Print Inspection: JQWX

The findings of the kitchen inspection, conducted 09/19/23 thru 09/20/23, 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 09/20/23, conducted 12/27/23, 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 second revisit to the kitchen inspection of 09/20/23, conducted 03/08/24, 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:

Observations of the facility kitchen areas, reviewed on 09/19/23 through 09/20/23, found the following:

a. The following areas were in need of cleaning and/or repair:

* Reach in freezer door with ice build up;

* Walk in cooler fans/cages covered with dust/dirt debris build up; and

* Screen door to outside not latching completely leaving large gaps where pests and insects could gain entry.

b. Multiple kitchen staff were observed handling RTE (ready to eat) food items (bread/muffins) with bare hands.

c. One kitchen staff was observed on multiple days not wearing a hair restraint.

d. A kitchen employee was observed eating food products in the kitchen area and did not wash/sanitize hands before returning to work duties.

e. A kitchen staff was observed handling dirty dishes, touching potentially contaminated items (sprayer handle and garbage can), and then proceeded to handle and put away clean dishes without a sanitation step when going from dirty to clean tasks.

f. A container of turkey gravy was observed in walk-in cooler with a use by date of 9/10/23. There was a large pan of cooked ground beef and a frosted cake found stored in walk-in cooler uncovered and open to potential contamination.

On 09/20/23 at approximately 10:00 am, the surveyor reviewed identified areas with Staff 1 (Administrator). S/he acknowledged findings.

1. Reach in freezer door ice build up, will be cleaned and removed.  Walk in cooler fan/cage will be removed and cleaned of debris and or dirt.  Outside screen door, will be adjusted to close gaps.  Staff is aware that RTE food must not be handled with barehands.  I will remind them of that, and observe to make sure it is being followed.  Either by using utensils, or wearing gloves.  Staff with long hair will be required to wear hair restraint, or be pulled back and tied with some kind of hair restraint.  Staff will not eat food in the kitchen while working, and all employees must wash sanitize hands before returning to work.  Staff will wash hands when going from dirty to clean.  Dated items will be reviewed weekly and discarded if expired.  All items should be dated and labeled if opened.

2. Observation and monitoring of staff, getting them in the routine of following these simple policies that we have.  Staff training at next employee, about above described items.

3. Immediately and quarterly

4. Administrator and Dietary Manager

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. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility kitchen areas, reviewed on 12/27/23, found the following:

a. The following areas were in need of cleaning and/or repair:

* Reach in freezer door with ice build up;

* Screen door to outside not latching completely leaving large gaps where pests and insects could gain entry.

b. Staff member observed entering the kitchen area multiple times without their hair restrained and did not wash hands. This individual went in and out of the walk-in cooler and was preparing salad bar salads for residents.

Additionally, a kitchen employee with facial hair did not have facial hair restrained as required.

c. Cook was not observed to check food temperatures before lunch meal service. There were no food temperature logs to review to validate facility was checking temperatures of food items prior to service. Surveyor asked staff to check temperatures and the food items were at required temperatures for meal service. Staff 1 validated it was his/her expectation that food temperatures were taken prior to service. S/he acknowledged that for this meal they were not.

d. Container of used fryer oil was stored outside. Lid was not securely closed leaving it open to attract potential pests. The container was used to prop open the screen door.

e. The industrial mixer, counter top mixer and food contact equipment for those were not stored covered and/or protected from contamination when not in use.

f. Scoops were found stored in multiple bulk food storage containers.  

On 12/27/23 at approximately 12:40 pm, the surveyor reviewed identified areas with Staff 1 (Administrator). S/he acknowledged findings.

1. New reach in freezer has been purchased from Direct Supply, delivery shall be in 6 weeks or so. Until then ice build up will be removed on a daily basis.  Screen door does not currently have a latch, either weather stripping, or a latch will be installed to ensure no gaps.  Will put in document form and discuss with staff about proper hair restraints, and proper hand washing, and will have them sign it.  Will discuss with both cooks the importance of checking temperatures, and watch and observe at random times to ensure this is happening.  Fryer oil has been removed and will be removed on a weekly basis, and will ensure that the lids are properly secured, and will no longer be used to prop open screen door.  Covers for mixers will be used, when mixers are not in use.  Scoops have already been removed from storage containers.

2. described items above will be inspected periodically to ensure compliance with OAR's.  Items will also be discussed at next employee meeting February 7th, at 2pm.

3. Immediately, and then quarterly or as needed when administrator or kitchen manager does audit.

4. Administrator, kitchen manager

Based on interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases including Norovirus and other gastrointestinal outbreaks. This failure had the potential to impact all residents residing at the facility. Findings include, but are are not limited to:

During the annual kitchen inspection survey the facility was asked to provide policy and procedures for staff exclusion of working in the kitchen if ill. They were also asked to provide the facility's policy and procedure on resident gastrointestinal outbreaks. The policies provided did not effectively address methods for preventing and addressing possible GI outbreaks at the facility.

On 09/20/23 at 10:00 am Staff 1 (Administrator) was interviewed and acknowledge the facility did not have policies on exclusion of sick employees and when not to work in kitchen or identifying and responding to communicable gastrointestinal out breaks.

1. Policies will be developed, implemented, and printed.  Policy will be developed on protocols to prevent the development and transmission of communicable diseases including Norovirus and other gastrointestinal outbreaks.  A policy will be developed and implemented on the procedure for staff exclusion of working in the kitchen if ill.

2. The above stated policies and procedures will be developed and implemented.

3. Immediately

4. Administrator

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

Refer to C 240.

Refer to C240