Print Inspection: VJED

The findings of the kitchen inspection, conducted 01/02/24, 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 revisit to the kitchen inspection of 01/02/24, conducted 03/20/24, 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 01/02/24, conducted 05/16/24, 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 third re-visit to the re-licensure kitchen inspection of 01/02/24, conducted on 07/15/24, 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 provide effective administrative oversight over the operation of the kitchen and kitchenettes. Findings include, but are not limited to:

During the second revisit to the annual kitchen survey of 01/02/24, conducted on 05/16/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number of repeat citations.

Refer to C 240.

The management team will meet on a regular basis and implement check lists to ensure all kitchen deficiencies are corrected and remain in compliant.

This will be monitored on a daily and as needed basis.

This will be completed by June 15th, 2024.

The Administrator, Chief of Financial Operations,

Site Manager, and/or Office Manager will be responsible in monitoring this correction is complete.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

1. On 01/02/24, observations of the facility main kitchen in Building Two identified the following:  

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:

* The can opener located inside the dry storage room;

* Reach-in and stand up refrigerators and freezer shelving and flooring;

* Interior and exterior of the stand up refrigerator;

* Ice machine, including the vent;

* Stainless steel shelving; and

* Walls and ceiling.

b. Scoops were observed inside the following bins: ice, oatmeal, flour, brown sugar, and white sugar.

c. A sack of potatoes was stored directly on the floor.

d. There were no pasteurized eggs available for soft-cooked entrees.

e. Staff were not cleaning the probe thermometer with alcohol wipes to sanitize after use.

f. Sanitation and Equipment:

* Staff were not using a sanitized wiping cloth to clean food surfaces and non-food surfaces;

* The temperature dial on the warewashing machine was not working;

* The warewashing machine was sanitized with chemicals and Staff 3 (Cook) verified she did not check the machine to ensure sanitization; and

* There were testing strips available to staff, but staff were not using them.

g. Cleaning and Repair

* Flooring in between the kitchen and dry storage area was worn down to sub flooring and was covered with a rubber mat;

* Shelves in the dry storage area were peeling and in disrepair;

* Window framing behind the kitchen sink was in disrepair;

* The hot water spigot on the coffee machine was leaking; and

* The ceiling above the spice rack was in disrepair.

2. On 01/02/24, observations of the facility kitchenette in Building One identified the following:  

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:

* Interior and exterior of multiple cabinets and drawers;

* Interior and exterior of stand up refrigerators and freezer;

* Caulking and wall behind the sink;

* Handles of the serving carts; and

* Vent above the stove.

b. A scoop was observed in the powdered sugar canister.

c. Sanitation and Equipment:

* Staff were not using a sanitized wiping cloth to clean food surfaces and non-food surfaces;

* A cooler used for milk storage was no longer functional;

* The warewashing machine was sanitized with chemicals and Staff 3 verified she did not check the machine to ensure sanitization; and

* There were testing strips available to staff, but staff were not using them.

d. Cleaning and Repair:

* There was an exposed electrical outlet behind the refrigerator;

* Multiple cabinets and drawers had scuffs and peeling paint;

* The sink had scuffs and chips;

* The sink sprayer was broken off;

* A lower corner cabinet had broken hinges; and

* There was an exposed electrical outlet behind the refrigerator.

e.  The refrigerator temperature was at 48 degrees Fahrenheit. There was no temperature log for that refrigerator to validate temperatures were being monitored. Protein rich food items where checked by survey team and temperatures were found at 49.1 degrees at 1:47 pm. Non shelf stable food items in refrigerator were discarded and maintenance contacted. Facility stated they would not be using that refrigerator until appropriate temperatures could be maintained.

The above areas were discussed with Staff 1 (Chief Financial Officer) and Staff 2 (Site Manager) on 01/02/24. They acknowledged the findings.

A daily, weekly, and/or monthly check list will be created to better assist the kitchen staff & management team maintain the cleanliness & ensuring the kitchen is kept in compliance.

The management team will look into purchasing pasteurized eggs and will make sure that all appliances are in working condition. This will be monitored on a daily, weekly, monthly, and as needed basis.

This will be completed by March 2nd, 2024.

The Administrator, Chief of Financial Operations, and/or Site Manager will be responsible in monitoring that these corrections are complete.

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 OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

1. On 03/20/24 at 9:10 am, observations of the facility main kitchen in Building Two identified the following:  

Sanitation and Equipment:

* Staff were not using a sanitized wiping cloth to clean food surfaces and non-food surfaces;

* Testing strips were not available to staff; and

* The low temperature chemical dish machine was observed to operate multiple times and inconsistently registered the required temperatures for sanitation.

2. Observations of the facility kitchenette in Building One identified the following:  

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:

* Interior and exterior of multiple cabinets and drawers;

* Vent above the stove; and

* The lower shelf of a metal, rolling cart.

b. Sanitation and Equipment:

* Staff were not using a sanitized wiping cloth to clean food surfaces and non-food surfaces; and

* Testing strips were not available to staff.

c. Cleaning and Repair:

* Multiple cabinets and drawers had scuffs and peeling paint;

* A small gap was visible between the cabinet and wall behind the sink;

* The sink basins had scuffs and brown marks; and

* Laminate was peeling/coming off the edge of a cabinet shelf located in the serving alcove.

The areas that required cleaning and repair were observed and discussed with Staff 1 (Chief Financial Officer) and Staff 2 (Site Manager) on 03/20/24. Both acknowledged that the areas observed needed to be cleaned and repaired. Staff 2 added he would immediately contact a company to service the dish machine in Building 2.

Management will provide a sanitation station with proper equipment to be used to clean food & non food surfaces. Sanitation testing strips have been purchased and staff are trained on how to use them properly. Dishwasher has been increased to reach required temperature.

All areas that had food splatter/spills, debris, etc. have been cleaned. All equipment & appliances have been cleaned and repaired.

A check list will be used to better assist the kitchen staff & management team maintain the cleanliness of the kitchen and to make sure all appliances are in proper working condition to ensure kitchen is kept in compliance.

This will be monitored on a daily, weekly, monthly, and as needed basis.

This will be completed by May 4th, 2024.

The Adminstrator, Chief of Financial Operations, and/or Site Manager will be responsible in monitoring that these corrections are complete.

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 OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

1. On 05/16/24 at 9:45 am, observations of the facility main kitchen in Building Two identified the following:  

a. Sanitation and Equipment:

* Sanitation testing strips were not being used properly. Staff lacked knowledge and understanding of how to prepare the sanitation buckets and use the test strips; and

* The low temperature chemical dish machine was observed to operate five times with sanitation temperatures ranging from 112-115 degrees F. which was not at the required 120 degrees F. (per the manufacture data plate).

b. Food Storage and repair:

* The reach-in freezer had an approximate two foot long break in the interior rear wall of the freezer and was not maintaining temperature which caused the frozen food to thaw.

On 05/16/24, Staff 1 (Chief Financial Officer) was observed discarding multiple food items from the freezer and stated he would purchase and pick up a new freezer today.

2. Observations of the facility kitchenette in Building One identified the following:  

a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following:

* Interior and exterior of multiple cabinets and drawers;

* Half wall below the serving alcove and the alcove wall facing the dining room;

* Interior and exterior shelves and drawers of the refrigerator and freezer;

* Interior and exterior microwave oven; and

* Stove door.

b. Food Storage:

* Multiple food items were left open to air on countertops, in the freezer and refrigerator; and

* Multiple leftover food items were unlabeled and undated in the refrigerator.

c. Sanitation and Equipment:

* Sanitation testing strips were not being used properly. Staff lacked knowledge and understanding of how to prepare the sanitation buckets and use the test strips.

d. Cleaning and Repair:

* The cabinet beneath the sink had a square cutout which created a gap between the cabinet and the wall underneath the sink;

* Approximately two foot by one foot rectangular cut in the floor covering underneath a table located to the left of the sink; and

* There was an infestation of roaches in multiple areas of the kitchen, including drawers and cabinets.

On 05/16/24, Staff 2 (Site Manager) reported a pest control company was immediately contacted for service.

The areas that required cleaning and repair were observed and discussed with Staff 1, Staff 2 and Staff 5 (Administrator) on 05/16/24. They acknowledged the findings.

Staff will be shown how to properly use the sanitation testing strips and preparing the sanitation buckets.

Dishwasher temperature was increased to the required 120 degrees F.

The broken freezer has been removed & replaced. Any food affected were thrown away.

A deep cleaning will be done to remove all food spills, splatters, debris, dirt, and/or black matter from all surfaces mentioned.

Staff will be reminded to properly store and label food items.

The cutout/gap in the cabinet beneath the sink and the cut in the flooring will be repaired.

Pest control has done two treatments for the roach infestation.

A check list will be used to maintain the cleanliness of the kitchen and to make sure all appliances are in proper working condition.

This will be monitored on a weekly and as needed basis.

This will be completed by June 15th, 2024.

The Adminstrator, Chief of Financial Operations, and/or Site Manager will be responsible in monitoring these corrections are complete.

Based on observation and interview, 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.

The management team will continue to meet on a regular basis with the kitchen staff to ensure that the corrections are made and the kitchen remains in complaint in all reported deficiences.

This will be monitored on a weekly and as needed basis.

This will be completed by May 4th, 2024.

The Administrator, Chief of Financial Operations,

Site Manager, and/or Office Manager will be responsible in monitoring that this correction is complete.

Based on observation and interview, it was determined the facility failed to ensure their kitchen 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 C 240.

The management team & kitchen staff will continue to meet on a regular basis to ensure that all corrections are made and the kitchen remains in complaint in all reported deficiences.

This will be monitored on a daily and as needed basis.

This will be completed by June 15th, 2024.

The Administrator, Chief of Financial Operations,

Site Manager, and/or Office Manager will be responsible in monitoring that this correction is complete.