The findings of the kitchen inspection, conducted 05/02/23 through 05/05/23, 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.

Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

OAR 411-054-0030 Resident Service Meals, Food Sanitation Rules.

The facility put an immediate plan of correction in place during the survey and the situations were abated.

The findings of the revisit to the kitchen inspection of 5/5/23, conducted 8/8/23, 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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facilities kitchen was observed in an extremely unsanitary condition and posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. The kitchen was closed for deep cleaning and repairs on 05/22/23. Findings include, but are not limited to:

1. Observation of the kitchen on 05/02/23 at 10:00 am 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;

* Kitchen drains;

* Electrical outlets and light switches;

* Trash cans;

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of cabinets and drawers;

* Ceiling fire sprinklers, smoke detectors and vents;

* Walls throughout kitchen;

* Vents on ice machine;

* Plastic container that stores ice scoop;

* Hand washing sink and faucet;

* Cabinets under the steamtable;

* Inside and outside of drawers storing utensils;

* Interior and exterior of fryer;

* Interior and exterior of microwave;

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

* Interior/exterior of ovens/steamer;

* Handles of reach in coolers/freezers;

* Wall behind hand wash sink and the sink;

* Open shelving throughout kitchen;

* Industrial mixer and slicer;

* Table top mixer;

* Bulk food bins;

* Stainless steel drawers under mixer;

* Large can opener;

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

* Large can goods storage rack;

* Rack shelving in dry good storage;

* Rack shelving storing equipment and dishes;

* Under and behind shelving in dry good storage;

* Door thresholds;

* Walls throughout kitchen;

* Open shelving throughout kitchen;

* Walk-in cooler racks with dried food and black mold like substance;

* Walk in freezer and cooler floors;

* Walk in cooler shelving and doors/windows;

* Fan near prep area with dust;

* Beverage area in dining room walls and beverage dispensers.

* Ceiling vents and fire sprinkler heads;

* Industrial toaster;

* Interiors and exteriors of stainless steel drawers;

* Pipe in store room with accumulation of black mold like substance;

* Beverage station in AL kitchenette;

* Microwave in AL kitchenette; and

* Flooring in AL kitchenette.

b. The following areas were in need of repair:

* Multiple areas of untreated wood throughout kitchen areas including in coolers and freezers;

* Cabinets and cupboards with chipped/ peeling wood;

* Cabinets under tray line service with noted rotting and decaying wood;

* Walk in freezer with large ice accumulation;

* Multiple cracked or missing tiles throughout the flooring;

* Under dish machine with hole in wall with access to the outside;

* Hole in wall under steamer.

* Standing water under steamer;

* Crack in ceiling in dry storage;

* Gap by sprinkler head in dry storage;

* Rusted metal racks in freezer and walk in cooler; and

* Hood above grill/stove not operational without loud noise and not being used.

c. Cutting boards were heavily scored and/or stained.

d. Piece of dirty frayed carpet in dry storage under a pole.

e. Multiple cups of fruit and plates of desserts stored uncovered in the walk in cooler.

f. Plastic cups observed with heavy staining.

g. All trash cans in kitchen did not have lids for when not in use.

i. Food service paper products stored in laundry space.

j. Ware washing machine not reaching necessary temperature of 180 degrees F for sanitization. Staff did not have sanitizer strips available for testing concentration of sanitizer buckets.

Staff 4 (Kitchen Manager) toured areas with surveyor and acknowledged identified items in need of cleaning and/or repair.

At approximately 12:00 pm on 05/02/23, the surveyor contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the kitchen.  A decision was made to close the kitchen until the unsanitary and unsafe condition was rectified, and a long term plan was put in place.

In an interview on 05/02/23 at 12:30 pm, Staff 1 (Campus Executive Director) and Staff 2 (Administrator) and were informed by the surveyor that the kitchen would be shut down for immediate cleaning. They were instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. At this time, the surveyor toured Staff 1 and 2 to the areas in the kitchen driving the immediate action. Staff 1 and 2 acknowledged the concerns. A plan to suspend kitchen operations until sanitation conditions improved was submitted.

At 4:55 pm, a plan was submitted and indicated the facility would provide meals from outside food vendors to all residents while the sister facility kitchen was cleaned and able to operate under sanitary conditions. This plan was reviewed and approved by surveyor on site.

On 05/05/23 at 4:00 pm, the surveyor reviewed the status of cleaning and approved use of Churchill retirement south kitchen for meal preparation for facility meal services. At that time the Immediate Jeopardy situation was abated and the facility was able to resume dietary service for it's residents. The kitchen for the independent living and north AL residents continued to be closed for cleaning and repair. The south kitchen would be utilized as the primary kitchen for campus.

2. Resident council meeting minutes were reviewed for the previous three months. On 04/21/23, a noted indicated residents had complained of food being served cold.

Review of temperature logs for meals documented several food service items being served at all meals at less than 135 degrees F.

In an interview on 05/02/23, Staff 4 acknowledged the temperatures on the logs were less than the required 135 degrees required for service. Staff 1 was informed of issues with food temperatures at service and complaints by residents of cold food. Staff 1 acknowledged the concerns.

A combination of facility staff and outsourced cleaning

company will be utilized to ensure that all areas listed on p

4-5 are corrected up to standards as outlined in OAR 411-

054-0030.

Cleaning checklists will be implemented and

monitored by the kitchen supervisor to ensure standards

are maintained. All kitchen staff will be

trained on these checklists to ensure proper completion.

All items on list will be repaired up to standards as outlined

in OAR 411-054-0030 (1)(a).

Cutting boards will be replaced and kitchen supervisor will

monitor for any 'scoring/stains' and replace as necessary

to ensure standards are maintained.

Piece of carpet will be removed, area cleaned and

maintained.

All kitchen staff will be trained on proper storage of food in

refridgerators in accordance with Oregon State food

handling requirements in accordance with OAR 411-054-0030(1)(a).

Trash can lids will be provided for when not in use.

Dish machine temperature will be taken and recorded daily

to ensure machine is operating appropriately. Sanitizer

strips will be stored in an easy to access area of the

kitchen to ensure staff test the concentration of sanitizer

buckets every 2 hours to maintain a concentration of (50-

200ppm).

All items on the walk in freezer floor will be removed and

propery stored in accordance with OAR 411-054-0030(1)

(a).

Kitchen supervisor will monitor and maintain general

cleanliness / accessability of walk in freezer.A combination of facility staff and outsourced cleaning

company will be utilized to ensure that all areas listed on p

4-5 are corrected up to standards as outlined in OAR 411-

054-0030. Cleaning checklists will be implemented and

monitored by the kitchen supervisor to ensure standards

are maintained. All kitchen staff will be

trained on these checklists to ensure proper completion.All items on list will be repaired up to standards as outlined

in OAR 411-054-0030 (1)(a)

Utility cart will be removed. New cart will be purchased and

utlized as required for proper functioning of kitchen.

Dish machine temperature will be taken and recorded daily

to ensure machine is operating appropriately. Sanitizer

strips will be stored in an easy to access area of the

kitchen to ensure strips are used to check once in the

morning to ensure the chemical amount is correct (50-

200ppm) and to change the bucket solution every two

hours.

Staff will ensure they check temperatures of food items

prior to beginning of tray service when satellite bulk food

items for Churchill estates kitchen arrive. Kitchen

supervisor will ensure all staff have easy to access food

temperature guidelines and thermometer with them at time

of service.

Administrator will ensure all staff obtain and maintain their food handlers certificates in accordance to OAR 411-054-0070 (3-4) and certificates are stored in the employee files at all times.

Based on record review and interview, it was determined the facility failed to ensure 2 of 18 staff (#5 and 6) who prepared and served food had active food handlers certificates. Findings include, but are not limited to:

On 5/2/23 employee records were requested and reviewed to ensure staff had active food handlers cards. There were three employees who's food cards could not be located. Staff 3 (Business Office Manager) indicated the HR representative may have better idea where they were.

On 05/05/23, the surveyor asked for food cards for the missing employees. Active food cards could not be located and the surveyor was provided electronic copies of food cards dated 05/05/23 on 05/05/23. Staff 3 acknowledged Staff 5 and 6's active cards were not located at the time of survey.

Administrator will ensure all staff obtain and maintain their food handlers certificates in accordance to OAR 411-054-0070 (3-4) and certificates are stored in the employee files at all times.