Print Inspection: 6MYX

The findings of the kitchen inspection, conducted 11/06/23, 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 11/06/23, conducted 04/16/24, 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.

Aprons were ordered and provided for all staff serving, with spare on hand. Beverages will be covered in kitchen before leaving station for service. Food will be delivered in food warming containers from main kitchen and temperatures will be taken before being served out to ensure correct temperatures.

Kitchen will ensure staff are wearing aprons before handing over food carts. All beverages will be poured by one staff member and covered immediately. Executive Chef will oversee follow through of new implementations and that temperatures are appropriate. Executive director will oversee corrections and monitor the follow through of these corrections.     

The findings of the second revisit to the kitchen inspection of 11/06/23, conducted on 06/05/24, 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 and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main kitchen and memory care kitchenette were conducted on 11/06/23 from 9:45 am through 2:40 pm and the following were identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Walls throughout kitchen;

* Walk-in cooler metal racks;

* Walk-in cooler fan and ceiling;

* Open stainless steel shelving;

* Ceiling with dust accumulation;

* Fire sprinklers with dust accumulation;

* Inside server station drawers;

* Industrial can opener and casing;

* Industrial mixer;

* Wall behind industrial mixer;

* Window frame;

* Interior of oven;

* Exterior of stove;

* Stove knobs and handles;

* Removable hood vents;

* Stainless steel wall behind stove/grill;

* Drain under steam table;

* Interior of ice machine; and

* Interior and exterior of microwave.

b. The following areas were in need of repair:

* Broken tile on floor to the left of stove;

* Stove knobs and handles;

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

* Oven (left side inoperable); and

* Caulking behind dish pit area with dark mold-like substance.

c. Poor infection control practices observed, but not limited to:

* Ice machine had pink and black mold-like residue on inside of machine;

* Dented containers storing food in walk-in refrigerator;

* Dining room had cutlery pre-set and not protected from potential contamination;

* Test strips to test sanitizer solution were not accurately reading chemical used in buckets;

* Cook used dry towel to wipe thermometer in-between checking food temps;

* Dishwasher racks found on floor;

* Bins containing food had scoops stored inside of bins; and

* A kitchen staff did not have facial hair restrained as required.

d. Memory care kitchenette was reviewed and the following items were in need of attention:

* Kitchenette half wall attached to door was separated from frame;

* Container of brown sugar was stored uncovered and open to potential contamination;

* One staff member was observed to double glove their hands while plating and serving MCC residents;

* Multiple staff did not perform hand washing correctly during lunch service;

* Staff plating salads in MCC did not have their hair properly restrained;

* Memory care staff did not wear aprons during dining service;

* When delivering meals to resident apartments, beverages were not covered during transit;

* Hot foods were not served hot. Plated food items were not covered when placed into meal delivery cart. Plates of food were removed from cart and set on counter top in memory care dining room. Plates sat on the counter for several minutes before being served to residents. Surveyors checked the temperature of meal items and it was found at 96.9 degrees for residents served in the dining room. The temperature was taken again before then last meal delivery and was found at 84.6 degrees F. These were not palatable temperatures for hot foods; and

* At 12:12 pm, memory care staff were interviewed and were not able to accurately verbalize correct temperatures food needed to be at when reheated for residents. Staff also acknowledged they did not have thermometers to check food temperatures.

At approximately 2:40 pm, surveyor reviewed above areas with Staff 1 (Executive Director), Staff 2 (Executive Chef), and Staff 3 (Memory Care Director), who acknowledged the identified areas.

A updated cleaning check list is now in place for daily, weekly, monthly cleanings.

Ice Machine on a regular cleaning schedule

New utensils ordered for the kitchen

Setting cutlery out only 30 minutes or less prior to the meal

Memory care staff were ordered hair nets and aprons to wear during meal service.

Food temp training and log and thermometor sanitation will be completed with MC staff

Hand washing training/glove wearing will happen with MC staff.

For room trays in MC they now deliver in a covered box instead of exposed on a rolling cart.

Executive Chef to oversee cleanings are being completed and to hold trainings for staff on kitchen related topics.

System to prevent re-occurance: ED to meet with Executive Chef bi weekly for check in's and walk through.  

Based on observation and interview, it was determined the facility failed to serve food in the memory care unit under sanitary sanitary conditions in accordance with Food Sanitation Rules, OAR 333-150-000. The facility also failed to ensure food was served to residents at palatable temperatures. This is a repeat citation. Findings include, but are not limited to:

Observation of the memory care kitchenette and lunch meal service was conducted on 04/16/24 from 11:35 am am through 1:30 pm and the following was identified:

* Memory care staff did not wear aprons during meal service to protect food/equipment from potential contamination on clothing from care giving tasks;

* When delivering meals to resident apartments, beverages were not covered during transit;

* Hot foods were not served hot. Plated food items were not covered when placed into meal delivery cart. The surveyor checked the temperature of meal items immediately following delivery to last resident served in their room. The meal consisted of chicken, baked potato and green beans. The temperature of the chicken was 82.9 degrees Fahrenheit, potato was 111 degrees Fahrenheit and green beans at 89.6 degrees Fahrenheit.  The temperatures of the chicken and green beans were not palatable temperatures for hot foods.

At 12:10 Staff 3 (Memory care Director) was interviewed and did not have knowledge of areas cited in previous kitchen survey. Staff 3 was unaware of need for care staff to wear a protective barrier (apron) during meal service. Staff 3 was unaware of plan of correction indicating food items would be covered in containers when delivered to rooms. Staff 3 acknowledged the low temperature readings and agreed they were not palatable for hot foods. Staff 3 was new to facility and had only been there for two days.

At approximately 1:15 pm, surveyor reviewed above areas with Staff 1 (Executive Director), Staff 2 (Executive Chef), and Staff 3 who all acknowledged the identified areas.

Aprons were ordered and provided for all staff serving, with spare on hand. Beverages will be covered in kitchen before leaving station for service. Food will be delivered in food warming containers from main kitchen and temperatures will be taken before being served out to ensure correct temperatures.

Kitchen will ensure staff are wearing aprons before handing over food carts. All beverages will be poured by one staff member and covered immediately. Executive Chef will oversee follow through of new implementations and that temperatures are appropriate. Executive director will oversee corrections and monitor the follow through of these corrections.     

Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.

Copies of kitchen survey will be provided to staff and management, so all team members are aware of correction plan and implementation of corrections.

The system will be corrected by making sure everyone has received a copy and signed acknowledgement will be kept on hand for each employee.

ongoing evaluation of food service oversight will be completed by the Executive Chef and ongoing monitored by the Executive Director.     

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 C 240.

See C240

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C240.

Current Executive Director has excemption with the state and is holding the license for both the MCC and ALF until new MCC director with license is hired.