Print Inspection: NM9Y

The findings of the kitchen inspection, conducted 08/11/22, 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 Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit of the kitchen inspection, conducted on 11/22/22, 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, OARs 411 Division 57 for Memory Care Communities, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 11/22/22, conducted 2/3/23, 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 third revisit to the kitchen inspection of 08/11/22, conducted 04/27/23, 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 and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was stored properly and surfaces were sanitized in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the MCC kitchen, food storage areas, food preparation, and food service on 08/11/22 revealed:

* The following areas needed cleaning or repair:

  - The interior of the microwave oven had food debris;

  - A box fan had lint on the grate;

  - There was black mold on the wall above the warewashing dish area;

  - A piece of corner trim to the right of the warewashing area had come loose from the wall; and

  - Dust pans had accumulated dried debris.

* Opened and leftover food items that were stored in the refrigerator were not consistently dated.

* The kitchen lacked test strips for determining if the sanitizing solution used to wipe down surfaces was prepared properly.

The findings were reviewed with Staff 2 (Dining Services Coordinator) on 08/11/22 at 1:30 pm. He stated his previous supervisor had not trained him on how to date food, and he had not been provided with chemical test strips.

The findings were reviewed with Staff 1 (Executive Director) on 08/11/22 at 2:45 pm. He acknowledged the areas needing cleaning, and the need for additional training for kitchen staff.

1)Community will institute a weekly cleaning schedule that all kitchen staff will be trained on.   

2) Kitchen staff will need to sign off that they have completed their portion of cleaning.

3) Dining Service Coordinator will monitor the cleaning schedule and hold kitchen staff accountable and retrain, if needed

4) Microwave oven will be cleaned daily as needed

5) Fans and covers will be cleaned in walk in refrigerator

6)Wall by dishwashing machine will be inspected and if mold is detected, it will be remediated and replaced

7) Corner trim near warewashing area will be repaired

8) All dustpans to be cleaned daily

9) Training will be held with all kitchen staff on proper food storage and label procedures and documented

10) Test Strips will be ordered for santizing solution and checked throughout the day as needed to verify sanitation standards

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, food was stored properly and surfaces were sanitized in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observations of the MCC kitchen on 11/22/22 revealed:

The following areas needed cleaning or repair:

*The interior of the microwave, refrigerators, freezers, and oven had food debris;

*The top of the ware-washing machine had food and debris build-up on it;

*There was black matter on the wall above and behind the ware-washing dish area;

*A piece of two corner trim pieces to the right of the ware-washing area had come loose from the wall; and

*Dust pans had numerous ants, debris, and food matter on it.

Multiple opened and leftover food items that were stored in the refrigerators were not consistently labeled and/or dated.

On 11/22/22, the findings of the MCC kitchen inspection were discussed with Staff 4 (Executive Director), Staff 5 (Assistant Executive Director), and Staff 6 (Cook). They Acknowledged the findings.

Facility will provide written training to all dining staff with the cleaning schedule, touching on all parts noted in re-survey.

Dining Services Manager, Memory Care Administrator will audit the memory care kitchen, food storage, and dining areas and the signed cleaning log daily.

Daily

Dining Services Manager  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observations of the ALF main kitchen and food storage areas on 2/3/23 identified the following:

* Splatters, spills, drips, dust and/or debris were observed on:

  - Floors behind, underneath and beside equipment and open shelving;

  - Vents and fire sprinklers;

  - Grill top, back splash and behind grill;

  - Stove top, exterior and interior of regular and convection ovens;

  - Ceiling and wall of walk in cooler;

  - Cooling fan covers in freezer;

  - Walls behind juice machine and by entrance/exit door to dining room;

  - Open shelving above steam table and where spices were stored;

  - The can opener blade and casing;

  - Interior and exterior of microwave and toaster and

  - Inside of plate warmer cabinet.

* There were 2 holes observed under a prep area table. They were acknowledged by Staff 1 (Executive Director). There was significant ice build up on the door to the walk in freezer, in the walk in freezer as well and noted dripping and rusting areas in the walk in cooler. A large section of exposed pressed wood by a window seal was observed from the smooth cleanable surface pealing off.

* Multiple items in walk in cooler found not labeled or dated.

* Multiple items in walk in cooler found uncovered.

* Multiple employees found not washing hands when entering kitchen area as well as not washing hands when changing from dirty tasks to clean tasks.

* Kitchen staff observed to heat up a can of tomato soup and did not check the temperature before serving to resident.

* Lunch item temperatures were not checked prior to start of service. They were removed from convection oven, placed in steam table, covers removed and staff served residents. Temperature logs were reviewed and multiple days of food temperatures were not recorded. Staff 1 (Executive director) and Staff 2 (Dining Services Coordinator) acknowledged temperatures were not recorded.

* Cleaning task list and schedule was reviewed with Staff 2 and she validated multiple days were missing documentation. She did state that staff frequently forget to write it down.

* Plan of correction presented by facility included weekly audits. Staff 1 was asked for documentation that audits were conducted and none was provided.

The areas needing cleaning and the failure to follow safe food handling and preparation practices was reviewed on 2/3/23 with Staff 1 (Executive Director) and Staff 3 (Associate Executive Director). They acknowledged the findings.

Facility will implement  Brookdale Menu Manager menus approved by Crandall Corporations Dieticians  as well as real time trainings with kitchen staff. Will follow the Daily Diet Modification sheets. Will provide mid morning, mid afternoon, and evening snacks daily.

Utilization of proper portioning serving tools to monitor correct servings of food served

Menus will be planned at least 2 weeks in advance and provide residents their copies of the menus.

Any substitution will be recorded on the Menu Substitution Log

Dining Services Manager, Interim Director, Memory Care Administrator

will monitor compliance by doing daily documented audits.

Educating our Dining associates by inservices and actual real time trainings in Food safety and sanitation.

ALF Main Kitchen

Cleaning Schedule is in place.

- Floors have been cleaned and is maintained by following cleaning schedules daily. Sweep and mop every after meal or as needed.

- Maintenance have scheduled clean up and repairs of vents and fire sprinklers.

- Scrubbed, clean and maintaining oven, grill and stovetop area by schedule, done daily by designated associate.

- Finished cleaning cooler ceiling and walls. Scheduled cleaning is in place, or clean as needed.

- Maintenance contacted repair company to fixed freezer/cooler.

- Walls behind juice machine cleaned and being maintained daily.

- Open shelving for spices is now organized and being maintained daily

- Ordered new can opener to be installed

- Microwave in brand new and daily clean up is part of assigned cleaning schedule

- Scrubbed and cleaned plate warmer. Daily clean up is part of assigned cleaning schedule

- 2 holes have been patched and will be painted

- Replaced pressed wood with real wood and will be painted

- Dining Leader continues to monitor practice of proper dating and food labeling - inserviced culinary associates.

- Spot audits are being done by different department heads to ensure compliance in food safety and sanitation.

- Proper heating of RTE food addressed. Instructed servers to request assistance from the cooks to properly take temperatures of any food before serving

- Inservices going on for proper food holding temperatures of cold and hot foods. Taking and documenting internal temperatures of food to know if temperatures are correct before placing in steam table. Taking temperatures of food before start of meal service and every 30 mintes thereafter. Hot food should be kept hot, cold foods cold.

- Temperature Logs are in place. Dining Leader monitors and inforce daily

Continually training and coaching associates to be compliance in Food Safety and Sanitation.

Based on observation and interview, it was determined the facility failed to comply with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility, except when the employee is alone in a closed room.

Observations of staff during the kitchen inspection revealed multiple instances of staff failing to wear their mask properly by covering both their mouth and nose.

On 11/22/22, the need to ensure all staff were properly wearing a face mask was discussed with Staff 4 (Executive Director), Staff 5 (Assistant Executive Director), and Staff 6 (Cook). They acknowledged the findings.

Facility will provide written counselling to the staff observed not wearing a mask properly, and written training to all staff regarding mask expectations.

Written training will be provided to all memory care staff, and enforced daily

The memory care community will be walked daily, and staff on duty observed to ensure masks are being worn properly.

Associate Executive Director (Memory Care Administrator)

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

Refer to C 240.

Please refer to C240  

Based on interview, observation and review of documentation, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C240

Refer to c240

Based on observation, interview and record review, 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.

see C 240

Based on observation, interview and record review, 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 and C 295.

Please refer to C295

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 C240.   

Refer to c240