Print Inspection: KIT000041

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observations and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 08/26/24 at 11:00 am through 1:30 pm revealed the following deficiencies: 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: * Interior of ice machine; * Flooring in corners, edges, between and under and behind equipment; * Floor mat and flooring under mat by service line; * Ceiling vents, light fixtures and sprinkler heads; * Hood vents above grill/range; * Industrial can opener and housing; * Interior of ovens; * Exterior and sides of grill; * Interior/exterior of convection oven; * Interior of microwave; * Walls behind and beside grill/stove; * Utility carts; * Radio in prep area; * Top shelf of steam line; * Open stainless steal shelving; * Metal racks in walk in cooler; * Walls behind prep areas; * Speed racks; * Can rack holder; * Multiple areas on walls throughout kitchen; and * Reach in Deli cooler. b. The following areas were found in need of repair: *Ice accumulation on door threshold and ceiling in walk in freezer; c. Large oval serving trays, Large black service trays and grill spatulas observed heavily damaged with integrity concerns making them uncleanable surfaces. d. Staff observed not performing hand washing when changing between dirty and clean dishwashing tasks. An additional staff member was observed to handle frozen raw beef products with gloves and then did not wash hands after removing gloves before beginning other tasks. e. Deli reach in cooler did not have a thermometer to effectively monitor cold food storage temperatures. Upon entry to kitchen at 11:00 am, the walk-in cooler door was observed propped open as staff was putting away stock. The cooler thermometer read 50 degrees. The door continued to be propped open until 12:00 pm. f. Multiple staff members preparing and/or serving food did not have hair/facial hair effectively restrained as required. g. Facility was presetting service ware between meals with utensils exposed to potential contamination. Upon interview with dietary staff, they confirmed that after one meal service was completed, tables were cleared and dishes/utensils set for next meal. Dining room was not able to close and staff, residents, visitors and vendors had access to dining room between meals. Staff were unaware silverware needed to be covered. h. Towels used for wiping/sanitizing found dirty and not stored appropriately in sanitizing solutions but random places around the kitchen. i. Multiple food items were noted uncovered in the deli fridge area. No food items in deli fridge contained dates when prepared or use by dates. Multiple items in walk in cooler observed without open or use by dates. j. Evidence of staff eating food in kitchen food prep area was found. Staff drinks were not of appropriate approved styles to ensure minimal potential contamination. k. During meal service, multiple facility staff observed touching RTE (Ready to Eat) foods with ungloved/bare hands. l. Facility using sponges for dishwashing. Multiple cleaning sponges were found heavily worn with evidence of pieces/chunks missing from them. Surveyor toured and reviewed above areas with Staff 2 (Dining Services Manager) and they acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator) and they acknowledged the areas in need of correction.

1. All areas identified in subsections a, b, c and l that were found to be deficient are in process of beng cleaned, repaired/replaced/modified. All areas identified in subsections d, f, j,k, l, g, and h, staff training will be provided to team members for the following topics: Proper handwashing and glove use. Proper use of hair and facial hair restraints when entering the kitchen. Designated storage area for personal beverages and eating to include proper use of lids and straws. Proper use and storage of sanitation rags. Proper storage for cold items. Proper protocol for preset silverware to prevent potential contamination. No use of sponges in the kitchen. 2. To ensure that this violation does not happen again, all areas in a, b, c, and l will be monitored via cleaning schedules and for items, d, f, j, k, l, g and h these items will be added to a sanitation inspection audit tool and will be used on a weekly basis to monitor these areas. 3. The Dining Services Director will be responsible to see that the corrections are completed/monitored by reviewing the cleaning schedules and kitchen sanitation inspection audit tool on a weekly basis.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observations and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and 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 11/05/2411:15am through 2:15pm and again on 11/06/24 from 11:15am through 12:15pm revealed the following deficiencies: 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: * Interior of ice machine; * Flooring in corners, edges, between and under and behind equipment; * Kitchen drains; * Shelving under tray line; * Ceiling vents, light fixtures and sprinkler heads; * Hood vents above grill/range; * Industrial can opener and housing; * Interior of conventional ovens; * Exterior of all ovens; * Interior/exterior of convection oven; * Interior of microwave; * Walls behind and beside grill/stove; * Utility carts; * Radio ; * Top shelf of steam line; * Open stainless steal shelving; * Metal racks in walk in cooler; * Walls behind prep areas; * Speed racks; * Trash cans: * Windowsills; * Interior of stainless steel drawers; * Shelving storing clean dishes; * Multiple areas on walls throughout kitchen; and * Reach in Deli cooler. b. Large oval and rectangular serving trays, Large black meal service trays continued with significant damage/integrity concerns making them uncleanable surfaces. c. Deli reach in cooler did not have a thermometer to effectively monitor cold food storage temperatures. d. Multiple staff members preparing and/or serving food did not have hair/facial hair effectively restrained as required. e. Towels used for wiping/sanitizing found dirty and not stored appropriately in sanitizing solutions but random places around the kitchen. f. Multiple items in walk in cooler observed without open or use by dates. Several items found not effectively covered/protected from potential contamination. Multiple items in cooler found past 7 days and should have been discarded. g. Scoops were observed in bulk food items with handles touching food surfaces causing potential contamination. h. Evidence of staff eating food in kitchen food prep area was found. Staff drinks were not of appropriate approved styles to ensure minimal potential contamination. i. During meal service, multiple facility staff observed touching RTE (Ready to Eat) foods with ungloved/bare hands. j. Food items were observed stored on the floor of walk in freezer and dry storage. Staff 2 (Dining Services Manager) validated stock was delivered the day before and should have been put away. Staff 2 acknowledge food should not be stored on the floor. Cleaning lists were reviewed for November and no items were documented as being cleaned for November 1st thru the 5th. The surveyor asked for October’s cleaning lists which could not be located/provided. On 11/05/24 staff 1 (Administrator) was informed of the unsanitary condition of the kitchen and the concern that the facility’s plan of correction was not followed and progress on the areas previously cited had not occurred. Staff 1 was shown areas of concern and they acknowledged areas were not sanitary. Surveyor asked facility for an immediate plan to ensure resident safety. A plan was provided, which included immediate cleaning of the kitchen to began. Surveyor returned to facility on 11/06/24 at 11:15 am to validate improved sanitation. Facility staff provided evidence of kitchen staff training and kitchen areas above were noted with improvement. Staff 1 acknowledged continue implementation of the provided plan would continue to ensure ongoing compliance.

Subsection A; The Dining Services Director, Administrator and Kitchen staff stayed on the night of the inspection and cleaned the kitchen for an inspection the next day. All areas were cleaned and a revised cleaning schedule has been created and implemented. We have also created a cleaning rotation form for the ice machine, that will include changing the filters. This will also let us know if we need a heavier duty filter to meet the needs of the machine. The radio in the kitchen has also been removed. Subsection B: the trays were removed that night and new trays ordered. The new trays were delivered on 11/15 and put into service. Subsection C: the deli reach in cooler now has a thermometer to monitor temperatures. Subsection d,f, g, h,i, j training was held on 11/5 and will be held again on 11/25/24. Administrator and Dining Services Director will be responsible for monitoring to make sure we stay in compliance.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

see C 240