Print Inspection: N68U

The findings of the kitchen inspection, conducted 7/24/23, 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 07/24/23, conducted 10/12/23, 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 07/24/23, conducted 12/27/23, 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, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:

Observation of the 5 cottage kitchens as well as the main kitchen meal preparation and food storage area on 7/24/23 at 11:45 am through 3:00 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 cabinets and drawers for all cottages;

* Interior of reach freezers in all cottages;

* Fan blades and external cages with heavy dust accumulation in all cottages;

* Bottom oven drawer in Clover;

* Cabinets under sinks in all cottages with splatter and black debris;

* Oven door in Blackberry with large accumulation of food debris; and

* Walk in cooler with large dust accumulation on fan cages and ceiling.

b. The following areas were found in need of repair:

* Cabinets below sinks in all cottages with water damage;

* Holes in walls of lower cabinets under sinks;

* Cabinets and drawers in all cottages with damage, heavily scored, chipped paint or exposed porous wood on the interiors;

* Flooring in Dandelion pealing up, water damage to cabinets and flooring by sink;

* Counter top in Dandelion near sink with damage;

* Oven door in Blackberry with damage (crack) on top of door

* Main kitchen floor found with multiple deep ridges/cuts/holes or splitting seams along with areas of dirt/debris build up and staining.

* Shelving above ware washing area in main kitchen splitting and pealing from moisture penetration.

* Walk in cooler with large cracks throughout the concrete floor making it not a smooth and cleanable surface.

c. Multiple cutting boards in each cottage were found damaged with heavy scoring and/or staining.

d. Food items not clearly separated when stored as required.

e. Evidence noted with dishes being put away wet with stagnate water found. Facility noted to be storing clean dishes on towels with no defined practice on cleaning or rotating towel to ensure they were clean.

f. Multiple divider plates and plastic mugs found with protective glaze missing and heavily scored. Cooking pans with visible paint chipping and scratches.

g. Multiple food and/or beverage items stored on the floor in the cottage dry storage pantries.

h. Scoops were found stored in bulk food item bins in the main kitchen area.

i. Dish machine in Blackberry was found not sanitizing at correct sanitation level. Facility did not have a current practice to ensure ware washers were sanitizing at correct level before use. Multiple machines in varying cottages had to be primed before correct sanitation levels were reached. Not all cottage staff were aware of needing to prime the machine. Staff 2 was not able to identify when the machine in Blackberry was last correctly sanitizing dishes. Machine was put out of order until maintenance could attend to the issue. When the machine was pulled out for inspection, a large amount of dirt/dust and food debris was located under the machine. Staff 2 acknowledged the area needing cleaning.  

Surveyor reviewed above areas with Staff 2 (Dietary Director) and s/he acknowledged the identified areas.  At approximately 2:45 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Business Office Manager). S/he acknowledged the areas.  

1. No residents were identified as being affected by these findings: Physical plant and operational findings will be corrected by:

a. clean the interior of the kitchen cabinets and drawers in all cottages.

b. clean the freezer section of the refrigerators in all cottages.

c. dust the fan blades and cages of all fans in the cottages

d. Clean the broiler drawer in the oven of Clover Cottage

e. Clean or repair/replace soiled cabinets under the sinks in all cottages, making sure any debris or splatter is eliminated.

f. clean the oven door in Blackberry Cottage that is splattered with cooked food.

g. clean the walk in cooler in the kitchen where dust has accoumulated on the fan cage and ceiling

h. repair/replace the water damaged below sink cabinets.

i. seal/cover the plumbing access holes in the lower cabinets below the sink

j. repair/replace cabinets and drawers that are heavily damaged or have exposed porous wood on the interiors, to allow adequate cleaning.

k. flooring repair from water damage in Dandilion will be completed; and damage to cabinets repaired/replaced

l. the damaged countertop in Dandilion near the sink will be repaired or replaced to allow for adequate cleaning.

m. the oven door in Blackberry will be replaced.

n. bids for a replacement floor in the kitchen will be obtained and the replacement planned.  For the immediate cleaning purposes a deep cleaning will be done and temporary sealing accomplished to allow floor to be kept clean.

o. Facility Maintenance team will review replacement/repair of shelving above the washing area in the main kitchen that is peeling and splitting.

p. repair the walk in cooler flooring so the surface is cleanable; seeking options available for this issue.

q. heavily scored or heavily stained cutting boards in the kitchen and cottages will be replaced.

r. Food items, that were found stored together,  were separated upon identification as is required.

s. dishes that were air drying on towels were re cleaned and dried per policy and inservicing will be done on infection control practises in regards to storing wet and drying practises.

t. dishes with protective glaze damage will be replaced; cooking pans that are damaged and can't be cleaned will be replaced.

u. food items stored on floor will be stored up off the floor; these items were taken off floor; inservicing will include why items should not be stored on floor.

v. scoops were removed from inside storage bins and replaced in appropriate holders - topic will be inserviced

w. Staff will be inserviced on the proper prep of the dishwashers and the importance of following all steps to insure proper sanitation; they will also be reminded of cleaning schedules under equipment.

x. finally staff will be inserviced on how the ice in the refrigerators and its container is kept clean to prevent the spread of germs.

2. To prevent these  findings in the future, the facility will:

A) revise cleaning schedules to clearly outline when and how often each task is done.  Care staff will be inserviced to the expectations and the updated cleaning plan.

B) Audits will be done of these identified areas, per cottage and the kitchen. An audit plan will be developed and implemented.

C) Inservicing of all care and dietary staff will be done on identified issues and review expectations of following cleaning plans. Inservice will also include reminders of using TELS to notify maintenance when repairs are needed in the kitchen areas.

3. To insure the inservicing and training was effective  audits will be done by assigned staff, weekly for one month Aug/Sept; if issues remain in compliance audits will revert to monthly for an additional 3 months Oct/Nov/Dec; if no further systemic failure is idenitifed by the QA Committee  audits will revert to quarterly for the remaining year Jan-July. Care team members will participate in the audits and be aware of the audit results.

4. Executive Director, Dining Manager and Maintenance,  are responsible for the efficacy and continuation of this plan of correction.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, 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 five cottage kitchens as well as the main kitchen meal preparation and food storage area on 10/12/23 at 2:30 pm through 3:30 pm revealed the following deficiencies:

a. The following areas were found in need of repair:

* Cabinets below sinks in Clover Cottage with severe water damage and active mold growth and wood rot;

* Holes in walls of lower cabinets under sinks in Clover and Acorn Cottages; and

* Cabinets and drawers in many cottages with damage, heavily scored, chipped paint or exposed porous wood on the interiors.

b. Evidence noted with dishes being put away wet with stagnate water found.

The surveyor reviewed above areas with Staff 2 (Dietary Director) on 10/12/23 and s/he acknowledged the identified areas.  At 3:00 pm Staff 3 (Maintenance Director) was made aware of the continued poor repair of cabinets in cottages and the mold growth in Clover. S/he acknowledged they were aware of the issue and that materials had been purchased but had not been able to complete the needed repairs. Surveyor emphasized the health and safety risk of the large area of mold growth and that food preparation should not occur in that cottage kitchen until replaced. Both Staff 2 and 3 voiced understanding. At approximately 3:15 pm the surveyor reviewed the areas in need repair and practices with Staff 1 (Business Office Manager). S/he acknowledged the areas.  

POC for C240, C455, Z142

No residents were identified as being affected by these findings. There is a potential for all residents to be affected by these findings.

Work to repair cabinets and drawers continues in all Cottages until completed in it entirity .

Identified wet dish(s) was removed from the cupboard, re-washed and drained dry before re storing in the cupboard.

The facility will correct the identified findings by:

a. finishing the repairs and/or replacement of cabinets and drawers that are heavily damaged or have exposed porous wood on the interiors, to allow adequate cleaning; not only in Acorn and Clover but the other three cottages as well. This includes painting the damaged interiors with a paint that will seal and can be cleaned by staff.  Work was completed in Clover under the sink with replacement of all affected drywall and closure of hole and repair of this newly identified leak.  Brown substance was also abated from the water leak area.  

Acorn Cottage  had the hole under the sink closed and the area was painted (access hole for pipe access).

Work continues in repairing the drawers and cabinets in the other three Cottages identified by ongoing POC audits.  

If this 5-cottage effort cannot be completed by 11/21/23 the facility will contact the Department and request an extension.

b. Auditing for any additional wet dishes in the cupboard; no additional dishes were found.

To prevent further findings, all staff will be re-inserviced on 11/14/23  about putting away wet dishes in the cupboards and about the importance of letting them fully dry before storing.  This inservice will also outline the expectation of reporting leaks or needed repairs to Maintenance promptly to avoid further damage or growth of organic materials.

To verify this Plan of Correction remains effective, the Facility will continue its monthly kitchen audits to verify no new issues arise from unexpected leaks or damage caused by use.  Audits will also check for repair work being completed and no new damage found.  Additionally the audits will check for dishes being put away wet.

Audit findings will be presented to QA Committee in Nov, Dec and January.  If no further issues are identified, audits will return to a quarterly basis until October 2024.  Any further issues identified will result in re-training, coaching and continued auditing.

Admininstrator/Executive Director, Dietary Manager and Maintenance Director are responsible for the effectiveness of this Plan of Correction

Based on observation and interview, 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 C240

Based on observation, record review, and interview, 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 C 240.

1. No residents were identified as being affected by these findings: Physical plant and operational findings will be corrected by:

a. clean the interior of the kitchen cabinets and drawers in all cottages.

b. clean the freezer section of the refrigerators in all cottages.

c. dust the fan blades and cages of all fans in the cottages

d. Clean the broiler drawer in the oven of Clover Cottage

e. Clean or repair/replace soiled cabinets under the sinks in all cottages, making sure any debris or splatter is eliminated.

f. clean the oven door in Blackberry Cottage that is splattered with cooked food.

g. clean the walk in cooler in the kitchen where dust has accoumulated on the fan cage and ceiling

h. repair/replace the water damaged below sink cabinets.

i. seal/cover the plumbing access holes in the lower cabinets below the sink

j. repair/replace cabinets and drawers that are heavily damaged or have exposed porous wood on the interiors, to allow adequate cleaning.

k. flooring repair from water damage in Dandilion will be completed; and damage to cabinets repaired/replaced

l. the damaged countertop in Dandilion near the sink will be repaired or replaced to allow for adequate cleaning.

m. the oven door in Blackberry will be replaced.

n. bids for a replacement floor in the kitchen will be obtained and the replacement planned.  For the immediate cleaning purposes a deep cleaning will be done and temporary sealing accomplished to allow floor to be kept clean.

o. Facility Maintenance team will review replacement/repair of shelving above the washing area in the main kitchen that is peeling and splitting.

p. repair the walk in cooler flooring so the surface is cleanable; seeking options available for this issue.

q. heavily scored or heavily stained cutting boards in the kitchen and cottages will be replaced.

r. Food items, that were found stored together,  were separated upon identification as is required.

s. dishes that were air drying on towels were re cleaned and dried per policy and inservicing will be done on infection control practises in regards to storing wet and drying practises.

t. dishes with protective glaze damage will be replaced; cooking pans that are damaged and can't be cleaned will be replaced.

u. food items stored on floor will be stored up off the floor; these items were taken off floor; inservicing will include why items should not be stored on floor.

v. scoops were removed from inside storage bins and replaced in appropriate holders - topic will be inserviced

w. Staff will be inserviced on the proper prep of the dishwashers and the importance of following all steps to insure proper sanitation; they will also be reminded of cleaning schedules under equipment.

x. finally staff will be inserviced on how the ice in the refrigerators and its container is kept clean to prevent the spread of germs.

2. To prevent these  findings in the future, the facility will:

A) revise cleaning schedules to clearly outline when and how often each task is done.  Care staff will be inserviced to the expectations and the updated cleaning plan.

B) Audits will be done of these identified areas, per cottage and the kitchen. An audit plan will be developed and implemented.

C) Inservicing of all care and dietary staff will be done on identified issues and review expectations of following cleaning plans. Inservice will also include reminders of using TELS to notify maintenance when repairs are needed in the kitchen areas.

3. To insure the inservicing and training was effective  audits will be done by assigned staff, weekly for one month Aug/Sept; if issues remain in compliance audits will revert to monthly for an additional 3 months Oct/Nov/Dec; if no further systemic failure is idenitifed by the QA Committee  audits will revert to quarterly for the remaining year Jan-July. Care team members will participate in the audits and be aware of the audit results.

4. Executive Director, Dining Manager and Maintenance,  are responsible for the efficacy and continuation of this plan of correction.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.

see C240