Print Inspection: C3ES

The findings of the kitchen inspection, conducted 08/14/23, 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.

A situations was identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0030 Resident Service Meals, Food Sanitation Rules.

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first revisit to the kitchen inspection of 08/14/23, conducted 02/14/24, 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.

The findings of the second re-visit to the 08/14/23 kitchen inspection, conducted 06/13/24, 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 kitchen's dry storage was observed in an unsanitary condition, which posed an immediate jeopardy situation that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

a. Observation of the dry food storage room occurred on 08/14/23 at 8:45 am and showed the following were in need of immediate cleaning:

* Multiple rodent droppings were observed under shelving units and on shelves in the dry food storage area;

* A wooden, spring-loaded rodent trap was on the floor under the shelving in the back of the dry storage. The trap had a partially disturbed scoop of peanut butter on the bait surface;

* A large jar of used peanut butter was observed on top of the stand freezer in the dry food storage area. The jar was labeled with a piece of paper that said "rat bait;" and

* Three jars of recalled peanut butter were on a shelf in the dry storage next to other items. There was no indication the jars were not for resident consumption other than Staff 1 (Administrator) statement the jars needed to be returned or disposed of.

At approximately 8:45 am on 08/14/23, observations were discussed with Staff 1 (Administrator). The peanut butter labeled as "rat bait" was removed from the food area. All shelving, lower and upper surfaces were checked for additional rodent droppings. Droppings were found only in an isolated area at the back of the dry storage, and a full cleaning of the whole area was requested. Additionally, Staff 1 removed the recalled peanut butter and disposed of the unopened jars.

At approximately 9:15 am on 08/14/23, observations and discussions held with Staff 1 were shared with Staff 2 (Owner). Staff 1 and Staff 2 were directed to get the rodent droppings cleaned up, any foods not factory sealed thrown out, shelves and other non-perishables food items disinfected, to contact their pest company and await further instructions. Cleaning began directly after droppings were shown to the staff.  

At approximately 9:35 am on 08/14/23, the surveyor contacted the Community Based Care Designee and shared concerns about the unsanitary condition of the dry storage. The dry storage was in a separate, closed room outside of the kitchen. The breakfast meal was already completed, and lunch items were perishable items located in the kitchen area, not the dry storage.

On 08/14/23 at 9:15 am an immediate plan of correction was requested from Staff 1 and Staff 2 to address the unsanitary conditions. Cleaning and disinfecting of the dry storage area had already begun and continued while a written plan was established.

The facility submitted a plan of correction on 08/14/23 at 10:10 am which was reviewed by the surveyor and the Community Based Care Designee, Additional information was requested for the immediate plan of correction. The plan of correction was approved on 08/14/23 at approximately 10:30 am.

On 08/14/23 at 11:33 am a re-inspection of the dry storage was completed. All areas were free of rodent droppings and affected areas had been disinfected, sealed food items cleaned, open items tossed. The floor in the dry storage had been swept and disinfected as well. The surveyor determined the unsanitary conditions had been corrected and the immediate jeopardy situation was abated.

b. Additional observations of the kitchen and breakfast meal on 08/14/23 at 8:20 am showed the following were in need of cleaning and/or repair:

* Spills, splatters, scrapes and chips were noted on walls throughout the dry storage;

* Debris and spills were noted inside multiple drawers and cupboards throughout the kitchen;

* Black accumulation was noted along edges of baseboards and flooring in the dry food storage and kitchen;

* Food debris, wrappers and packages of briefs were located under the shelves in the dry food storage;

* A piece of duct tape was on the edge of the countertop where laminate was missing, loose laminate edges were noted to the countertop near the door and sink area;

* Wood and fiber board shelves in the dry storage and kitchen had stains, spills and exposed wood with peeling and/or cracked shelf paper, laminate or linoleum. A large section of shelves in the dry storage area had exposed, unsealed/uncovered wood or fiber board;

* The kitchen did not have a working probe thermometer to check food temperatures prior to serving. Temperatures were not consistently taken of cooked items such as eggs prior to serving the residents;

* Cutting boards were stained and had rough, gouged surfaces;

* Gloves were not used for preparation and delivery of items such as toast;

* Spills and debris were noted on the shelves of the stand freezer located in the dry food storage room;

* White tape was noted on the floor in the dry storage with torn edges. The tape had black accumulation and debris at the edges and center where the tape had split open;

* Aprons were not observed on care staff who were delivering plates to the dining room;

* A large gap was noted between the flooring and wall in the dry storage room;

* Missing paint, black stains, dark accumulation and bowed cupboard bases were noted under both sinks in the kitchen; and

* Significant debris, crumbs and stains were noted in the lower corner cupboard in the kitchen.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 and Staff 2 on 08/14/23. The staff acknowledged the findings.

1:

a) Immediately the pantry was emptied, sanitized (walls, shelves, floors, canned goods and containers - nonperishables) and all perishable products that could have been contaminated were disposed of.

b) All shelves are now covered with an easy to clean vinyl.

c) Terminix was contacted, copies of their last 3 visits were given to the surveyor, two Terminix inspectors shoued up within 48 hours to do an inspection and a copy was E-Mailed to the surveyor.

d) Terminix made a few recommendations along with sealing a couple of exterior entry points around the facility. They are scheduled to make all recommended repairs on 08/31/2023

e) A deep clean was performed throughout the kitchen and cabinets.  All spices and condiments were checked for dates and freshness.  

2: Defined roles of responsibility and cleaning schedules will be implemented to prevent this violation from happening in the future.

3) Both the Pantry and the Kitchen will be inspected weekly for the next few months to ensure the process is being followed. A deep-clean checklist has been made for the ease of the resident aide to follow. Once we are assured that the process is being followed, the inspections will be conducted monthly.

4: The Administrator and the Ex-Managers/owners will make sure all corrections are completed and will be monitoring/inspecting the areas.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation.  Findings include, but are not limited to:

Observation of the kitchen on 02/14/24 at 1:15 pm revealed the following:

* At the time of the re-visit survey, the kitchen was under construction. Staff 1 (Administrator) reported the kitchen had a leak, resulting in the need to repair the flooring, countertops, and cupboards. The repairs were in progress revealing exposed subflooring, plywood counter tops and an unfinished cabinet under the sink;

* The dry food storage room had unfinished drywall including a large gap between flooring and wall; and

* There was no evidence the kitchen was using a small-diameter probe thermometer to measure thin foods.

The survey team was unable to do a complete kitchen inspection due to the current construction taking place.

The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was reviewed with Staff 1 on 02/14/24. She acknowledged the findings.

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

Refer to C240.