Print Inspection: 1KL7

The findings of the kitchen inspection, conducted 09/27/23, 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 09/27/23, conducted 01/26/24, 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. include, but are not limited to:

Observation of the six cottage kitchens and facility food storage areas on 9/27/23 at 11:00 am am through 3:30 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, underneath or between the following:

* Interior of reach in refrigerators and freezers;

* Hand held can openers;

* White shelving in main food storage area;

* Fan next to walk in cooler;

* Interior and exterior of kitchen drawers, cupboards and cabinets;

* In between range and counter tops;

* Interior of ovens;

* Interior of microwaves; and

* Floors in storage areas where reach in freezers located.

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

* Multiple drawers or cupboards with damaged wood (not smooth/cleanable);

* Metal shelves in main food storage area rusted and corroded;

* Holes under sinks in kitchenette; and

* Multiple pots/pans/bowls, etc., heavily scored or peeling protective coating.

c. Multiple cutting boards were found damaged and in poor repair.

d. Multiple potentially hazardous food items were found not labeled or dated.

e. Facility was not using pasteurized eggs for undercooked egg foods like poached or soft-fried eggs.

f. Potentially hazardous foods stored incorrectly found next to or above ready-to-eat foods.

g. Scoops were found stored in bulk food item bins and ice bin.

h. Clean dishes were observed stored next to hand washing/prep sink without protection from potential splash contamination while drying. These dishes were also sitting next to a crock pot of food during lunch service.

i. Direct care staff not able to state the correct reheating and/or cook-to temperatures for food items.

j. Individual house pets were having their food bowls stored in kitchens with food left in bowls, posing a potential attractant for pests. Facility pets should be kept out of food preparation and serving areas as best as possible to avoid potential contamination of food, food preparation areas and equipment.

k. Multiple direct care staff who were responsible for ensuring dishes were cleaned and sanitized were not using the identified correct cycle for sanitizing of dishes. Per interview with maintenance, the cycle that would sanitize and that staff are to be using was the heavy-duty cycle. Five of six houses were using the normal/short cycle. The facility did not have a current system in place to validate that the dishwashers were effectively sanitizing dishes.

l. The facility did not have a system in place to ensure the ice makers in the house/unit freezers and water filters were cleaned and maintained per manufacturer's recommendations to ensure ice was safe to consume. Staff 17 (Maintenance Coordinator) was interviewed and acknowledged he had not changed the filters or cleaned the ice makers, and he did not know when they were last done.

Surveyor reviewed above areas with Staff 2 (Food and Supply Lead/PIC) and s/he acknowledged the identified areas.  At approximately 3:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Executive Director). S/he acknowledged the identified areas.

Plan of Correction:

1- On 10/2/2023, rounds to each of the 9 homes was completed by the Administrator and Maintenance Coordinator to identify cleaning and repair needs. During these rounds the following was addressed or is in process of being addressed:

a-Each reach-in refrigerator and freezer has been cleaned by the Resident Coordinator for each home.

b-Every handheld can opener was inspected by the Administrator. Damaged can openers were discarded and replaced with new ones. Dirty can openers were cleaned by the Resident Coordinator for each home.

c-The white shelving in the main food storage area was replaced and the fan next to the walk in cooler in the main food storage area was deep cleaned by the Food and Supply Coordinator. Weekly cleaning of all fans and shelving was added to the Food/supply chore list on 10/9/2023.

d-The interior of all ovens and microwaves have been cleaned by the Resident Coordinator for the home.

e-The interior and exterior of all kitchen drawers, cupboards and cabinets are in process of being deep cleaned as directed by the Resident Coordiantor for each home.

f-The space between the counters and range has been deep cleaned by the Food and Supply team. The Maintenance Coordinator purchased cleanable barriers on 10/10/2023 and will have them installed for each range by 10/30/2023 to prevent an accumulation of food and debris from gathering in that space. Food and Supply Department will now pull out each range and clean around and behind it for each home monthly. This was added to the montly chore list for the Food and Supply Department on 10/9/2023.

g-The flooring in each outside storage area where reach in freezers are located was cleaned by the Food and Supply Department. The Maintenance Coordinator purchased new flooring for the areas on 10/10/2023 and is currently in process of replacing the flooring in each storage area for each home. The flooring will be entirely replaced by 11/22/2023.

h-All drawers and cupboards with damaged wood (not smooth and not cleanable) were identified by the Maintenance Coordinator. We are in process of completing patching/repairing and it will be completed by the Maintenance team on 11/22/2023. The installing company has been contacted and they will be out to look at them to assist with repair or replacement as needed.

i- The metal shelving in the main food storage area that was rusted and corroded has been removed and replaced with new shelving.

j- All areas under each kitchen sink was inspected by the Maintenance Coordinator to identify holes or gaps. Each area identified has been patched and repaired by the Maintenance team as of 10/9/2023.

k- For each home, all pots, pans, bowls, utensils, and cutting boards were inspected. For those items that were peeling, heavily scored, or damaged a plan was made for replacement. The items have been ordered and the damaged items are being replaced as the new items arrive.

l-All food that was not labeled or dated was identified and was all labeled and dated by the Resident Coordinator for each home.

m- All potentially hazardous foods that were stored incorrectly and found next to ready to eat foods were identified and moved to the proper location. Labels were created for these items so all staff know where they should be safely stored.

n- Bulk food and ice bins were inspected for any scoops and all scoops were removed.

2- On 10/11/2023, the Food and Supply Coordinator made contact with our food vendor and will now be ordering pasturized eggs in a carton for scrambled/casserole items and regular pasturized eggs for residents who prefer undercooked eggs. The Food and Supply Coordinator purchased plastic cleanable containers for the eggs to be stored in each home. Upon arrival, those will be distributed to each home.

3- The Administrator identified each home that has a house pet. For each of those pets, we will now include the location of the food and designated feeding area in the pets individual service plan to prevent pets from being fed or allowed into the kitchens. This service plan will be reviewed quarterly with each homes quarterly review, by the Administrator, to ensure these items are included in the service plan.

4- On 9/28/2023, the Administrator notified each home, via email and phone call to each Coordinator, that all dishes must be cleaned with the dishwasher (not handwashed) and clean/dirty dishes must not be stored on the counters.

5- The Admin Assistant is in the process of creating a laminated sign for each kitchen identifying the correct reheating and/or cook-to temperatures that the staff can refer to. The leadership team met on 10/12/2023 to retrain on this process. Each Resident Coordinator is now planning a mandatory team meeting which will be taught by the Administrator and Resident Coordinator, for all staff to retrain on the proper food procedures. Until the team meeting can occur, each Supervisor during the day will be verbally retraining each staff. The supervisors on duty at night and on weekends will be making daily rounds to verbally retrain all staff which will include observation of meal prep and serving.

6- The Maintenance Coordinator confirmed for each manufacture type, that in order to sanitize our dishes, each dishwasher needs to be run on the "heavy-duty" cycle. The Administrator trained all Coordinators on this at the leadership meeting on 10/12/2023. Each Coordinator is now in process of planning a mandatory team meeting for all staff to retrain their teams on this protocol for sanitizing dishes. This meeting will be taught by the Administrator and Resident Coordinator. In the meantime, a sign has been placed in each kitchen notifying all staff of this requirement.

a- The Maintenance Coordinator obtained a temperature gauge for the dishwashers and will now be checking the temperature of each dishwasher, while run on the heavy-duty cycle, monthly to ensure the proper temperature is reached for santization. The Maintenance QA form is now in process of being updated by the Administrator to include this monthly inspection.

7- Each refrigerator and freezer ice maker filter and water filter was replaced by the Maintenance Coordinator on 10/10/2023. A plan for cleaning/replacement of each filter according to each manufacturer type has been created by the Maintenance Coordinator and will be completed monthly. The Maintenance QA form is now in process of being updated by the Administrator, to include this monthly inspection and service.

8- On 10/12/2023, the Administrator and Staffing Coordinator met with each department supervisor to review and re-educate on the following (including but not limited to):

a-Our policies and procedures around kitchen cleaning, utilizing chore lists and holding their employees accountable and checking their work after chores are completed.

b- the process for properly sealing, dating and labeling all food and fluids in the pantry, freezer, refridgerator and in dry storage.

c-The correct storage of potentially hazardous foods.

d-Not storing scoops or utensils in ice bins or bulk bins.

e-Washing all dishes in the dishwasher on the "heavy-duty". cycle. Laminated signs were distributed to each supervisor to post in their homes kitchen.

f-Not storing clean or dirty dishes on the kitchen counters.

g-The proper reheating and/or cook to temperatures and cooldown process for food items.

h- Proper storage of pet food and not feeding pets in the kitchens. Trained on our new process of including this information in each of our pets service plans which will be checked quarterly by the review team.

i- Reporting Maintenance issues to the Maintenance team right away which includes: holes or gaps under the sinks, any damaged wood or surface that is not cleanable, damaged cutting boards, pots/pans, utensils, dishes, cups etc.

j- A plan was identified for each of the supervisors to work with each of their employees they supervise, to re-train them on the subjects covered in this meeting until their mandatory team meetings taught by the Administrator and Staffing Coordinator are set with a date.

9-  An annual in-service training has been created and added to the training calendar. This in-service will be mandatory for all staff to attend and all will need to pass a competency exam following the training. The in-service will be taught by the Administrator and Staffing Coordinator, and will include the subjects listed below (including but not limited to):

a- Our chore lists and cleaning procedures/protocols.

b-Reporting Maintenance concerns in a timely manner.

c- Reporting damaged cookware to the proper department.

d- Protocol for labeling/dating and proper storage of all food including potentially hazardous foods.

e-The proper sanitization of all dishes.

f-  Proper storage of clean dishes and proper handling of dirty dishes.

g- Proper reheating and cook-to temperatures including proper cooldown methods.

h- Proper storage of pet food and areas to feed house pets including the location of this information in the pet service plan.

10- Our Environmental Quality Auditing form is in process of being updated by the Administrator, to include the following:

a- Checking posted chore lists to ensure they are being completed. This will include a walkthrough of each kitchen to check for food/trash debris, splatters, dirt, dust, black matter or grease on all surfaces, appliances, flooring, walls etc.

b- Checking the main food storage area for cleanliness and to make sure all shelving is in good condition without rust or any compromise of any surface which would make it uncleanable. Check all fans for cleanliness.

c- Checking all utensils, pots/pans, cutting boards, all dishes to make sure they are in good repair and free from heavy scoring, rust or damage. If noticed, they will be replaced.

d- Checking all cabinets, drawers, doors for damaged surfaces that would make them uncleanable and if noted, will report to the Maintenance Department for repair.

e- Checking around and behind each range and refridgerator for food debris or spills.

f- Check outside food storage area to make sure flooring is clean with no gaps or scratches.

g- Inspect the area under the kitchen sink for holes or gaps. If noticed, contact the Maintenance Department.

h- Check food storage to make sure all is sealed, labeled, dated and stored properly.

i- No scoops located in the bulk bins or ice bins.

j- Inteview staff working to make sure they are using the "heavy-duty" cycle and washing all dishes in the dishwasher and not by hand.

k- Make sure staff are not storing clean or dirty dishes on the counter.

l- Interview the staff in the home to make sure they know the proper cool down methods, the proper cooking/reheating temperatures and check to make sure the laminated sign with these instructions is posted in the kitchen.

m- Visually check the area that the pet food is being stored, make sure pets are not allowed in kitchen or being fed in kitchen. Check the pet service plan to make sure the location of the food and area for feeding is identified.

11- This Environmental Quality Audit will be completed quarterly for each home by the Administrator and Staffing Coordinator. All results will be documented and resolved with the Supervisor for each home. The Administrator will meet with the auditing team weekly to make sure the auditing schedule is followed and all issues are addressed in a timely and accurate manner.

12- The Maintenance Quality Audit form is in process of being updated to include the following:

a-  Monthly inspection of all kitchen filters including repair, cleaning and replacement as directed by each Manufacture type.

b- Running each dishwasher monthly, on the heavy duty cycle and checking the temperature to make sure sanitization is reached.

13- This Maintanance Quality Audit will be completed montly for each home by the Maintenance Coordiantor. The Administrator will check in monthly with the Maintenance Coordinator to make sure the audit was completed and all issues were addressed.  

14- 8- The Administrator and Staffing Coordinator shall oversee and ensure these changes are implemented and monitored.

Based on record review and interview, it was determined the facility failed to ensure 13 of 39 staff reviewed who prepare and serve food had active food handler's certificates (#s 4 thru 16). Findings include, but are not limited to:

On 09/27/23 at approximately 2:30 pm, surveyor reviewed employee records for active food handler's cards. There were 10 employees who did not have a food handler's card on file and three that were found to be expired. At 2 pm, Staff 1 (Executive Director) verified there were multiple staff that did not have active food handler's certification. Staff 1 verified that those staff duties did include preparing food to residents.

Plan of Correction:

1- On 9/28/2023, an audit of all current employees was completed by the HR Coordinator to identify which employees needed a current Food handlers card. This list was was then given to the Staffing Coordinator who called each employee on 9/28/2023. By 9/29/2023, every employee had a current card on file.

2- To prevent reoccurrence, the HR Coordinator will now complete a company-wide audit every two weeks to identify employees who are needing their cards renewed or close to needing their cards renewed. After that audit, the HR team will communicate with the employees and track the progress until the new/updated card is received. The HR team and the Administrator will meet weekly to discuss the audit, who was identified as needing documentation, and the plan/progress on obtaining the cards.

3- The Administrator will be responsible to ensure the corrections are completed and monitored.

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 C370.

Refer to plan of correction for C240 and C370.