Print Inspection: KIT001690

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 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 facility kitchen on 12/10/24 from 10:00 am thru 2:00 pm revealed the following deficient practices. 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: * Ceiling/Wall adjacent to grill/stove; * Exterior sides of oven; * Range top; * Exterior sides of fryer; * Removable hood vents; * Top of knife holder; * Floors in-between/behind equipment; * Open stainless steel shelving; * Stainless steel spice shelves; * Reach in coolers and freezers; * Movable Utility/baking rack; * Counter top mixer; * Plastic trays storing clean dishes; * Exterior of reach in cooler; * Black reach in cooler door handles; * Interior of drawers in dining room beverage station; * Plastic drawer station holding bread; * Flooring in walk in freezer under/between metal racks; b. The following areas needed repair: * Holes around pipes in ceiling of condiment storage closet; * Holes around electrical conduit in kitchen area; * Industrial dish machine not consistently dispensing chemical sanitizer effectively/correctly. c. Multiple food items/packages/containers observed stored in reach in and walk in cooler without dates when opened/prepared. Multiple potentially hazardous food items found past seven days from preparation date. One item found multiple days past manufactures use by date. d. Multiple food items observed stored on the floor in the walk-in cooler, walk-in freezer and dry storage. The day of survey was not stock delivery day and Staff 2 (Dining Service Manager) acknowledged it should have been put away, but staff hand not had opportunity to get to it related to staffing concerns. e. Dish machine was tested for adequate chlorine concentration levels. Machine was run multiple times yielding no parts per million (PPM) of sanitizer. Facility had no consistent process in place to monitor sanitation levels of dish machine to ensure dishes were sanitized per rule. The facility had test strips for chlorine but were noted to be expired in 2017. The facility had a log to monitor dishwasher wash temperatures but not sanitizer ppm and the last log entry was in October 2024. f. A red surface sanitation bucket was tested for sanitizer levels. No active PPM registered on the available sanitizer strips. Staff 2 validated that facility was not changing buckets every 2 hours as required to ensure effective sanitation of surfaces and was instead changing after each meal. g. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. This staff was observed to handle utensils, touch handles, and other potentially contaminated items or surfaces with their gloves and then touch ready to eat items. This staff was observed to not change gloves or wash hands when appropriate to ensure cross contamination did not occur. Staff was also observed to handle RTE lettuce with bare hands which is prohibited per rule. h. Food contact surfaces of utensils were observed stored exposed to potential contamination. Dining room was observed to have pre-set utensils on the tables with the food contact surfaces uncovered exposing them to potential contamination. i. Facility had a census capacity greater than 17 residents and did not have a 3 compartment sink as required. Staff 2 toured the kitchen with surveyor and was informed of concerns found and they acknowledged the issues. At approximately 1:30pm, staff 1 (HR/Facility representative) and surveyor reviewed identified areas in and they acknowledged the areas.

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: * Ceiling/Wall adjacent to grill/stove; * Exterior sides of oven; * Range top; * Exterior sides of fryer; * Removable hood vents; * Top of knife holder; * Floors in-between/behind equipment; * Open stainless steel shelving; * Stainless steel spice shelves; * Reach in coolers and freezers; * Movable Utility/baking rack; * Counter top mixer; * Plastic trays storing clean dishes; * Exterior of reach in cooler; * Black reach in cooler door handles; * Interior of drawers in dining room beverage station;* Plastic drawer station holding bread; and * Flooring in walk in freezer under/between metal racks. 1. All areas will be cleaned by 02/01/2025. 2. Daily and weekly cleaning checklists developed with Dining Service Manager weekly audits. 3. Dining Service Manager will audit cleaning checklists and audit areas on checklist and report to Executive Director weekly. 4. Executive Director. b. The following areas needed repair: * Holes around pipes in ceiling of condiment storage closet; * Holes around electrical conduit in kitchen area; and * Industrial dish machine not consistently dispensing chemical sanitizer effectively/correctly. 1. a. Holes around pipes and electricl conduit were repaired/filled on 12/31/2024. b. Industrial dish machine was serviced on 12/11/2024 where a leaking solenoid valve was replaced and intake screen was cleaned. 2. a. Maintenance team will survey area monthly for open holes in sheet rock on walls, flooring and ceiling. b. Working with EcoLab on replacement of dish machine and any dispensing error will be reported to the Dining Service Manager or Executive Director immediately. 3. a. Monthly review by Maintenance team. b. Dish machine will be checked twice daily to make sure it is operating correctly and errors will be immediately along with regular maintenance until machine is replaced. 4. Executive Director. c. Multiple food items/packages/containers observed stored in reach in and walk in cooler without dates when opened/prepared. Multiple potentially hazardous food items found past seven days from preparation date. One item found multiple days past manufactures use by date. 1. All items were removed/discarded by 12/10/2024. 2. Dates including opened/prepared/expiration along with proper storage of items will be reviewed daily and included on daily cleaning checklist. 3. Dining Service Manager will audit cleaning checklist and audit areas on checklist and report to Executive Director weekly. 4. Executive Director d. Multiple food items observed stored on the floor in the walk-in cooler, walk-in freezer and dry storage. The day of survey was not stock delivery day and Staff 2 (Dining Service Manager) acknowledged it should have been put away. 1. All items were picked up and stored properly by 12/10/2024. 2. Staff will verify stock and food items are off the floor and stored properly daily on daily cleaning checklist. 3. Dining Service Manager will audit cleaning checklist and audit areas on checklist and report to Executive Director weekly. 4. Executive Director e. Dish machine was tested for adequate chlorine concentration levels. Machine was run multiple times yielding no parts per million (PPM) of sanitizer. Facility had no consistent process in place to monitor sanitation levels of dish machine to ensure dishes were sanitized per rule. The facility had test strips for chlorine but were noted to be expired in 2017. The facility had a log to monitor dishwasher wash temperatures but not sanitizer ppm and the last log entry was in October 2024. 1. Policy and procedure written, sanitation levels will be checked at least two times per shift. Chlorine strips were purchased on 12/10/2024 and service was completed 12/11/2024. 2. Dish machine station will be completed by 02/01/2025 equipped with chlorine strips, temperature and chlorine results log along with error tracking and steps to be taken when an error occurs including a call to EcoLab and Dining Service Manager and/or Executive Director. 3. Chlorine checks will be completed twice a shift and monitored daily and recorded on the log. Dining Service Manager will review daily. 4. Executive Director. f. A red surface sanitation bucket was tested for sanitizer levels. No active PPM registered on the available sanitizer strips. Staff 2 validated that facility was not changing buckets every 2 hours as required to ensure effective sanitation of surfaces and was instead changing after each meal. 1. Policy and procedure written, sanitation buckets will be changed every 2 hours or when visibly soiled. Sanitation levels will be checked at least twice per shift and documented after each test. 2. Cleaning/sanitizing station will be completed by 02/01/2025 equiped with sanitizer testing strips, result log and laminated sign with time of last sanitizer change. 3. Sanitizing buckets will be changed every 2 hours or when visibly soiled and sanitizing levels will be checked at least twice a shift and monitored daily and recorded on the log. Dining Services Manager will review daily. 4. Executive Director g. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. This staff was observed to handle utensils, touch handles, and other potentially contaminated items or surfaces with their gloves and then touch ready to eat items. This staff was observed to not change gloves or wash hands when appropriate to ensure cross contamination did not occur. Staff was also observed to handle ready to eat lettuce with bare hands which is prohibited per rule. 1. Kitchen staff were re-trained on proper glove wear and hand washing on 12/17/2024. 2. PPE station will be completed by 02/01/2025 equipped with gloves, aprons, and other necessary PPE. Quick glove areas reassessed to harbor ease. 3. Dining Service Manager and leadership team will monitor glove use daily by observing and monitoring during food service. 4. Executive Director h. Food contact surfaces of utensils were observed stored exposed to potential contamination. Dining room was observed to have pre-set utensils on the tables with the food contact surfaces uncovered exposing them to potential contamination. 1. All items have been properly stored. 2. Daily checklist developed. Staff will verify the proper storage of utensils both on dining tables and on dish rack daily. 3. Dining Service Manager will verify proper storage daily and weekly with audit. 4. Executive Director. i. Facility had a census capacity greater than 17 residents and did not have a 3 compartment sink as required. 1. New 3 compartment sink ordered awaiting shipment date. 2. 3 compartement sink will be installed. Currently using sink and tub to equal 3 compartments. 3. Dining Service Manager will review weekly until new 3 compartment sink is in place. 4. Executive Director. Concerns were identified in the following areas and the facility was provided with technical assistance: C 295: Per Oregon Administrative Rule 333-019- 1011(1): Facilities must 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 possible food borne outbreaks and gastrointestinal outbreaks which includes having a food worker sick policy for exclusion as outlined in Oregon Food Sanitation Rules. 1. New policy and procedure written and implemented. 2. Quickguide posted throughout facility to help guide staff when they are sick. Infection prevention and food borne illness training will be completed every three months. 3. Will review any outbreaks and further training during quaility assurance quarterly meeting. 4. Executive Director.

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: