Print Inspection: X32V

The findings of the kitchen inspection, conducted 1/27/23, 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 revisit to the kitchen inspection of 01/27/23, conducted 04/26/23, 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 revisit to the kitchen inspection of 01/27/23, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the kitchen on 1/27/23 at 9:45 am through 11:30 am revealed the following deficiencies:

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

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;

* Spice shelves;

* Juice dispenser;

* Dining room beverage area;

* Kitchen drains;

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of drawers;

* Ceiling fire sprinklers and vents;

* Walls and floors throughout kitchen;

* Open shelving under the steamtable;

* Interior and exterior of microwave;

* Stove/grill/oven knobs, doors, interior, exterior;

* Area around grill/stove;

* Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers;

* Open shelving throughout kitchen;

* Industrial mixer;

* Large can opener housing;

* Floors throughout the kitchen had black matter build-up, food and trash debris and grease in corners, under equipment, shelving and around perimeter edges;

* Wall in walk in freezer;

* Floors in walk in refrigerator and freezer;

* Baking rack;

* Under and behind shelving in dry good storage;

* Door thresholds;

* Fans by prep/cooking/serving area;

* Ceiling with food splatters/stains;

* Mop sink area;

* Ice scoop holder;

* Deli refrigerator cart;

* Shelves/drawers by microwave; and

* Inside of drawers.

b. The following areas were found in need of repair:

* Kitchen entrance and exit door with damage and missing paint in threshold and door;

* Missing area of threshold floor cover with dirty and debris built up;

* Caulking around dish machine area with black substance buildup;

* Cooling fans in walk in with dust buildup;

* Leak under steam table where cooking pans stored;

* Cabinets and walls by and near beverage station in dining room with damage;

* Multiple areas of cracked or missing tile flooring;

* Damage to wall over wood area near tile;

* Caulking by hand washing sink cracked, and chipping away;

* Multiple areas of ceiling tiles with gaps/cracks causing areas where potential pests could enter kitchen area;

* Open shelving under steam table with missing or damage to shelves causing an un-cleanable surface;

* Vents/fire sprinklers in kitchen with dust/dirt build up; and

* Threshold doors to Staff 2 office and dry storage with damaged/missing paint.

c. Food items found in dry good storage were not covered/sealed to prevent potential contamination.

d. Cutting boards and surfaces of cart, steam table, deli cart found to be heavily scored and/or stained.

e. Salad dressings not labeled with use by date.

f. Multiple utility carts or cooking utensils/tools with damage and/or heavily scored not allowing for smooth cleanable surface.

g. Plastic container for storage of ice scoop with visible dark matter substance in the bottom and dust build-up on the top.

h. Food items from delivery from previous day stored on floor of dry storage, freezer and cooler.

In an interview, Staff 2 (Cook) acknowledged there were multiple areas of kitchen that were not cleaned per task list. She stated there was not a cleaning schedule for certain dates and times. She further stated, the Dietary Services Manager was working on a cleaning schedule.

Staff 3 (Dietary Manager) and Staff 1 (Administrator) toured the kitchen with the Surveyor and acknowledge the above areas of concern.

C240-A

Dietary Service Director will work with the Regional Maintenance Director to hire a professional cleaning company to deep clean the entire kitchen including all areas identified in C240.

Dietary Service Director will create daily, weekly, monthly cleaning task sheets.  The task sheets will be seperated and assigned to Dining Assistants, and Prep/Cooks.  The tasks sheets will be turned into the Administrator, and the Administrator will conduct spot checks to ensure the cleaning has been completed, and stays in compliance.

Maintenance Director will complete the ceiling, fire sprinklers, and vents fixed.

C240-B

*Maintenance Director will painting of kitchen entrance and exit door with damage and missing paint in the threshold.

*Regional Director will work with the Maintenance Director in replacing the kitchen flooring.

*Maintenance Director will replace caulking around the dish machine by hand washing sin.

*Maintenance Director will ensure the leak under the steam table is fixed.

*Maintenance will fix the damaged cabinets and walls near the beverage station in the dining room.

*Regional Director will work with Maintenance Director in replacing the kitchen flooring.

*Maintenance Director will fix the multiple areas of ceiling tiles with gaps and cracks.

*Maintenance Director will fix damage under the steam table.

*Dietary Manager will clean the vents/fire sprinklers in the kitchen, and add to the cleaning task sheet.

*Maintenance Director will repaint threshold doors to staff 2 office and dry storage with damage and missing paint.

Maintenance Director will conduct weekly checks in the kitchen to maintain any damages, painting, and repairs needed.  The Maintenance Director will report to the Administrator findings, and together determine the proper action to take for repairs.

C240-C

Dietary Manager will check dry good storage daily to ensure food is covered and or sealed properly.

C240-D

Dietary Mangager ordered all new cutting boards including the steam table, and the deli cart. Dietary Manager will reorder as needed to avoid heavily scored and/or stained cutting boards.

C240E

Dietary Manager to provide kitchen staff additional training regarding properly labeling salad dressings and all other foods that require dates and labels.

C240-F

Dietary Manager to reorder new cooking utensils/tools including new utility carts.

C240-G Dietary Manager will order a new holder. The ice holder has been added to the cleaning task sheet,

C240-H

Dietary Manager to provide additional training to kitchen staff regarding putting away orders timely upon delivery.

C999 - Technical Assistance

Staff member completed the Food Handlers Certification while survey was in process.

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

Observation of the kitchen on 04/26/23 at 10:00 am through 12:00 pm revealed the following deficiencies:

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

* Flooring under mats in dish washing area;

* Juice dispenser;

* Cupboards in dining room beverage area;

* Ceiling fire sprinklers;

* Open shelving under the steamtable;

* Open stainless steel shelving storing dishes;

* Interior and exterior of microwave;

* Grill top, area around grill, grease trap;

* Industrial mixer;

* Ceiling with food splatters/stains;

* Deli refrigerator cart;

* Pan under microwave;

* Inside of drawers; and

* Trash can lid on large garbage can.

b. The following areas were found in need of repair:

* Missing area of threshold floor cover with dirty and debris built up;

* Cooling fans in walk in with dust buildup;

* Multiple areas of ceiling tiles with gaps/cracks causing areas where potential pests could enter kitchen area; and

* Open shelving under steam table with missing or damage to shelves causing an un-cleanable surface.

c. White trash can without lid when not in use.

d. Exposed wood blocks under equipment noted with dirt/debris and moisture accumulation.

e. Food items from delivery from previous delivery day found stored on floor in freezer.

In an interview, Staff 2 (Cook) acknowledged the identified areas needing cleaning and stock being on the floor that should have been put away sooner. Staff 2 stated there was a new cleaning list and surveyor visualized. These daily sheets had multiple missing entries and Staff 2 acknowledged it was not being filled out/followed as directed.

Staff 3 (Business Office Manager/Manager on Duty) toured kitchen with surveyor and acknowledged areas of concern.

Staff 1 (Executive Director) and surveyor reviewed areas in need of continued cleaning and maintenance. S/he acknowledged areas of concern.

Based on interview, observation and review of documentation, 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.