The findings of the kitchen inspection, conducted 01/11/23, 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 revisit to the kitchen inspection of 01/11/23, conducted 03/13/23, 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 ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 01/11/23 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas:

* Entryway door and door frame to the kitchen;

* Door to the walk-in refrigerator;

* Floor, floor drains and transition strips throughout the kitchen including the walk-in refrigerator and the dry storage areas inside of the garage;

* Convection oven, gas range, refrigerators, serving cart in hall, shelves between convection oven and cold serving line, wall next to gas range, outside of warewasher and ice machine;

* White storage bins containing dried goods;

* Spice and cooking oil containers;

* Chemical containers;

* Backsplash behind three-compartment sink;

* Outside of garbage disposal;

* Stainless steel prep tables, stainless steel shelves including the walk-in refrigerator, and cabinet interiors;

* Ceiling vent covers and rotating fan above the hot serving area; and

* Caulking between the three-compartment sink and backsplash had a black substance on its surface and was missing in some areas.

The following food items were improperly stored:

* Three bags and one white bucket of rice located in the dry storage area inside of the garage were open and not maintained to prevent rodent and pest infestation.

The following areas and equipment were observed to need repair:

* Multiple ceiling tiles throughout the kitchen and wall panels above the walk-in refrigerator were missing;

* Wood trim affixed to the wall in front of the hot serving line had chipped paint, gouges and was not a cleanable surface.

* The facility failed to ensure the warewasher was operated according to the data plate wash temperature of 120 degrees F and failed to ensure the three-compartment sink was in good repair.

On 01/11/23 between 11:55 am and 1:07 pm, several observations of the wash temperature, showed the temperature registered between 98 degrees and 102 degrees F.

In a interview with Staff 4 (Cook Supervisor), he stated the warewasher temperature was not monitored by the facility.

* The glass door of the convection oven was shattered and held in place with tape.

Staff 1 (Administrator) and Staff 3 (Environmental Services Manager) were immediately notified. A service vendor and plumbing company were contacted for immediate repairs.  

* On 01/11/23 at 12:46 pm, a surveyor observed Staff 5 (Nutritional Services Supervisor) preparing food without wearing proper hair restraints.

The need to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 and Staff 2 (Assistant Administrator) on 01/11/23. They acknowledged the findings.

OAR 333-150-0000

Entryway door and door frame to the kitchen;

1Action was taken immediately after Survey exited. Entryway door and door frame were cleaned

2This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

1Door to the walk-in refrigerator;

1.Action was taken immediately after Survey exited. Door to the walk-in refrigerator was cleaned

2.This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3.This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4.Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks????

??Floor, floor drains and transition strips throughout the kitchen including the walk-in refrigerator and the dry storage areas inside the garage;

1. Action was taken immediately after Survey exited. L&J Janitorial Commercial & Residential Cleaning Services have been hired and scheduled to deep clean entire kitchen, walk-in refrigerator, and dry storage in garage. L & J Janitorial Services will replace transition strips once floors have power washed

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing maintenance needs, cleanliness, compliance and maintain accountability for completion of tasks

?Convection oven, gas range, refrigerators, serving cart in hall, shelves between convection oven and cold serving line, wall next to gas range, outside of ware washer and ice machine;

1. Action was taken immediately after Survey exited. All surfaces were deep cleaned. The Environmental Services Manager is ordering a stainless-steel wall cover to be mounted next to the gas range for improved cleaning

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A & B attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks?????

White storage bins containing dry goods;

1. Action was taken immediately after Survey exited. The white storage bins were cleaned and sanitized

2. This task was not previously tracked, and staff were not educated to complete the

task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks????

Spice and cooking oil containers;

1. Action was taken immediately after Survey exited. The spice and cooking oil containers were cleaned thoroughly

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to the new kitchen cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks   ????

?Chemical containers;

1. Action was taken immediately after Survey exited. The chemical containers were cleaned and sanitized

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to the new kitchen cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks  

Backsplash behind the three-compartment sink;

1. Action was taken immediately after Survey exited. The backsplash behind the three-compartment sink was cleaned and sanitized

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Outside of garbage disposal;

1. Action was taken immediately following the Survey exit. The garbage disposal exterior was cleaned and sanitized; upon further inspection it was found to be out of order. Lovett repaired the disposal to working order on 01/16/23

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Stainless steel prep tables, stainless steel shelves including the walk-in refrigerator, and cabinet interiors;

1. Action was taken immediately after Survey exited. Staff have received continued education regarding sanitation protocols for food prep and storage areas. All surfaces and interiors were cleaned and sanitized. L&J Commercial Services has been contracted to deep clean the shelves, cabinets, and the walk-in refrigerator surfaces

2. This task was not previously tracked and staff were not educated to complete the task routinely, it has been added to kitchen's new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4.Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Ceiling vent covers and rotating fan above the hot serving area;

1. Action was taken immediately after Survey exited. L&J Commercial Services has been contracted to deep clean the ceiling vent covers, fans, and kitchen surfaces

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen and Environmental Services new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Caulking between the three-compartment sink and backsplash had a black substance on its surface and was missing in some areas;

1. Action was taken immediately following the Survey exit. Environmental Services contacted L&J Commercial Services to deep clean. Environmental Services will re-caulk once the deep cleaning is complete

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen and Environmental Services new cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Three bags and one white bucket of rice located in the dry storage area inside of the garage were open and not maintained to prevent rodent and pest infestation;

1. Action was taken immediately to store the dry food safely and securely. Four 22 qt Cambro Food Storage Containers with lids and four 12 qt Cambro Food Storage Containers with lids were ordered to replace all previous storage bags

2. Staff education and competency checks completed regarding how to properly store dry goods following food safety sanitation protocols

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Multiple ceiling tiles throughout the kitchen and wall panels above the walk-in refrigerator were missing;

1. Action was taken immediately following Survey. The missing ceiling tiles were installed by the Environmental Services Manager. Environmental Services Manager has requested L&J Commercial Services to replace the missing panel inside walk-in refrigerator where fan is located

2. This task was not previously tracked and staff were not educated to complete the task routinely, it has been added to kitchen and Environmental Services new cleaning schedule (see addendum A & B attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Wood trim affixed to the wall in front of the hot serving line had chipped paint, gouges, and was not a cleanable surface;

1. Actions taken immediately following Survey include the Environmental Services Manager ordering a stainless-steel sheet to be mounted to wall in front of hot serving line and all wood trim will be removed for improved surface cleaning

2. This task was not previously tracked, and staff were not educated to complete the task routinely, it has been added to kitchen cleaning schedule (see addendum A attached)

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4.Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

Facility failed to ensure the ware washer was operated according to the data plate wash temperature of 120 degrees F and failure to ensure the three-compartment sink was in good repair;

1. Action was taken immediately following Survey. The plumbing was repaired by Lovetts on 01/19/23 for three-compartment sink. The ware washer was repaired by Rose's Equipment & Supply on 01/13/23. Westside Electric assessed the electrical panel on 01/23/23 and will add an additional panel and booster to ensure the appropriate water temperature is maintained

2. The kitchen staff completed continued education regarding temperature checks, logging accurately, and reporting out of range temperatures to the Nutritional Services and Environmental Services Managers immediately. The installation of the booster will also help prevent low temperatures

3. The ware washer temperature will be monitored by kitchen staff daily and documented in the ware washer temperature log and is stored in the dietary task binder. The Nutritional Services Manager will audit systems on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

The glass door of the convection oven was shattered and held in place with tape;

1. Action was taken immediately following the Survey. The Environmental Services Manager contacted General Parts on 02/04/2023. The replacement convection glass has been ordered

2. Staff were educated to routinely evaluate and report all maintenance concerns to the Nutritional and Environmental Services Manager. Maintenance checks have been added to kitchen's new cleaning schedule (see addendum A attached) to ensure ongoing compliance

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager, Environmental Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks

On 01/11/23 at 12:46PM, a surveyor observed Staff 5 (Nutritional Services Supervisor) preparing food without wearing proper hair restraints;

1. Action was taken immediately following the Survey. The dietary dress code and dietary policies and procedures were reviewed, and all dietary staff have been reeducated on the required food safety dress code. The dietary staff will always wear hairnets when they are working

2. Immediate education was provided to all dietary staff on 01/11/23. All survey related outcomes, kitchen action plans, and dietary staff responsibilities will be discussed, evaluated, and reviewed at next Nutritional Services meeting on 02/16/2023

3. This will be routinely evaluated for quality assurance and audited on a bi-weekly basis

4. Nutritional Services Manager and Administrator will monitor ongoing cleanliness, compliance and maintain accountability for completion of tasks?