Print Inspection: QITQ

The findings of the kitchen inspection, conducted on 01/11/23, 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 01/11/23, conducted 05/17/23, 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 re-visit to the kitchen inspection of 01/11/23, conducted 07/06/23, 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 in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

a. On 01/11/23 at 10:30 am, the facility kitchen was observed and the following areas were in need of cleaning and repair:

* Entrance of the kitchen door frame had gouges and scrapes;

* The ice maker, stove, a free-standing freezer and grill had spills, drips and grease build-up on the front and sides of the equipment and on the wall behind them;

* Stove knobs had spills and grease buildup;

* Shelves, to store clean stainless-steel bowls, below prep areas had dried food, spills and splatter;

* Walls throughout the kitchen had multiple spills, smears, splatters or brown matters;

* Floors beneath equipment (ice maker, stove, grill), and prep areas had dried food,  debris, grease build-up and dust;

* Floors throughout the kitchen had thick black matter build-up and dust in corners and around edges of floor;

* Ceiling ventilation vents, near F2 (Freezer two), had a layer of dust;

* Ceiling vents near the entry of the kitchen had peeling off paint;

* The exhaust fan grates inside the walk-in refrigerator units had dust build-up;

* The dish machine, electrical box, walls, floor and pipes under the dish machine and sink had an accumulation of white matters and debris;

* Sink in janitor area had grease build-up; and

* Missing bottom panel from the F1 (Freezer one).

b. A bucket of sanitizer was tested with a facility test strip and the solution did not reach the required sanitizing level. During the tour on 01/11/23 at 11:23 am, Staff 2 (Food Service Director) reported he used the wrong test strip, and he did not have the correct test strips to check the sanitizing solution.

c. A box of potatoes were stored on the floor.

The above areas were shared and discussed with Staff 1 (ED) and Staff 2 on 01/11/23. They acknowledged the findings.

C240 a.

*Entrance of Kitchen door frame-

1.Corrective Action Taken: Maintenance scheduled to replace door frame with more durable non-wood frame

2 System Improvement: Weekly leadership meetings will include repair issues.  Monthly building walk-throughs by maintenace looking for gouges and scrapes.

3. Ongoing Action: Monthly kitchen inspections

4. Person/Persons Responsible: Food Service Director (FSD) and Maintenance Director

C240 a.

*Icemaker, stove, free-standing freezer and grill had drips and grease buildup

*stove knobs had spills and grease

*Shelves had dried food and splatter

*walls spills and splatter

1.Corrective Action Taken: Thorough kitchen cleaning done immediately

2 System Improvement:  Weekly, monthly and quarterly cleaning schedule created and implemented

3. Ongoing Action: FSD to ensure cleaning schedule is followed

4. Person/Persons Responsible: FSD

C240 a.

*Floors dried food, grease build up-

1.Corrective Action Taken: Immediate thorough mopping done, Multiple estimates requisitioned to professionally clean the floor.  Cleaning to be completed on or before 3/01/23

2 System Improvement.  Monthly walk through the kitchen to look for issues including the cleanliness of the floor.

3. Ongoing Action: Professional floor cleaning to be scheduled as needed to maintain floors

4. Person/Persons Responsible: FSD, Maintenance Director

C240 a.

*Ceiling vents had layer of dust and peeling paint, walk in refridgerator exhaust fan has dust build up

1.Corrective Action Taken: Maintenance cleaned vents and repaired peeling paint 1/24/23

2 System Improvement: Vent cleaning added to the regualar maintanance schedule on TELS

3. Ongoing Action: Kitchen/Refridgerator Vents will be cleaned quarterly

4. Person/Persons Responsible: Maintenance Director

C240 a.

*Lime buildup on dish machine, electrical box, walls, floor and sink

1.Corrective Action Taken: Lime Chemicals purchased to assist with the cleaning

2 System Improvement:Lime descaling part of monthly cleaning schedule.

3. Ongoing Action:Lime Descaling added to monthly cleaning schedule

4. Person/Persons Responsible:FSD, Maintenance  Director

C240 a.

*Missing bottom Panel from Freezer 1-

1. Corrective Action Taken: Panel replaced immediately 1/11/2023

2: System Correction: Staff inserviced to not remove covers until job is ready to start and replace them when they walk away from the job.

3: Ongoing Action: Monthly building inspections will include looking for equipment missing pieces.

4: Person/Persons Responsible: FSD, Maintenance Director

C240 b.

*Sanitizer did not meet required sanitation levels.

1.Corrective Action Taken: Ordered correct testing strips according to the chemical supplier.

2. System Correction: Checking for correct testing supplies will be added to the monthly kitchen walk through.

3. Ongoing Action: Monthly kitchen walk through will check for correct chemicals and testing supplies.

4: Person/Persons Responsible: FSD

C240 c.

* Box of potatoes stored on the floor

1. Corrective Action Taken: Potatoes moved from the floor.

2.  System Correction: Kitchen staff inserviced on proper food storage requirements.

3. Oncoing Correction:  Monthly inservices with kitchen staff, discussing regulations and policies, and inspecting kitchen together.

4: Person Responsible: FSD

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

The facility's kitchen was toured on 05/17/23 at 10:35 am.

a) Observations revealed an accumulation of grease, splatter, food debris, dirt and/or dust on or underneath the following:

* Flooring under cold prep area;

* Walls behind cold prep area, including electrical outlets;

* Shelving below cold prep area;

* Flooring under freezer one, griddle and stove;

* Walls and pipes behind freezer one, griddle and stove;

* Freezer one;

* Deep fryer;

* Griddle;

* Stove;

* Garbage can near stove;

* Walls at threshold of kitchen and dry storage area;

* Shelving beneath stand-up mixer;

* Walls beneath sink near stand-up mixer;

* Ovens;

* Ice machine, including pipes;

* Door and door frame near ice machine;

* Freezer two;

* Walls surrounding warewasher; and

* Warewasher, including pipes and digital reader.

b) The door frame near the ice machine had gouges and scrapes which rendered it an uncleanable surface.

The kitchen was toured and the areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 2 (Food Service Director) on 05/17/23 at 1:10 pm. They acknowledged the findings.

C240

a. Accumulation of grease, splatter, food debris and or dust

1. COrrrective action taken: deep cleaning work party scheduled on or before June 26th.

Professional floor cleaning rescheduled to get few missed spots.

2. System Improvement: ED will ensure this is complete.

3. Ongoing plan of action: Weekly and monthly cleaning schedules to be turned into ED, who will ensure they are being completed on time,

4. Person/Persons respnsible: ED, FSD, and Maintenance Director

b. back door frame had gouges and scrapes

1. Corrective Action Taken: Mantenance Director to replace door frame.

2. System improvement- Monthly inspections to be scheduled

3. Ongoing Action: Maintenance Director and FSD will inspect kitchen monthly looking for damaged surfaces and report findings to ED.

4. Person/Persons responsible: ED, FSD and Maintenance Director

C 455 not in full compliance after first survey

see c240

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

Refer to C240.

Refer to C240