately.

e. Room tray sanitation requirements were reviewed by staff and implemented immediately.

2.The weekly cleaning check list will be reviewed to ensure that it reflects any areas of violations.  QAPI audits will be done to further assess cleanliness and compliance.

3. All areas will be monitored daily, weekly and quarterly.

4.Corrections will be completed & monitored by Dietary Director, Administrator, and Mainenance Director.

Based on observation and interview, 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 10/17/24 at 1:45 am through 3:00 pm revealed the following:

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:

* Industrial can opener and housing;

* Open shelving where pots/pans were stored; and

* Open shelving under steam table/service line.

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

* Open shelving under steam table with damage to shelves causing uncleanable surfaces. Multiple areas were covered by a tin foil like substance not meeting code requirements;

* Section of caulking in dish machine area had black debris build up; and

* Multiple cabinets had white duct tape covering worn areas of cabinets not meeting construction material requirements per code.

c. Surface area on tray line and countertops in prep area with scratches and heavy wear.

d. Multiple items stored in reach in coolers were not dated when opened. Multiple items did not have prepared or use by dates. Some items were passed 7 days from prepared date and were in need of discarding per rule.

e. Bag of frozen chicken breasts were stored directly on top of ground meat causing potential for cross contamination from chicken drippings.

f. Multiple food items in reach in coolers/freezers observed not covered/protected from potential contamination.

At approximately 2:45 pm the surveyor reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Executive Director) who acknowledged the identified areas needing addressed.

1.

   a.Kitchen will receive a deep clean to remove all accumulation of food spills, splatters, loose food, trash debris, dirt, dust, black matter and grease including industrial can opener and housing, and open shelving.

   b. Existing steam table and damaged work island have been scheduled for removal.  Bid for tile flooring repair has been received and work will be scheduled to repair flooring once island is removed.  Replacement steam table equipment and stainless steel work table have been ordered for delivery.  The State will be notified when work is scheduled.  Any damaged or discolored caulking will be repaired/cleaned and/or replaced as needed.

   c. Stainless steel work tables have been sourced to replace the worn countertops and cabinets.  Equipment will be ordered once the work on the island is complete to minimize kitchen disruption.

   d. All food will be labeled appropriately in the kitchen.  Kitchen staff will check dates on prepared food and discard within appropriate timeframe and no later than 7 days.  Unlabeled food was discarded immediately.

e. All food will be stored appropriately in the kitchen according to Food Sanitation Rules.  Food stored improperly was discarded immediately.

   f.  All food will be stored appropriately in the kitchen according to Food Sanitation Rules.  Food stored improperly was discarded immediately.

2.The cleaning check list will be reviewed routinely to ensure that tasks are being completed.  QAPI audits will be done to further assess cleanliness and compliance.

3. Kitchen staff have received training on use of the FoodKeeper App (FoodSafety.gov) to determine safe storage guidelines, and will be required to complete the 1-hour training class through Oregon Care Partners "Keeping Food Safe and Nourishing for Older Adults" that focuses on how to safely store, prepare, and serve food to reduce the risk of foodborne illnesses to residents living in community-based care.

4. All areas will be monitored daily, weekly and quarterly.

5.Corrections will be completed & monitored by Dietary Director, Administrator, and Maintenance Director.  

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

Refer to C240.

   Refer to C240