Print Inspection: 3TLG

The findings of the kitchen inspection, conducted 03/21/23, 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 revisit to the kitchen inspection of 03/21/23, conducted 09/28/23, 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. The facility was receiving meals from the assisted living community. The memory care kitchenette was remodeled into a medication room.

Based on observation, record review and interviews, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

A. On 3/21/23 at 11:00 am the main kitchen area was observed to need cleaning in the following areas:

*Pillar in beverage area;

*Walls in beverage service area;

*Shelving liner in beverage area;

*Interior and exterior of cupboards and drawers of beverage service area;

*Floors in the corners, edges and between/under equipment throughout kitchen;

*Multiple sprinkler heads with dust/dirt/debris build up;

*Walls in dish washing area;

*Multiple ceiling tiles with splatter, dirt, stains and dust build up;

*Wall corners and edges with build up of dirt and debris;

*Industrial slicer had dried food debris on food contact surfaces;

*Open stainless steel shelving by prep areas and under steam table;

*Hood and vents above grill/stove/fryer with build up of dust/dirt/debris;

*Handles and knobs of equipment; and

*Gray utility cart used for ice/water pitchers;

The following areas were found to need repair;

*Cupboard doors and drawers in beverage area were damaged and peeling exposing pressed wood;

*Multiple metal racks throughout kitchen were rusted;

*Multiple sprinkler heads had gaps in the ceiling;

*Multiple sprinkler heads were rusted;

*Metal sections of ceiling, holding ceiling tiles, were rusted;

*Section of grout in dish machine area had black mold like substance;

*Open metal shelving throughout kitchen had worn, dirty aluminum foil wrapped over original surfaces as they were not smooth cleanable surfaces.

*Large gaps and holes in ceiling tiles throughout the kitchen allowing for possible areas of potential entry of pests into kitchen;

*Ice machine had large dust build up on intake vent;

*Hole just above floor tile by prep table;

*Cutting boards on steam table were heavily scored/stained; and

*Large ice build up in walk-in freezer.

- The large industrial and small counter top mixer were observed not covered when not in use. The industrial slicer was also not covered when not in use. Staff 2 (Dietary Services Manager) confirmed there were no covers for those items.

- Kitchen staff were observed to serve residents without checking temperature of food items. When asked by surveyor to check temperatures, chicken was at 125 degrees F. Kitchen employee stated that it was well over 165 degrees when brought out of the oven. Kitchen employee put the chicken back in oven to reheat. Kitchen employee was able to state the need of food to be served at no less than 135 degrees F. Kitchen employee rechecked temperature of chicken, it was at 145 degrees F, and she returned to service. Upon interview with Staff 2, she validated that the kitchen employee should have reheated the chicken to 165 degrees before continuing to serve food item and should not have began serving until checking that all items were 135 degrees or hotter. Staff 2 indicated that kitchen staff would received additional education on serving and reheating temperatures.

- Trash cans in dish area did not have lids.

- Kitchen staff were observed to handle clean dishes after handling dirty dishes and did not wash or sanitize hands.

- Container of used and dirty rags were observed stored in the dish area. Staff 1 acknowledged these items should not have been stored there.

Staff 2 and 3 (Memory Care Program Manager) toured kitchen with the surveyor and acknowledged the identified concerns. Staff 1 (Executive Director) was provided areas of concern via telephone.

B. The memory care kitchenette was toured with the surveyor and Staff 3 on 03/21/23 at approximately 12:30 pm. The following was observed to need cleaning and repair:

- The floor was found to have tears and rips in areas and a large seem in the middle that was spreading. This created areas that were not smooth and cleanable surface.

- The stove and oven were found to need cleaning. The oven door was damaged and not closing correctly.

- The area around and behind the sink was dirty. The soap dispenser had visible food debris on the handle.

- The exterior and interior of cupboards and drawers had food debris, splatter or drips.

- There was a plate of uncovered food stored up on one of the shelves in the cupboard.

- Scoops were found stored in bulk food containers of brown sugar, sugar, and coffee.

Staff 3 acknowledged the findings. Staff 1 and 2 were notified of the findings in the memory care.

C240 B.

Memory Care Kitchen area is to be demolished and no longer utilized to serve, store or prep food that will be served to the Residents or staff. The oven will be removed and disposed of. All food will be prepared and plated by the dietary staff in the kitchen and served directly to the residents in the dining room. Expected completion 5/20/2023.  

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.

C240A. Summit Facility Services here to steam clean the kitchen floor tiles 4/27/2023 Then on a bi annual schedule thereafter

Del with C&S Fire-Safe services here to service, clean hood vent above grill/stove 4/26/2023 and will then be on a quarterly maintenance schedule.

Addcox cleaning and air will be here 4/7/2023 to service and clean the ice machine and on a routine schedule every 6 months as well as Pacific View maintenance team servicing and cleaning monthly as assigned in TELS

Cutting boards ordered and will be replaced

Rusted Metal racks ordered and will be replaced

Rusted tables ordered and will be replaced

Maintenance will clean and replace caulking/grout behind dish machine

Hole in wall will be repaired by maintenance

Ice build up in Freezer will be cleaned and then monitored and cleaned by maintenance once monthly as assigned in TELS

Deep cleaning in kitchen scheduled 4/16/2023. New cleaning schedule implemented, staff inserviced and weekly inspections by Dietary Manager and Monthly inspections by ED or MCPM that will be kept in Dietary Office.

Maintenance to clean the ceiling, replace tiles as needed and patch holes where able. C&S Fire Safe Services will be out to replace/repair rusted cups around fire sprinklers and clean sprinkler heads.5/10/2023

Maintenance to replace damaged cabinets in service area of dining room

Inservice of correct serving temps done with all Cooks, serving temps posted as a reminder, weekly spot check audit put into place by dietary manager.

Covers for Mixers/slicer now in use and changed with each use of mixer (clean plastic bags are being used as suggested by surveyor)

Container used for rags removed from dish area

Inservice done 4/6/2023 with staff regarding infection control, food temps and sanitation rules of handling clean dishes after Dirty without handwashing or sanitizer and a sanitizing dispensor placed in Dish pit for easy access between clean and dirty side. Dietary Manager to do spot checks and observations during weekly inspections and temp checks.