Print Inspection: 5NHB

The findings of the kitchen inspection, conducted 11/08/23 and 11/10/23, 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 immediate plans of correction in place during the survey and the situations were abated.

The findings of the revisit to the kitchen inspection of 11/10/23, conducted 02/06/24, 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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facility's kitchen was observed in an unsanitary condition, in need of repair, and poor food handling practices by staff were observed. Findings posed immediate jeopardy, a situation that could threaten the health, safety, and/or welfare of residents. Findings include, but are not limited to:

Observation of the kitchen on 11/08/23 from 10:00 am through 3:30 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:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;

* Dining room table bases had an accumulation of food spills, splatters, and loose food debris;

* Dining room floor had accumulation of food spills and loose food debris;

* Spice shelves;

* 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, vents and light fixtures;

* Walls throughout kitchen;

* Window frame had dust and dirt build up;

* Stove/grill knobs, doors, and exterior;

* Grill top and interior of ovens;

* Open shelving throughout kitchen;

* Industrial mixer;

* Base holding mixer;

* Exterior and interior of plate warmer;

* Large can opener and housing;

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

* Rack shelving in walk-in refrigerator;

* Rack shelving in dry good storage;

* Rack shelving storing equipment and dishes;

* Under and behind shelving in dry good storage;

* Robo coupe machine and supplies;

* Utility racks;

* Soup kettle; and

* Beverage area in dining room drawers and cabinets.

b. The following areas were in need of repair:

* Door hinge to kitchen missing screws;

* Cabinets in dining area with water damage;

* Caulking throughout kitchen was damaged, missing or had black debris build up;

* Multiple areas in walls were damaged or had missing paint;

* Large hole under prep sink area;

* Small holes around electrical conduit;

* Several cooking utensils were observed to have integrity concerns (example: parts of cooking utensils were melted) and;

* Open shelving next to stove above prep space with areas of non cleanable surface.

c. Test strips for dish machine were not available to staff to accurately test chemical concentration of dish machine. Staff were monitoring the temperatures of the rinse but not the chemical concentration. The dish machine used chlorine for sanitation.

d. Two packets of frozen pre-cooked pork and two packages of frozen imitation crab meat were noted in sink defrosting. Slow/trickling water was dripping on the pork but the product was not submerged as required. The imitation crab was not under any running water.  Staff 2 was not aware it should have been fully submerged in running water. The meat products had been in sink for two hours prior to surveyors identifying the issue. The food products were checked for temperature and found at 27 degrees which was still out of the danger zone and facility placed in cooler immediately.

e. Multiple dry good items were not dated when opened.

f. All cutting boards were heavily scored and/or stained.

g. Multiple containers of bulk dry goods had cups or scoops stored in them.

h. Multiple items in freezer and refrigerator were not dated or labeled when opened or prepared. Bag of frozen sausages was found open and freezer damaged.

i. A kitchen staff person was observed during lunch service to prepare items of different meat/protein sources including high risk allergen materials (eggs/fish) and cut fresh ready to eat items (lettuce/tomatoes) on the same cutting board and cut with the same knife. S/he was observed to wipe the cutting board and knife with a dry towel in between.

j. A kitchen staff person was observed to handle ready to eat items with potentially contaminated gloves while making sandwiches. The staff was observed to handle utensils, touch handles, and other potentially contaminated items with his/her gloves and then touch ready to eat items. This staff was observed to not change gloves or wash hands when appropriate.

k. Kitchen staff was observed to check the temperature of the marinara sauce for service and was at 157 degrees Fahrenheit and proceeded to serve to residents. He also temped the tortellini which was at 140 degrees and was going to serve to residents until surveyor insisted the cheese filled pasta be brought to correct temp of 165 degrees to be "fully cooked" prior to serving to residents. This staff indicated that they usually "undercooked" some items like eggs and pasta so they did not "overcook" on them by the end of the hour long tray service. Surveyor provided education that items needed to be fully cooked before placing in the steam table.

l. Multiple rags were observed lying about the kitchen prep areas and not in appropriate sanitizer buckets with sanitizer at appropriate concentrations.  

m. Staff preparing food did not have facial hair restrained as required.

n. Dining area was observed to have preset silverware and service ware that was not protected from potential contamination as required.

At approximately 12:30 pm on 11/08/23, the surveyor contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the kitchen, the needed repairs, and the unsafe preparation and service practices. 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 11/08/23 at 12:45 pm, Staff 1 (Executive director) and Staff 2 (Dining Services Manager) were informed by the Surveyor that the kitchen would be shut down. They were instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. Staff 1 acknowledged concerns and acknowledged a plan to suspend kitchen operations until kitchen sanitation was started and improved.

The facility submitted a plan of correction on 11/08/23 at 3:30 pm, which was approved by the Surveyors.

On 11/10/23 at 10:30 am, the kitchen areas of greatest concern were cleaned to appropriate sanitation expectations. Facility was able to provide documentation on training to all kitchen staff on appropriate food preparation, service and sanitary practices. The Immediate Jeopardy situation at that point was abated and the kitchen was able to resume meal service.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

1) Southern Hills team came together and cleaned the ceiling, floor, walls, all drains, walk in cooler and freezer, under all racks, inside dish warmer, oven and stove, along the line, the vent covers, etc. We removed old cupboards and installed stainless steel shelving, repaired the hole in the wall, repainted, put screws in the hinge on the "in" door and replaced caulking. On-going any items identified as needing repaired will be put into our TELS system as a work order for the Maintenance Supervisor to complete.

2) Community has implemented daily, weekly, and monthly task sheets for dining services staff. These will be turned into the Dining Services Manager each day and he/she will verify by eyesight if the tasks were completed.

3) An Adminstrator/Executive Director daily kitchen walk through has been implemented. Dining Services Director to do weekly/monthly trainings with staff on relevent topics acording to identifed needs.

4) Dining Services Director, Administrator/Executive Director and the Health Service Director are monitoring the kitchen and dining room daily.

Based on interview and record review, it was determined the facility failed to ensure the person designated for their infection control specialist was qualified by education, training and experience or certification. Findings include, but are not limited to:

On 11/08/23 at approximately 1:30 pm, Staff 1 (Executive Director) was interviewed. During this interview it was stated that the facility's designated infection control specialist was the Maintenance Director. Staff 1 confirmed that this individual took the specialized training identified by the department but acknowledged they did not have any prior education, training, experience or certification in infection control principles or protocols. Staff 1 believed that the specialized training was all that was needed to be qualified. Staff 1 indicated they would ensure someone with appropriate knowledge, education, training or certification would be designated for that role.

OAR 411-054-0050 (1-5) Infection Prevention & Control

1) The Health Services Director/RN and Assistant Health Services Director/LPN have registered for the next webinar to be certified.

2) I will have two certified clinical team members.

3) Community will reevaulate annually.

4)The Administrator/Executive Director.