Print Inspection: W2XZ

The findings of the kitchen inspection, conducted 3/12/24, 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 03/12/24, conducted 05/13/24, 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 re-visit to the kitchen inspection of 03/12/24, conducted 07/25/24, 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.

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

The findings of the third revisit to the kitchen inspection of 03/12/24, conducted 09/19/24 and 09/20/24, 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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility ALF kitchen was completed on 03/12/24 from 11 am through 3:30 pm and the following was identified:  

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

* Floors and walls under dish machine;

* Floors throughout kitchen;

* Walk in cooler floors/corners/edges/walls;

* Walls throughout kitchen;

* Fans and metal cages of fans;

* Reach in coolers and freezers;

* Open shelving throughout kitchen;

* Interior and exterior of microwave;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Range top, grill top;

* Metal shelves storing pots/pans/dishes;

* Knobs of steam table;

* Steam table wells;

* Cabinet with plate warmer;

* Industrial can opener and housing;

* Steamer with scale build up and dirty on interior and exterior;

* Industrial mixer;

* Door thresholds with food debris/splatter;

* Interiors and exteriors of stainless steal drawers;

* Go racks stored in walk in;

* Metal racks in walk in cooler;

* Freezer fan cages;

* Outside and handles of trash cans;

* Small appliances (blender/robot coupe);

* Ice scoop holder;

* Window seal and screens; and

* Kitchen drains.

b. The following areas were in need of repair:

* Hole in wall under prep counter where cutting boards stored;

* Three compartment sink faucet with leak;

* Spring loaded sprayer broken and sitting at bottom of sink;

* Caulking behind hand washing sink and ware washing area with black mold like substance;

* Pipe from wall next to large fan with gap needing sealed; and

* Sprinkler in walk in cooler leaking.

c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination.

d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple pans/utensils with damage and wear needing to be replaced.

e. Multiple food items found in walk in cooler without proper labels and/or dates as required. Items found open or not sealed appropriately to protect from potential contamination.  

f. Multiple food packages were found open in dry storage.

g. Shell eggs and liquid eggs stored over box of "fresh greens". Cardboard box of food items with visible wet debris. Staff stating sprinkler in walk in leaking.

h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them.

i. Large meat roast observed being thawed under cold running water upon entry to kitchen. These roasts were then observed at 12:25 on a large pan on a go rack in the main kitchen. Again at 1:35 pm these meat roasts were still observed out of refrigeration on the pan on the go rack.  

j. Cardboard and recyclables were not stored appropriately and were not separate from food preparation areas. Staff 2 indicated they did not have a good space to store them until taking out to garbage area.

k. At 12:05 a staff member entered into kitchen and got ice out of ice machine. The staff member did not wash hands and did not have their hair restrained as required.

At 12:25 pm, the memory kitchen area was observed and noted the following areas in need of cleaning: Floors, plastic and metal shelves, toaster, utility carts, reach in fridges/freezers, walls, drains, hand washing sink, reach in oven. The ice machine lid was broken and did not close appropriately, falling to the floor when opened. The dish machine temperature gauge was not functioning properly and was not reaching the required 180 degrees F as required. Surveyor checking temperature with temp strips and the sanitation was validated, however no one was aware the gauges were not operating correctly. Facility staff were documenting temperature readings at 160-180 for final rinse temperatures. Staff 2 acknowledged the temperatures should be 180 and that staff had not alerted them to any temperatures under that requirement.

Staff 2 (Dining Service Coordinator) toured kitchen areas with surveyor and acknowledged identified areas needing attention. At approximately 3:00 pm, surveyor reviewed above areas with Staff 1 (Administrator), who acknowledged the findings.

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

Observation of the facility ALF kitchen was completed on 05/13/24 from 10:15 am through 12:45 pm and the following was identified:  

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

* Ceiling vent near prep area

* Floors throughout kitchen;

* Walls throughout kitchen;

* Fans and metal cages of fan by serving area;

* Open shelving throughout kitchen;

* Interior and exterior of microwave;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Range top, grill top;

* Metal shelves storing pots/pans/dishes;

* Steam table wells;

* Industrial can opener housing;

* Steamer interior and exterior;

* Industrial mixer;

* Door thresholds with food debris/splatter;

* Interiors and exteriors of stainless steel drawers;

* Window sill and screens; and

* Kitchen drains.

b. The following areas were in need of repair:

* Areas by electrical conduit/pipes with gaps.

c. Scoops observed in bulk food containers with handles touching food surfaces.

d. Multiple food items found in walk-in cooler without proper labels and/or dates as required. Container of cut tomatoes was found stored in walk-in cooler. It was dated 04/30/24 multiple days past seven days that is allowed per rule.

e. Multiple food packages were found open in dry storage without open dates.

f. Thawing meats were not stored correctly according to appropriate cook to temps to prevent potential cross contamination. Whole pork roasts were noted to be stored directly under ground meat products.

At approximately 11:15 am, the memory kitchen area was observed and noted the following areas in need of cleaning: Floors, microwave, can opener and housing, toaster, utility carts, steam table wells, and reach in fridges/freezers. The ice machine lid was open exposing ice to potential contamination. Kitchen staff were interviewed and they were not able to correctly state the proper dish rise sanitation temperature. Staff stated rinse temperatures were ranging from 160-170 degrees F. Staff indicated appropriate sanitizing temperature was 170 degrees. Facility dishwashing temperature records documented 22 instances since 05/01/24 where the rinse temperature was under the required 180 degrees to effectively sanitize dishes.

Staff 2 (Dining Service Coordinator) toured kitchen areas and Staff 3 (MC Administrator) toured memory care kitchenette with surveyors and acknowledged identified areas needing attention. At approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Interim Executive Director), who acknowledged the findings.

- Floors throughout the kitchen cleaned and added to daily checklist

-Walls throughout the kitchen cleaned and added to daily checklist

Open shelving throughout kitchen cleaned and added to daily checklist

Interior and exterior of microwave cleaned and added to daily checklist

Interior and exterior of convection ovens cleaned and added to daily checklist

Exterior and interior of steamer cleaned and added to daily checklist

Range top, grill top cleaned and added to daily checklist

Metal shelves storing pots/pans/dishes cleaned and added to daily checklist

Steam table wells cleaned and added to daily checklist

Industrial can opener housing cleaned and added to weekly checklist

Industrial mixer cleaned and added to daily checklist

Door threshholds with food debris/splatter cleaned and added to daily checklist

Interiors and exteriors of stainless steel drawers cleaned and added to weekly checklist

Window seal and screens cleaned and added to weekly checklist

Kitchen Drains cleaned and added to weekly checklist

-Areas with electrical conduit pipes that have gaps will be filled in by Maintenance staff by 5/31/24

Proper labeling of all food items will be done by kitchen staff and be monitored daily

Dry storage items that are opened will be labeled with open dates and monitored daily

Storage scoops will be put up and not sitting in food bins and monitored daily

Thawing meats will be stored according to the food storage heirarchy and monitored daily

**Staff will be retrained on the following:

-Proper storage of scoops in bulk food containers

-Proper labeling and storage of food in both dry storage and in refrigerators and freezers

-Food storage heirarchy

Memory care kitchen:

-Floors, Will be cleaned and mopped daily

-microwave, will be cleaned weekly

-can opener and housing will be cleaned weekly

-toaster will be cleaned weekly

-utility carts will be cleaned daily

-steam table wells will be cleaned weekly

-reach in fridges/freezers. Will be cleaned monthly

-The ice machine lid will remain closed

-Education on use of dish sanitizer was provided by ECOlab on 6/15/24 and temps over 180 are consistently reached and recorded.

All Items will be monitoried by the ED and Dining Services Manager.

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

Observation of the facility ALF kitchen was completed on 07/25/24 from 12:00 pm through 1:45 pm and the following was identified:  

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

* Floors throughout kitchen;

* Fans and cages in walk in cooler;

* Floors in walk in cooler;

* Open shelving throughout kitchen;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Metal shelves storing pots/pans/dishes;

* Baking "go" racks;

* Number 10 can storage racks; and

* Kitchen drains.

b. Scoops were observed in bulk food containers with handles touching food surfaces.

c. Box of frozen hamburger patties were found open and uncovered in the walk in cooler.

On 07/25/24, Staff 2 (Dining Service Coordinator) toured the kitchen and acknowledged the findings.  At approximately 1:30 pm, surveyor reviewed above areas with Staff 1 (Interim Executive Director) and Staff 3 (Memory Care Administrator), who acknowledged the findings.

2.  Executive Director and Dining Serivces Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on kitchen cleanliness checklists, and inservice staff on proper food storage.

3. Areas of correction wil be audited weekly

4. Eecutive Director and dining Services Coordinator are responsible for monitoring and ongoing compliance.

Based on record review and interview, it was determined the facility failed to ensure 2 of 5 sampled staff (#s 2 and 3), who prepared food had active food handlers certificates. Findings include, but are not limited to:

On 03/12/24 employee records were requested and reviewed to ensure staff had active food handlers cards on file. There were two employees, Staff 2 (Dining Services Coordinator) and Staff 3 (Cook) whose food cards could not be located. Staff 1 (Executive Director) acknowledged the need to have active food handler cards on hand for these individuals.

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

Refer to C240.

1. Food spills,splatters,loose food, trash debris, and dust/dirt floors throughout kitchen, including floors in walk in cooler and ares under open shelving will be swept and mopped twice daily. Baking "go" racks, Number 10 storage racks, and metal shelves storing pots/pans/dishes will be pressured washed by 8/14/2024. Interior and exterior of convection ovens will be cleaned by 8/12/2024. Exterior and interior of steamer has been cleaned as of 8/4/2024. Kitchen drains have been cleaned as of 8/4/2024. Fans and cages in walk in will be cleaned as 8/12/2024. Scoops for bulk food storage have been removed from bins and signage posted for staff reference on preventing handles from touching food as of 8/8/2024.

2.  Executive Director and Dining Services Coordinator will audit areas of focus as outlined in plan of correction, inservice staff as needed on daily kitchen cleanliness checklists, use and storage of bulk food scoops. and inservice staff on proper food storage.

3. Areas of correction wil be audited weekly and as needed.

4. Executive Director and Dining Services Coordinator are responsible for monitoring and ongoing compliance.

Based on observation, record review, and interview, 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.

Based on observation and interview, 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 C240.

Refer to C240

Based on observations and interviews, 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 C240.

see Plan of Correction for C240