Print Inspection: BEEW

The findings of the kitchen inspection, conducted 08/05/24, 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.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the revisit to the kitchen inspection of 08/05/24, conducted 10/04/24, 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 in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main facility kitchen and the memory care unit kitchenettes on 08/05/24 from 10:30 am through 2:00 pm revealed the following deficient practices:

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:

* Fan above reach in fridge cages and blades;

* Reach in refrigerator by beverage area in kitchen;

* Industrial can opener blade;

* Stainless steel shelving in baking/prep area;

* Ceiling of microwave;

* Reach in refrigerator in Rockies unit;

* Toasters in units;

* Lazy Susan cabinets in units;

* Kitchenette floors in units; and

* Table bases in Cascades unit.

b. The following areas needed repair:

* Caulking in ware washing area with black matter debris buildup;

* Cabinets under microwave in units with shelving with exposed pressed/porous wood making non-cleanable surfaces; and

* Reach in refrigerator in kitchen by beverage station reading 50 degrees during survey.

c. Kitchen staff member observed to handle dirty dishes and reach into garbage disposal and handle lemons with the same gloves that they then handled clean dishes. No hand hygiene step was observed when going from a dirty task to a clean task as required.

d. Thermometer in a reach in refrigerator holding resident beverages, multiple condiments, whipped topping and a pasta salad for evening meal was observed to be at 50 degrees. The thermometer was located in the door at the warmest portion of the fridge. Surveyor moved thermometer to the back/coldest part of the fridge and rechecked the temperature which dropped to 46 degrees but still above the required 41 degrees for cold storage. Review of refrigerator temperature logs revealed multiple days in May and July that the same fridge had been noted to be above 41 degrees and at times at 50 degrees. No evidence was found that the facility identified the incorrect and unsafe storage temperature of the fridge and made appropriate corrective actions to ensure food/beverages were being stored at the appropriate temperatures.

e. Multiple small black ants were observed crawling on the floor around the small reach in refrigerator in Cascades unit. The ants were observed to crawl in/out of the broken seals in the floor/wall cove base.

In an interview on 08/05/24 at 1:45 pm, Staff 1 (Executive director) and Staff 2 (Dining Services Manager) were informed of concerns found. Both staff 1 and 2 acknowledged areas in need of correction. Staff 2 was asked about the refrigerator temperatures and indicated whenever they checked the temperature it was at 41 degrees or below as required but indicated it was first thing in the morning and that the other cook checked the temperature in the afternoon. Staff 1 was unaware that the refrigerator was not effectively holding temperatures at 41 degrees or below and acknowledged there was no evidence that the appropriate interventions were put in place when temperatures were documented above the 41 degrees. Staff 1 indicated they would have maintenance look at the fridge and see if it could be adjusted to be cooler and that anything potentially hazardous would be discarded. If the current fridge could not maintain temperature, it would be repaired or replaced.

A. All areas in the main kitchen noted to need cleaning have been deep cleaned and will remain on a deep cleaning schedule monitored by the DSD.  

All areas of the kitchenetts noted to need cleaning have been deep cleaned and will remain on a weekly deep cleaning schedule monitored by the resident care coordinator.

B. The caluking around the wall at the back of the dish area will be replaced and added to the deepcleaning schedule monitored by the DSD.

The Cabninets under the nicrowaves in the units will have the edging replaced as to repair the non cleanable surfaces.

The refrigerator noted to be at 50 degrees at survey has been turned down and has been monitored daily by DSD and is reading below 41 degrees. we will continue to monitor daily and replace or repair if needed.  

The particle board making up the bottom of the cuppards under the sinks have been replaced closing up the open cut out areas. The pipes have all been inspected and cleaned.

The items under the sinks have been removed .

C. A staff training on hand hygiene for clean and dirty tasks will be heald by the DSD. DSD will monitor kitchen staff  daily to ensure that procedures are being followed.

D. A staff training on logging refrigerator temps and when to report them to the DSD will be held. The DSD will monitor the temps daily to ensure that they are within range.

E. The kitchette floor has been cleaned and the ants have been removed. The small crack in the caulking on the floor trim has been repaired.

Based on observations, interviews and record review, 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.

Refer to POC for C240