Print Inspection: CL9G

The findings of the kitchen inspection, conducted 04/23/24 thru 04/24/24, 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 revisit to the kitchen inspection of 04/24/24, conducted 07/10/24, 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 four cottage kitchen areas (1, 2, 3, 4) and food storage (Pantry) were reviewed on 04/24/24 from 10:45 am through 2:30 pm and identified the following:

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:

* Cracks in concrete floor in pantry;

* Range top in house 2;

* Ceiling vent in house 1; and

* Screen and windowsill in house 3.

b. Staff 3 (Cook) was observed to not follow 3 compartment method when sanitizing utensils/equipment used for meal prep. Staff were wiping dishes with a sanitized rag from sanitizer bucket after washing and rinsing utensils/equipment, pots and pans. Staff were not submerging and soaking items as required. S/he acknowledged the facility did not  have availability to effectively sanitize pots, pans and knives.

c. During observations in cottages, surveyor noted dishwashing cycles to be on quick wash cycles. Staff interviewed in three of the four houses stated they washed the dishes for resident meal service on the one-hour cycle (quick wash) for the dishwasher. Staff interviewed were not able to validate the cycle effectively sanitized the dishes. Staff 1(Administrator) and Staff 2 (Person in Charge/Assistant Administrator), acknowledged the facility did not have a clear process for ensuring residential dishwashers were effectively sanitizing dishes and that all staff knew which cycles were effectively sanitizing dishes and ensuring that was the cycle used.

d. Scoops were observed stored in bulk ice containers. Staff 1 and 2 acknowledged there was not a current system to ensure refrigerators with ice makers were cleaned and maintained in order to ensure ice produced was done in a clean and sanitary way to ensure safety of residents.

e. During interviews with staff in all houses the following was identified:

*Staff were not aware of proper cooling procedures for left overs;

*Staff were not checking temperature of food products to ensure temperatures were at 41 degrees or below within 6 hrs;

*Multiple staff were also not sure of temperatures required for reheating and the surveyor was unable to validate food was reheated to 165 degrees Fahrenheit as required.

f. Multiple food items were observed not dated when opened and/or did not have use by dates. In house 4, a container of sauce was found passed 7 days and should have been discarded.

g. The Pantry building was constructed to have large breaks in flooring which had accumulated dust/dirt and debris and the wall junctures were not coved as required. The pantry building stored a large amount of bulk dry storage food items, and multiple reach in freezers and/or refrigerators.

h. Surveyor observed multiple meal trays delivered to resident rooms uncovered/protected from contamination.

The findings were reviewed with Staff 1 and Staff 2 at 2:00 pm, Staff acknowledged the areas.

A.The Administration team has developed a comprehensive cleaning schedule and task list to maintain the outdoor pantry's cleanliness and orderliness. The maintenance team has been tasked with thoroughly cleaning the kitchen vents to prevent dust, grime, and grease accumulation. The kitchen manager will conduct regular kitchen inspections 1x per month in every kitchen. A detailed deep cleaning list was developed by the Kitchen Manager that includes routine cleaning of all range tops, screens, and windowsills. The RCC team will monitor daily and ensure compliance and competency with our care team.

To address the chips and cracks in the pantry, a work order has been issued to our maintenance team. Concrete crack filler and epoxy concrete paint will be applied to repair the damage. The maintenance team will incorporate monthly inspections of the pantry flooring into their routine duties to ensure its upkeep and compliance. Monthly inspections by the kitchen manager will ensure proper upkeep of the pantry and kitchen areas were completed by.

B. Timber Town Living has purchased a commercial-grade tub to ensure all staff are able to utilize a three-compartment sink that is sufficiently sized to allow for the complete submersion and sanitization of all cookware, such as pots, pans, and knives. The RCC's will ensure that the staff are knowledgeable about proper utiliztion of the sanitizing bucket in every staff members onboarding and orientation. The kitchen manager has provided a separete tub that can be utilized for wiping down surfaces as a way to redirect this habit to the appropriate bucket. The RCC's and the Lead Care Givers will ensure the daily compliance of properly sanitizing dishes. All concerns will be reported to the kitchen manager.

C. The Timber Town Living maintenance team will utilize a waterproof electric thermometer to verify the dishwasher's temperature. Monthly checks will be conducted by the maintenance team to ensure the water reaches the appropriate temperature for sanitization, and the results will be meticulously recorded in a maintenance log. Signage will be prominently displayed on all dishwashers, providing staff with clear instructions on the proper cycle to use for dishwashing.

D.To ensure employees do not place scoops in the ice makers, the scoops will be stored in a clearly marked ziploc bag in the freezer. After each use, staff members will return the scoops to the bag. Signage will be placed on all freezers and ice makers to remind employees to keep scoops out of the machines. Our maintenance team will fully defrost the ice makers montly, allowing the care team to thoroughly clean and sterilize all ice makers and ice maker trays. The facility administration team has added this deep clean schedule to the daily and monthly duties of the maintenance and care teams. The RCC's will monitor the care team daily and report to the kitchen manager of any concerns.

E. The administrative team has developed a comprehensive training program to ensure all employees understand the proper cooling procedures. This training covers the handling, storing, refrigerting and reheating of leftovers. Signage has been placed in all kitchens to provide guidelines for proper cooling and warming methods and temperature danger zones. Additional supplies will be provided to the care team as needed throughout this transition. Additionally, the cooling process has been incorporated into the training and competency packet provided to all staff.

G. The care team has been tasked with ensuring that all food items are properly labeled and discarded when they reach their expiration date. As part of their daily routine, the kitchen manager now conducts thorough kitchen inspections, paying special attention to the pantries and refrigerators to identify any outdated or improperly labeled food items.

H.Timber Town Living's pantry was intentionally placed with expansion joints in the concrete to prevent cracks and buckling. Concrete expands and contracts as temperatures fluctuate and absorbs moisture, which can cause excess stress on the concrete. Without expansion joints, this movement can cause severe stress points that weaken the structure and may lead to early replacement or significant damage. Timber Town Living will submit an exemption to request that these joints be left in place in order to preserve the concrete. Timber Town Living has created a deep cleaning program for the cooks to properly clean out the expansion joints on a regular basis. Timber Town Living management will be doing daily rounds to ensure this is being done. Timber Town Living maintenance installed molding to every wall junction on 4/29/24.

To ensure the prevention of food contamination, Timber Town Living has made an investment in food trays and covers. These items have been incorporated into Timber Town Living's training materials. All staff members have received comprehensive training on the proper procedure for delivering meal trays to residents' rooms.  

Based on observations and interviews, 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.

See C240