Print Inspection: RBQ7

The findings of the kitchen inspection, conducted 01/25/24, 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 01/25/24, kitchen inspection, conducted 03/15/24, 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 of 01/25/24, conducted 05/17/24, 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 proper food storage, proper preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The facility kitchen was toured on 01/25/24, observations of the facility kitchen, including food storage areas outside of the kitchen, food preparation, food service, and interviews with staff were conducted during the kitchen inspection.

a. Observations of food storage identified the following:

* Multiple dry food containers had scoops stored inside the containers (sugar and flour) and the exterior of the food bins were visibly soiled;

* Cold food items in multiple refrigerators were not properly covered, labeled and dated (solo cups, cheese slices, unidentified yellow substance, boxed potato salad);

* Multiple perishable food items in the walk-in refrigerator were stored past their expiration dates and were not discarded;

* Food items in the mini freezer (on top of the ice machine) were open and uncovered, which exposed the food items to potential frost burn and/or environmental cross contamination;

* Two dry food storage racks located in the garage were in close proximity to trash and recycling receptacles; and

* The dry food storage area located in the garage had a door that could be closed to deter the entry of pests however, the door was open throughout the inspection.

b. Observations of food preparation, food service and employee infection control practices identified the following:

* Alcohol wipes were not used to sanitize the probe thermometer and food temperatures were not taken prior to the beginning of food service;

* Dedicated utensils for serving each food item were not available;

* Proper plating technique to avoid cross contamination wasn't used;

* Dedicated cutting boards when chopping or prepping multiple protein-based food items were not used;

* Food contact surfaces were not sanitized after each use;

* Staff failed to ensure gloves were single use, hand hygiene was preformed between tasks and clean gloves were donned;

* Hand hygiene wasn't preformed upon entering the kitchen and between dirty and clean tasks; and

* Multiple kitchen staff wore visibly soiled aprons.

c. Sanitation of equipment identified the following areas had a build up of dust, debris, grease and/or food particles:

* Visibly soiled knives were stored on the magnetic holder that was hung on the wall to the right of the steam table;

* The steam table and shelf below the steam table;

* Interior and exterior of fryer;

* Interior and exterior ovens;

* Grease trap on the grill was full;

* Wall behind the stove, oven and grill top;

* Rack to the right of the grill and the liquid ingredient bottles on the rack;

* Mini freezer (sitting on top of the ice machine) had a buildup of frost and ice inside the freezer;

* Interior and exterior salad cooler;

* Wall to the right of the salad cooler;

* Interior and exterior of the convection oven and cooling cart below the oven;

* Table mounted can opener housing and blade;

* Meat slicer was stored uncovered on the counter next to the prep sink;

* Two stainless steel carts used in the dishwasher area were visibly soiled with clean dishes on it;

* Hobart mixer and stand were visibly dirty when not in use, lacked a cover and accessories were observed on the floor underneath the stand;

* Floor drains underneath the steam table, sink near the ice machine, warewashing area and food prep sink;

* All garbage cans throughout the kitchen lacked covers when not in use;

* Walls above and below the warewashing area had a buildup on black and brown matter;

* The low temperature warewash machine lacked adequate chlorine sanitation levels; and

* The facility lacked test strips to ensure adequate sanitation levels for the quaternary based sanitizer used for sanitizing food contact surfaces.

Staff 2 (Nutritional Services Manager) called the vendor for the warewashing machine, who corrected the sanitation levels during the kitchen inspection and provided the correct test strips.

d. The following areas within the kitchen required repair:

* The food storage racks in the walk-in refrigerator were rusted;

* The walk-in refrigerator had inconsistent ventilation, exposed insulation, rust on or near the condenser, blower cages, floor and walls;

* Holes in the wall to the right of the convection oven;

* Ceiling vents and ceiling tiles throughout the kitchen were discolored and had built up of dust around the ceiling fixtures including the fire sprinkler system;

* The floor of the garage area where dry food storage and a freezer was located was porous (made of cement like material) and lacked a seal or coved baseboard;

* The loft area in the garage which stored single use food items, paper products, bulk dry goods, dishware, and other kitchen equipment had a floor that was porous and made of exposed plywood which rendered the surface uncleanable; and

* There was no dedicated handwashing sink (shared with the eye wash station).

The kitchen was toured, and the above areas were discussed with Staff 1 (Executive Director), Staff 2 and Staff 3 (Facilities Manager) on 01/25/24. They acknowledged the findings.

C 240 SS=F OAR 41 l-054-0030 (l)(a) Resident Services Meals, Food Sanitation Rule

1. Immediately following the survey, a thorough walkthrough of the kitchen area was conducted by the Nutrition Services Manager and Administrator to directly address each violation listed. This involved physically inspecting the kitchen space, equipment, and practices to ensure compliance with safety regulations and standards. Additional staff training and education directly related to food safety, sanitation, and compliance was assigned and immediate interventions were enacted.

2. A root cause analysis of the systems and processes was completed by the Nutritional Services Manager, Administrator, Assistant Administrator, all dietary staff, and the Environmental Services Manager. A thorough review of the initial training, onboarding, orientation, continued education and daily, weekly, monthly, semi-annual compliance was completed.

A Nutritional Services meeting was held to gather feedback and provide immediate education and training.

The Nutrition Services team has been provided with mandatory training videos from OregonCarePartners.

1.Keeping Food Safe and Nourishing for Older Adults.

2.and the CBC Annual Kitchen Inspection.

3. Each individual Nutritional Services staff member will be responsible for daily food safety and compliance accountability, as assigned by their job role. Additional weekly compliance evaluations and audits have also been implemented.

4. The Nutrition Services Manager and Assistant Administrator will monitor ongoing cleanliness and compliance on a weekly basis. Dietary staff will take responsibility on a daily basis.

C 240 SS=F OAR 41 l-054-0030 (l)(a) Resident Services Meals, Food Sanitation Rule

1. Immediately following the survey, a thorough walkthrough of the kitchen area was conducted by the Nutrition Services Manager and Administrator to directly address each violation listed. This involved physically inspecting the kitchen space, equipment, and practices to ensure compliance with safety regulations and standards. Additional staff training and education directly related to food safety, sanitation, and compliance was assigned and immediate interventions were enacted.

2. A root cause analysis of the systems and processes was completed by the Nutritional Services Manager, Administrator, Assistant Administrator, the Environmental Services Manager and all Nutritional Services teammates. A thorough review of the initial training, onboarding, orientation, continued education and daily, weekly, monthly, semi-annual compliance was completed.

A Nutritional Services meeting was held to gather feedback and provide immediate education and training.

The Nutrition Services team has been provided with mandatory training videos from OregonCarePartners.

1.Keeping Food Safe and Nourishing for Older Adults.

2.and the CBC Annual Kitchen Inspection.

The Nutrition Services Manager, Director of Nursing, RN Case Manager, Assistant Administrator and Environmental Services Manager will complete the OregonCarePartners Infection Control Specialist Training for Community Based Care.

3. Each individual Nutritional Services teammate will be responsible for daily food safety and compliance accountability, as assigned by their job role. Additional weekly compliance evaluations and audits have also been implemented.

4. The Nutrition Services Manager and Assistant Administrator will monitor ongoing cleanliness and compliance on a weekly basis. Nutritional Services staff will take responsibility on a daily basis.

C 240 SS=F OAR 41 l-054-0030 (l)(a) Resident Services Meals, Food Sanitation Rule

1. Immediately following the survey, a thorough walkthrough of the kitchen area was conducted by the Nutrition Services Manager and Administrator to directly address each violation listed. This involved physically inspecting the kitchen space, equipment, and practices to ensure compliance with safety regulations and standards. Additional staff training and education directly related to food safety, sanitation, and compliance was assigned and immediate interventions were enacted.

2. A root cause analysis of the systems and processes was completed by the Nutritional Services Manager, Administrator, Assistant Administrator, the Environmental Services Manager, and all Nutritional Services teammates. A thorough review of the initial training, onboarding, orientation, continued education and daily, weekly, monthly, semi-annual compliance was completed.

A Nutritional Services meeting was held to gather feedback and provide immediate education and training.

The Nutrition Services team has been provided with mandatory training videos from OregonCarePartners.

A.Keeping Food Safe and Nourishing for Older Adults.

B.CBC Annual Kitchen Inspection training.

Additional corrective action interventions include:

A.The Mini Freezer was thawed on 02/02/2024, thawing the mini freezer has been added to the bi­monthly cleaning list.

B.Equipment covers were ordered on 02/02/2024, they have been delivered and are now in place for both Hobart Mixer and Meat Slicer.

C.Brand new pedal release trash cans were purchased on 02/02/2024 and are now in place.

D.On 2/7/2024, a new vendor contract was signed to ensure comprehensive maintenance services and ongoing compliance for the kitchen.

3. Each individual Nutritional Services teammate will be responsible for daily food safety and compliance accountability, as assigned by their job role. Additional weekly, bimonthly, and monthly compliance evaluations and audits have also been implemented.

4. The Nutrition Services Manager and Assistant Administrator will monitor ongoing cleanliness and compliance on a weekly basis. Nutritional Services teammates will take responsibility on a daily basis.

C 240 SS=F OAR 41 l-054-0030 (l)(a) Resident Services Meals, Food Sanitation Rule

1. Immediately after the survey exit, a comprehensive checklist was prepared to identify all necessary repairs based on the cited rule violations. The identified repairs were prioritized based on their urgency and severity, with immediate attention given to critical issues that pose an immediate risk to safety or compliance.

Corrective action interventions include:

A.The food storage racks and walk in refrigerator repairs have been scheduled with a vendor on 02/14/24.

B.The holes in the walls to the right of the convection oven were repaired on 01/25/2024.

C.Environmental Services deep cleaned the kitchen and ceiling tiles on 1/25/2024.

D.A property services vendor has been contracted to replace the garage flooring with an industrial strength sealant and install new baseboards.

E.Waterproof linoleum flooring was ordered on 2/8/2024 and will be installed upon delivery.

F.The eyewash station has been removed from the handwashing sink. A new eyewash station was installed.

2. Root cause analysis of the systems and processes was completed by the Nutritional Services Manager, Administrator, Assistant Administrator, the Environmental Services Manager. A thorough review of the initial training, onboarding, orientation, continued education and daily, weekly, monthly, semi-annual compliance was completed.

3. Monthly safety inspections will occur regularly, led by the Nutrition Services Manager, Environmental Services Manager and Assistant Administrator to identify any areas needing repair or replacement.

4. The Nutrition Services Manager, Assistant Administrator and Environmental Services Manager will monitor ongoing safety and compliance.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair 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 kitchen was toured on 03/15/24, observations of the facility kitchen, including food storage areas outside of the kitchen revealed the following:

* Stainless steel storage shelves and racks throughout the kitchen had a build up of black and brown debris and food particles; and

* The floor of the garage area where dry food storage and a freezer was located was porous and lacked a seal or covered baseboard and was not a cleanable surface.

The kitchen was toured, and the above areas were discussed with Staff 1 (ED) and Staff 2 (Nutritional Services Director) on 03/15/24. They acknowledged the findings.

C 240 SS= F OAR 411-054-0030 (1)(a)

Resident Services Meals, Food Sanitation Rule

1. Immediately after the survey exit, a comprehensive checklist was prepared to identify all necessary repairs based on the cited rule violations. The identified repairs were prioritized based on their urgency and severity.

Corrective action interventions include:

A. Stainless steel storage shelves and racks throughout the kitchen were replaced with epoxy coated shelving on 2/27/24. The entire kitchen was deep cleaned and staff were retrained on the kitchen safety, sanitation, and cleaning rules.

B. City Wide Facility Solutions completed the garage floor scrape, scrub, prime, applied two coats of industrial grade concrete paint sealant and installed new rubber cove baseboards, completed on 3/23/24. This will be completed every two years and as needed.

2. Root cause analysis of the systems and processes was completed by the Nutritional Services Manager, Administrator, Assistant Administrator, and the Environmental Services Manager. A thorough review of the initial training, orientation, continued education and daily, weekly, monthly, semi-annual, annual and biannual compliance was completed and calendared.

3. Monthly safety inspections will occur regularly, led by the Nutrition Services Manager, Environmental Services Manager and Assistant Administrator to identify any areas needing repair or replacement. The garage floor will be serviced as needed and at minimum every two years.

4. The Nutrition Services Manager, Assistant Administrator and Environmental Services Manager will monitor ongoing safety and compliance.

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

Refer to C 240.

C 455 SS=F OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

1. Following the survey exit, the leadership team prepared a comprehensive checklist to identify all necessary repairs based on the cited rule violations. Vendors were contacted to ensure timely service completion and procurement of enhanced kitchen sanitation products were purchased.  

2. Following the survey, the Nutritional Services Manager, Administrator, Assistant Administrator, and the Environmental Services Manager undertook a detailed root cause analysis of the Plan of Corrections systems and processes. This analysis focused on identifying and understanding the underlying causes of the compliance failures. In response to this analysis, the scheduling for the garage flooring maintenance, which had been previously delayed due to vendor availability, was reevaluated and adjusted to ensure timely servicing. Additionally, the kitchen sanitation procedures were thoroughly reviewed, leading to the procurement of new epoxy products designed to enhance infection control measures. This reevaluation included revising cleaning protocols and staff training to effectively use these new products.

3. Regular monthly safety inspections were instituted and conducted by the Nutritional Services Manager, Environmental Services Manager, and Assistant Administrator. These inspections focused on identifying any areas requiring repair or replacement, with special attention to the garage flooring, which is serviced as needed and at a minimum every two years.

4. The ongoing safety and compliance monitoring were assigned to the Nutrition Services Manager, Assistant Administrator, and Environmental Services Manager. These individuals were responsible for overseeing the implementation of the corrective measures and ensuring their effectiveness in meeting the compliance standards.