Print Inspection: PZXY

The findings of the kitchen inspection, conducted 07/10/23 through 07/11/23, 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 first revisit to the kitchen inspection of 07/11/23, conducted 10/17/23 through 10/18/23, 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 07/11/23, conducted 12/05/23, 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. Findings include, but are not limited to:

Observation of the kitchen on 07/10/2023 at 10:00 am revealed the following areas needing cleaning, repair and stored properly:

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:

* Industrial mixer;

* Interior of both ovens, stovetop, grease trap and adjacent wall;

* Two of three blinds in main kitchen;

* Trash can and lid;

* Rolling cart were stained and un-cleanable;

* Interior and exterior of cupboards and drawers beneath prep table;

* Flooring in corners, edges, between and under equipment in main kitchen and dry storage;

* Dead bugs/debris on windowsill in dry storage room;

* Interior of Freezer #s 3 and 4, and Cooler # 2; and

* Storage table below warming pans.

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

* Hole on floor below prep table on side closest to oven;

* Can opener dull with metal shavings observed;

* Multiple cooking pans damaged and stained;

* Oven missing left bottom front cover exposing wiring;

* Ice build-up in Freezer #s 3 and 4;

* One set of blinds broken in main kitchen; and

* Small holes and black stains on wall next to handwashing sink.

c. The following food items observed were not stored appropriately:

* A bin of flour had a scoop in the product;

* Industrial mixer lacked a cover to protect from possible contamination; and

* Multiple food items found in Cooler #1 and Freezer # 3 were not properly covered, labeled, and/or dated.

Staff did not know how to use the test strips available to validate concentration of sanitizer used for surface sanitation buckets.

During an interview and tour with Staff 3 (Culinary Director) on 07/11/23, he acknowledged the identified areas needing to be cleaned, repaired, improper storage of food in freezers and coolers, and use of test strips for proper sanitizing.

On 07/11/23, the Surveyor reviewed  areas in need of cleaning, repair and improper storage of food and utilization of test strips with Staff 1 (Executive Director) and Staff 2 (Assistant ED/Business Office Manager). They acknowledged  the identified areas reviewed.

C240 Resident Services Meals, Food Sanitation Rule

A) Dining Service Director coordinated for the kitchen to be deep cleaned focusing on the areas identified during the survey.  All areas under this citation were cleaned on 7/20/23.  The Dining Service Director will create kitchen cleaning schedules for daily, weekly, and monthly cleaning, and will review each cleaning lists accordingly.  This will ensure the kitchen remains clean and avoids future citations in this area.

*The Maintenance Director will replace the kitchen blinds.

*The Dining Service Director will make sure the kitchen staff is reeducated and make sure the garbage can lids remain in tact.

*The Executice Director &  Dining Service Director will order new rolling carts.

C240 Resident Services Meals, Food Sanitation Rule

B)

*The Maintanence Director will coordinate the repairs to the hole on the floor below the prep table.

* Dining Services Director will order a new can opener.

*Dining Service Director will order new cooking pans to replace the damaged and stained pans.

*Dining Service Director put the missing front cover back on the oven where the wires were exposed.

*Dining Service Director defrosted freezers #3 & #4, and will add defrosting of freezers to the cleaning schedule.

*Maintenance Director will replace kitchen blinds.

*Maintenance Director will repair small holes and Dining Service Director will clean the black walls on the wall next to the handwashing station sink.

C)

*Dining Service Director will ensure scoops are not left in dry storage food bins.

*Kitchen staff will keep the industrial mixer clean, and covered when not in use to limit possibilities of contamination.

*Dining Service Director will audit weekly the cooler's and freezers to ensure all foods are covered, labled, and dated properly.

The Executive Director will coordinate a in-service training with the chemical supplier to properly train staff how to use the test strips to validate concentration of sanitizer used for surface sanitation buckets.

Based on observation and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 10/17/2023 at 09:30 am revealed the following areas needing cleaning and repair:

a. An accumulation of food spills, splatters, loose food and debris, dirt, dust and black matter was visible on or underneath the following:

* Trash can and lid;

* Interior and exterior of cupboards and drawers beneath prep table;

* Flooring under the shelving in the dry storage room; and

* Storage table and wheels below warming pans.

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

* Multiple cooking pans damaged and stained;

* Ice build-up in Freezer three, reported by staff to be related to a broken seal; and

* Three sets of blinds broken in main kitchen.

During an interview and tour with Staff 2 (Assistant ED) and Staff 4 (Cook) on 10/17/23, they acknowledged the identified areas needing to be cleaned and repaired.

On 10/18/23, the Surveyor reviewed  areas in need of cleaning and repair with Staff 1 (Executive Director) and Staff 3 (Culinary Director). They acknowledged  the identified areas reviewed.

C240  - Resident Service Meals, Food Sanitation

a. An accumulation of food spills, splatters, loose food and debris, dirt, dust and black matter was visible on or underneath the following:

* Trash can and lid;- Those areas were cleaned immediately.

* Interior and exterior of cupboards and drawers beneath prep table Those areas were cleaned immediately;

* Flooring under the shelving in the dry storage room; and

* Storage table and wheels below warming pans. Those areas were cleaned immediately.

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

* Multiple cooking pans damaged and stained;-  New pans will be ordered by the Executive Chef by date the community alleges compliance.

*

* Ice build-up in Freezer three, reported by staff to be related to a broken seal- To be completed soon; and

* Three sets of blinds broken in main kitchen.

The kitchen blinds will be replaced by the date the community alleges compliance.

A) Executive Director will implement a new daily, weekly, monthly cleaning task sheet.  The kitchen staff will be responible to mark off each item completed daily, weekly, and monthly.  The cleaning task sheet will be reviewed by the Executive Chef, and turned into the Executive Director at the end of each week.  Executive Director will conduct random audits on the kitchen and dry storage area.  The Executive Chef will conduct audits of the kitchen weekly, and monthly.

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

Refer to C 240.

C455 - Inspections and Investigations

Executive Director and Executive Chef will work together weekly to maintaing kitchen compliance and cleanliness.

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.

Z142 Administration Compliance

The Executive Director will work with the Dining Service Director and Maintenance Director to ensure all cleaning and repairs are completed and maintained.  Executive Director will also work with the departments to replace any equipment identified within this survery. The Executive Director will audit all cleaning schedules and audits of the kitchen to ensure iuditas MC remains in compliance.

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.

Z142-Administration Compliance

Refer to C240 Plan of Correction