Print Inspection: JK9O

The findings of  the kitchen inspection, conducted on 04/04/23, 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 first re-visit to the kitchen inspection of 04/04/23, conducted 08/22/23, 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 the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

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

* Doors, door frames, and transition moldings;

* Walls throughout the kitchen;

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

* Shelves under the steam table and in dry storage room;

* Open shelving units;

* Multiple food carts;

* Garbage cans;

* Tops and sides of dry storage bins;

* Light switches;

* Refrigerator door handles;

* Knobs on stove;

* On and under appliances;

* Pipes under sinks, dishwasher and steam table;

* Bottom and sides of pans in the steam table;

* Window sill;

* Counter tops;

* Interior and exterior of freezer 1;

* Vents on ceiling, ice machine, and two dehumidifiers;

* Floor drains;

* Interior and exterior of drawers;

* Industrial can opener and housing;

* Grease and food debris on stove burners and grill; and

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

2. The following areas were in need of repair or replacement:

* There were multiple areas where the linoleum flooring had separated, and it had buckled under the triple sink;

* The paint on a wooden shelf in the front of the steam table had chipped paint with raw wood exposed;

* The shelves in the dry storage room had multiple areas where the paint had chipped or worn through and raw wood was exposed;

* The corner guard by the ice machine had missing areas and the drywall was exposed;

* There were multiple holes, gouges, and chipped paint on doors and walls throughout the kitchen;

* An overhead light fixture by the back door was missing a cover;

* Multiple cutting boards and plastic handles of utensils were deeply scored and discolored;

* The water faucet of the prep sink was broken and it ran continuously;

* The seal on the refrigerator door closest to the entrance did not close properly;

* Rust had developed on wire shelves of the open shelving unit closest to the dry storage room, and on the perimeter of floor drains;

* There was a broken outlet cover in the dry storage room; and

* There was missing trim along the wall between the dry storage and the back door.

3. Additional food safety observations included:

* Staff 2 (Kitchen Manager) failed to use a probe thermometer to ensure the proper cooking temperature had been achieved when making scrambled eggs. The facility did not use pasteurized eggs;

* Staff 2 was observed to put two eggs on a discolored wiping cloth on the counter;

* A cell phone was observed on the same counter top where pancakes were being mixed;

* Sanitation buckets were not observed and Staff 2 stated they did not have test strips;

* The garbage can lids were hand-operated;

* Staff 5 (CG) did not have her hair fully restrained;

* An aerosol can of air freshener and a spray bottle of disinfectant were stored on a counter where food was being prepared; .

* Staff 2, Staff 4 (Dishwasher/ Dietary Aide) and Staff 5) failed to wash hands and change gloves after touching multiple kitchen surfaces and between changing tasks;

* Scoops were left in bins of flour and sugar; and

* There was an open bag of rice in the dry storage room.

The kitchen was toured with Staff 1 (Administrator) and Staff 2 (Kitchen Manager) on 04/04/23. The areas in need of cleaning and repair were reviewed, as well as the additional food safety issues noted above. They acknowledged the findings.

Cleaning and Sanitation

1. Dining Services Manager or designee will keep log of daily cleaning of the kitchen with check off list and signature sheet, as well as weekly deep cleaning days that will be posted on the schedule and a cleaning log with check off list with signature will be kept.  The Dining Services Manager will hold a monthly staff meeting on kitchen sanitation, hand sanitation and meal services.

2. Kitchen staff will be trained hands on how to properly clean and keep up the kitchen's appearance and cleanliness.  As well as monthly training meetings instructing kitchen sanitization and meal services.  Kitchen staff will comre together once a week for a deep cleaning day that will allow the kitchen staff to address anything that needs further cleaning or kept up.

3. Dining Services Manager or designee will keep a maintenance log of items needing addressed and will provide this log to the Facility Services Manager weekly for items in need of repair and/or replacement.

4. Dining Services Manager or designee will go over proper temperatures and how to use a probe thermometer properly during the montly kitchen staff meeting.  Dining Services Manager will insure there are probe thermometers available for use in the kitchen and verify they are being used per temperature check logs.

5. Corrections will be evaluated daily by Administrator, Dining Services Manager or designee.

6. Administrator, Dining Services Manager or designee will see that these corrections are completed and monitored daily.

Repair or Replacement:

- Flooring

   1. Maintenance manager will replace flooring where damaged.

  2. Item is on monthly inspection checklist to ensure flooring are not in need of repair/cleaning.

  3. To be completed during monthly inspection.   

  4. Maintenance manager to ensure corrections are completed, ED to monitor for completion during weekly 1:1's

- Paint on Wooden Shelf

   1. Maintenance Manager will sand and repaint where there are areas of exposed wood.

   2. Item is on monthly inspection to ensure there are no areasof wood are exposed.

   3. To be completed during monthly inspection

   4. Dining Manager to report any areas needing repaired to maintenance, maintenance manager to ensure corrections are completed. ED will monitor for compeltion during weekly 1:1's

-Corner guards, walls, drywall

    1. Maintence manager will replace corner guard and replace drywall.

    2. Item is on monthly inspection checklist to ensure walls, corner guards, drywall are not in need of repair.

  3. To be completed during monthly inspection.  

   4. Dining Manager to report any areas needing repaired to maintenance, maintenance manager to ensure corrections are completed. ED will monitor for compeltion during weekly 1:1's    

-Kitchen Untensils /Cutting Boards

    1. Damaged cooking utensils and cutting baords will be removed and disposed of.

  2. Dining Manager will ensure inpsection of all utensils or small kitchen equipment is done weekly or monthly. Any items needing replaced will be added to the weekly department order form.

  3. To be completed during monthly inspections.

  4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's.  

- Water Faucet

   1. Maintenance Manager to replace leaking faucet

   2. Item will be added to monthly facilities checklist to ensure no leaks or broken faucets.

  3. To be completed during monthly inspections.

  4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's.  

- Rusted Shelves

    1. Shelves will be replaced

   2. Item will be added to monthly dining checklist to ensure craks, rust or exposed wire on shelves are present.

  3. To be completed during monthly inspections.

  4. Dining Manager will be responsible to see that inspection is completed, ED to monitor for completion during 1:1's.  

- Outlet covers

   1. Outlet covers will be replaced by maintenance.

   2. Item will be added to monthly checklist to ensure all outlet cov ers are in good and not in need of repair.

   3. To be com pleted during monthly inspection.

   4. M aintence will ensure inspection is completed and any areas needing correction. ED will monitor for completion during weekly 1:1

-Missing Trim

   1. Missing trim will be replaced by maintenance.

   2. Item will be added to monthly checklist. to ensure all dorr trims are in g ood standing, none missing or in need of repair.

   3. To be completed furing monthly inspection

   4. Maintenance manager is repossible to see that inspection is completed and items are corrected. ED will mon itopr for compeltion during weekly 1:1's

-Additional Food Safety Observatios:

      New thermometers will be ordered, DSM will ensure there are working thermometers weekly and report to ED weekly during 1:1. DSM will provide traiing to kitchen staff and ensure food temperature signs are located in the kitchen.

      Staff will be trained durring next Ktichen meeting regardin crtoss contaminatiopn of foods.

      Sanitation buckets and test strips will be ordered, and added to a daily checklist. Training will be provided on the use of saitation buckets, how to use test strips, when to refill, etc.

      New foot operated transcans will be ordered.

      Staff will be trained during all staff on prooper hand hygiene, glove usage, ensureing hair is pulled back, etc.

       All room sprays and cleaniing products should be put away and never stored where food prep areas are. Training to be done during next dining meeting and all staff meeting.

      Dining manager will need to do daily/weekly inspections of pantry/kitchen to ensure allcleaning, repair, and food safety are being done peoperly.   

Based on observation, interview and record review, it was determined the facility failed to ensure compliance with licensing rules related to Residential Care and Assisted Living regulations.  Findings include, but are not limited to:

Refer to C240.

Refer to C240