Print Inspection: SS6T

The findings of the kitchen inspection, conducted 06/04/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the first revisit to the kitchen inspection of 06/04/24, conducted 09/10/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

The findings of the second re-visit to the kitchen inspection 06/04/24, conducted 12/09/24 through 12/11/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on observation, record review, 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. Findings include, but are not limited to:

1. Observations of the main facility kitchen, food storage areas, food preparation, and food service on 06/04/24 revealed splatters, spills, drips, and debris on:

- Can opener blade and casing;

- Stand mixer;

- Food Processor;

- Carts;

- Interior and exterior of the microwave;

- Interior of drawers;

- Walls throughout the kitchen;

- Flooring and cove base throughout the kitchen;

- Floor drains throughout the kitchen;

- Interior of walk in freezer;

- Food packages and containers in dry food storage area;,

- Dishes and cookware stored on open shelving and racks;

- Open stainless steel shelving and metal wire rack shelving;

- Sides, front, knobs, and interior of the oven, grill, and range;

- Range hood and grease trap;

- Ceiling vents throughout the kitchen;

- Front grate and interior of the ice machine;

- Underneath shelving and equipment;

- Floor of the walk in refrigerator and freezer;

- Fan blades of the walk in refrigerator;

- Dishwashing area including flooring, walls, and equipment; and

- Walkie-Talkie.

* Prepared foods were unlabeled and undated.

* Packaged foods were not dated when opened.

* Cutting boards were deeply scored and stained.

* Scoops and cups were left in bulk bins of food.

* Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine.  

* A large hole was observed in the wall below the prep area table across from the walk in refrigerator.

* The wall behind the ice cream freezer was damaged.

* The laminate counter and cabinets in the back of the kitchen by the dishwashing area were damaged creating un-cleanable surfaces.

* The hand washing sinks lacked splash guards and were located next to food preparation or storage areas.

* Open garbage was observed full and stored next to a sink used for food preparation.

* The storage shelf next to the ice machine was broken, spilling clean utensils and cookware onto the floor.

* The back door to the kitchen was left propped open allowing for the entrance of pests.

* A visibly dirty fan was stored in contact with clean cookware.

* Dead ants were noted stuck in debris on the wall under the tray line shelf.

* Staff were observed to not change gloves between tasks while preparing food and handling ready to eat foods.

2. Observations of the service kitchens on the individual units revealed:

* Undated and unlabeled foods stored in the reach in refrigerators.

* Un-covered plate of food was observed left in a microwave.

* Interior of drawers had spills and debris.

* Counters and cupboards were damaged.

* There was no documented evidence of monitoring the temperatures of the mini-refrigerator/freezers. Temperatures were noted above 45 degrees.  The need to ensure foods were stored below 42 degrees discussed with Staff 1 (Assistant Executive Director). She agreed to dispose of protein based foods from the mini-fridges with low temperatures.

The food handling and storage concerns, and the areas in need of cleaning and repair were reviewed with Staff 1. She acknowledged the findings.

1.) All identified splatters, spills, drips and debris on equipment, walls and flooring have been cleaned.  Unlabeled and undated food has been disposed of. Undated packaged foods have been disposed of. Scoops and cups have been removed from food bins. A large hole in wall has been patched. Laminate on counter repaired, splash guard placed next to handwashing sink.  Temperature logs have been placed in each cottage.

2.) New Executive Chef has created a cleaning schedule to be followed and Executive Director will round through kitchen daily to inspect. Executive Chef has provided education regarding labeled and dated foods. Education regarding scoops and cups in bins,cleaning schedule, open garbage, changing of gloves and temp logs

3.) Daily,Weekly

4.) Executive Chef, Maintenance Director and Executive Director     

Based on observation, record review, 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. Findings include, but are not limited to:

The facility kitchen, food storage, and kitchenettes were toured with Staff 9 (Executive Chef) on 09/10/24.

1. Observations of the main facility kitchen, food storage areas, food preparation, and food service on 09/10/24 revealed splatters, spills, drips, and debris on:

- Flooring and cove base throughout the kitchen;

- Food packages and containers in dry food storage area;

- Dishes and cookware stored on open shelving and racks; and

- Underneath shelving and equipment.

* Prepared foods were unlabeled and undated.

* Packaged foods were not dated when opened.

* Scoops and cups were left in bulk bins of food.

* Dish washing racks were stored on the floor.

* The hand washing sinks lacked splash guards and were located next to food preparation or storage areas.

* A visibly dirty fan was in operation in contact with clean cookware.

* Dishes were stored on the floor.

* Boxes were on the floor in the walk-in freezer.

2. Observations of the service kitchenettes on the individual units revealed:

* Undated and unlabeled foods stored in the reach in refrigerators.

* Un-covered plates of food were observed left in microwaves.

* Interior of drawers had spills and debris.

* Counters, cupboards, and drawer interiors were damaged.

* There was no documented evidence of monitoring the temperatures of the mini-refrigerator/freezers. Temperatures were noted above 45 degrees.

The food handling and storage concerns, and the areas in need of cleaning and repair were reviewed with Staff 8 (Executive Director). She acknowledged the findings.

1.) Flooring and cove base throughout kitchen has been cleaned, food packages and containers in dry stoarage area put up; Dishes and cookware stored on open shelving and racks have been covered; Underneath shelving and equipment have been cleaned; Prepared foods were thrown out as they were not labled and dated; Packaged foods not dated once opened thrown out; Scoops and cups left in bulk bins of food have been removed; Dish washing racks were removed from the floor; Hand washing sinks lacked splash guards and were located next to food preparation and storage unit stand mixer next to handwashing sink covered; Dirty fan by back door cleaned; Boxes on floor of walk in freezer removed from floor and placed on shelf.  In cottages undated and unlabled food from  refrigerators thown away; un-covered plates of food left in  microwave thrown away; Spills and debris in drawers cleaned; Damaged counters cupboards replaced; Documented evidence of monitoring refridgerator/fridge re-posted.  Education provided regarding temperatures over 45 degrees.

2.) New Executive Chef has created a cleaning schedule to be followed and Executive Director will round through kitchen daily to inspect. Executive Chef has provided education regarding labeled and dated foods. Education regarding scoops and cups in bins,cleaning schedule,  and temp logs

3.) Daily,Weekly

4.) Executive Chef, Maintenance Director and Executive

Based on observation, record review, and interview, it was determined the facility failed to ensure 5 of 8 sampled staff (# 2, 3, 4, 5, and 6) reviewed for food handlers certificates had current cards at the time of survey. Findings include, but are not limited to:

On 06/04/24 the facility was asked to provide verification that staff who prepared and served food had current food handlers cards.

There was no documented evidence Staff 2 (Dietary Staff) and Staff 3, 4, 5, and 6 (caregiving staff observed to plate and serve food ) had food handlers cards.  

Staff 1 (Assistant Executive Director) acknowledged the missing documentation.

1.) Audit completed of all staff who work in kitchen or serve food to ensure food handlers cards, staff without cards now have cards.

2.) Education provided regarding importance of food handlers cards and will be needed upon hire.

3.) Weekly, Monthly

4.) Executive Chef, Assistant Executive Director/BOM, Executive Director

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

Refer to C 240.

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 and C 370.

Refer to tags C240 and C370

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.

Refer to C240