Print Inspection: XHSG

The findings of the kitchen inspection, conducted 12/07/23, 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 12/07/23, conducted 02/22/24, 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 12/07/23, conducted 06/27/24, 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 12/07/23, conducted 08/06/24, 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, interview, and record review, 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:

On 12/07/23 at 10:15 am, the facility's kitchen was toured, and food preparation and food delivery was observed.

a. Food spills, splatters, debris, dust and dirt was observed on, inside, around or underneath the following:

* Flooring edges and base trim throughout the kitchen;

* Walls throughout the kitchen;

* Ceiling vents throughout the kitchen;

* Ceiling tiles throughout the kitchen;

* Stainless steel shelving throughout the kitchen;

* Legs of stainless steel shelving throughout the kitchen;

* Drains throughout the kitchen;

* Ice machine grate;

* Cabinets under steam table;

* Wall and pipes behind the stove and ovens;

* Chains suspending the warming lamp of the steam table;

* Caulking near warewasher;

* Industrial can opener;

* French fry slicer;

* Kitchen Aid mixer;

* Walk-in refrigerator fan guard and surrounding surfaces;

* Microwave;

* Blenders;

* Handles of spice cabinet;

* Radio mounted under spice cabinet;

* Stand-up mixer; and

* Fans throughout the kitchen.

b. The following equipment was in need of repair:

* Trim and corner guards throughout the kitchen were lifted, broken or missing;

* Ceiling tiles with holes near entrance to dining room;

* Door frame to dining room had gouged wood and chipped paint;

* Sealant of previously repaired floor near drink station was worn;

* Clean dish racks had peeling and chipped sealant;

* Non-stick coating on frying pans was worn;

* Temperature gauge of warewasher was broken;

* Cabinets under the steam table had exposed wood and a broken handle;

* Laminate of shelving was lifted under microwave;

* Stand-up mixer coating was chipped;

* Stainless steel three tiered cart had a broken handle;

* White cutting board had brown marks and was warped; and

* Walk-in freezer door was broken with frozen condensation lining the exterior edges.

c. Multiple food items in the dried storage were open to air.

d. Staff lacked good infection control related to the use of aprons for caregivers serving food, hand hygiene during food preparation, hand hygiene between dirty and clean tasks, and use of gloves.

The need to ensure the kitchen was clean, in good repair, and infection control processes were followed in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 12/07/23. They acknowledged the findings.

C240 -(A) Maintenance department and kitchen staff - under the direction of Dietary Supervisor -  will close kitchen for two nights to complete noted list of required cleaning and repairs to ensure all food spills, splatters, debris, dust and/or dirt  as noted in the statement of deficiency . (B) In addition repairs as noted to include all environmental/equipment noted in the statement of deficiency.  (C) All dry storage items will be tight fitting containers ensuring they are not open to air (D) Staff will have frequent and easy access with reminders to ensure wearing of appropriate aprons, hairnuts, gloves and frequent hand washing with proper use of donning off and on gloves between uses ie: dirty and cleaning tasks.  

Ongoing cleaning schedules for all noted deficiences will be maintained and audited by Kitchen Supervisor as indicated by internal processes

Z142 - see noted POC above  

Please see attached formatting for cleaning. Audits will occur at least once weekly depending on the task.

Based on observation 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. This is a repeat citation. Findings include, but are not limited to:

On 02/22/24 at 1:33 pm, the facility's kitchen was toured and food service was observed.

a. Food spills, splatters, debris, dust and dirt was observed on, inside, around or underneath the following:

* Flooring edges and base trim throughout the kitchen;

* Walls throughout the kitchen;

* Ceiling vents throughout the kitchen;

* Ceiling tiles throughout the kitchen;

* Stainless steel shelving throughout the kitchen;

* Legs of stainless steel shelving throughout the kitchen;

* Multiple food service carts;

* Ice machine grate and air vents;

* Cabinets under steam table;

* Wall and pipes behind the stove and ovens;

* Chains suspending the warming lamp of the steam table;

* Caulking around warewasher area and wall underneath warewash and sprayer sink;

* Industrial can opener;

* Kitchen Aid mixer;

* Walk-in refrigerator fan guard and surrounding surfaces;

* Microwave;

* Blenders;

* Conveyor toaster;

* Handles of spice cabinet;

* Radio mounted under spice cabinet;

* Stand-up mixer;

* Fans throughout the kitchen; and

* Floor drains throughout the kitchen;

b. The following equipment was in need of repair:

* Trim and corner guards throughout the kitchen were lifted, broken or missing;

* Ceiling tiles with holes throughout the kitchen;

* Door and door frame to the dining room had gouged wood and chipped paint;

* Sealant of previously repaired floor near drink station was worn and missing in some areas;

* Dish racks were chipped and broken;

* Temperature gauge covers of the warewasher machine were missing;

* Cabinets under the steam table had exposed wood and multiple broken handles and misaligned doors;

* Stand-up mixer coating was chipped;

* Stainless steel three tiered cart had a broken handle;

* Multiple cutting boards had brown marks and were warped;

* Walk-in freezer door was rusted and had a broken seal which caused frozen condensation to line the exterior edges of the door;

* Walk-in refrigerator door, walls and floors were rusting, including around the fire sprinkler system;

* White upright refrigerator had a discolored and broken seal around the door;

* Prep sink pipes were leaking;

* Unpainted wood panel attached to the wall underneath the prep sink; and

* Sink faucet in warewash area was broken and unable to be turned off.

c. Staff lacked good infection control related to the use of aprons for caregivers serving food, hand hygiene during food preparation, hand hygiene between dirty and clean tasks, and use of gloves.

The need to ensure the kitchen was clean, in good repair, and infection control processes were followed in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 2 (Dining Services Director), Staff 3 (Designee) and Staff 4 (Maintenance) on 02/22/24. They acknowledged the findings.

Cleaning:

oFan guard and surrounding surfaces. (Complete 3/29)

oMicrowave. (complete 3/29)

oBlenders. (complete 3/29)

oConveyor toaster. (complete 3/29 / will be replaced)

oHandles of spice cabinet. (complete 3/29)

oRadio mounted under spice cabinet. (complete 3/29)

oStand-up mixer: Food spills, splatters, debris, dust, and dirt was observed on, inside, around or underneath

(complete 3/29 / will be replaced)

oFlooring edges and base trim throughout the kitchen.

(complete 3/29)

oWalls throughout the kitchen. (complete 3/29)

oCeiling vents throughout the kitchen. (complete 3/29)

oCeiling tiles throughout the kitchen. (complete 3/29)

oStainless steel shelving throughout the kitchen.(complete 3/29 - some will be replaced)

oLegs of stainless-steel shelving throughout the kitchen. (complete 3/29)

oMultiple food service carts. (complete 3/29)

oIce machine grate and air vents.(complete 3/29)

oCabinets under steam table.(complete 3/29 / getting        bids on replacement upgrade to stainless steele)

oWall and pipes behind the stove and ovens. (complete 3/29)

oChains suspending the warming lamp of the steam table. (complete 3/29)

oCaulking around ware washer area and wall underneath ware wash and sprayer sink. (complete 3/29)

oIndustrial can opener.(complete 3/29)

oKitchen Aid mixer.(complete 3/29 / will be replaced)

oWalk-in refrigerator (complete3/29)

oFans throughout the kitchen; and floor drains in the kitchen. (complete 3/29)

Plan of Correction / Cleaning:

1. Commercially Cleaning the Kitchen to give the           staff a starting point of cleaning.

2. Cleaning schedule established to be more comprehensive in cleaning efforts. Cleaning schedule to be daily, weekly and monthly along with replacing some older equipment.

3.Daily, weekly and monthly

4. Dietary supervisor and Administrator

The following equipment needed repair:

oTrim and corner guards throughout the kitchen were lifted, broken, or missing. (completed 3/26)

oCeiling tiles with holes throughout the kitchen (completed 3/26)

oDoor and door frame to the dining room had gouged wood and chipped paint. (completed 3/26)

oSealant of previously repaired floor near drink station was worn and missing in some areas. (completed 3/26)

oDish racks were chipped and broken. (disposed of and replaced)

oTemperature gauge covers of the ware washer machine were missing. (replaced)

oCabinets under the steam table had exposed wood and multiple broken handles and misaligned doors. (completed 3/26 / getting bids for replacement)

oStand-up mixer coating was chipped.(being replaced)

oStainless steel three-tiered cart had a broken handle.(being replaced)

oMultiple cutting boards had brown marks and were warped.( disposed of and replaced)

oWalk-in freezer door was rusted and had a broken seal which caused frozen condensation to line the exterior edges of the door. (Technician scheduled for 4/15/ 2024)

oWalk-in refrigerator door, walls and floors were rusting, including around the fire sprinkler system. (scheduled tech on 4/15)

oWhite upright refrigerator had a discolored and broken seal around the door. (replace for stainless fridge)

oPrep sink pipes were leaking.(complete 3/26)

oUnpainted wood panel attached to the wall underneath the prep sink and

oSink faucet in ware wash area was broken and unable to be turned off. (complete 3/26 )

Plan of Correction / Repair and Replacement:

1. Director of Maintenance is getting several bids to replace several pieces of kitchen equipment such as the steam table, cabinets, upgrading the entire kitchen to Stainless Steele, replacing the refrigerator and ice bin, stand up mixer, 3 tier racks inside and outside of the walk in. Walk in Freezer door seal replacement.

2. Adding a scheduled monthly walk through and maintenance log with the facility maintenance team and dietary supervisor to ensure the kitchen is well maintained and in good repair.

3.This is monitored daily, weekly and monthly

4. Dietary Supervisor, facility maintenance and Administrator

Infection control related to the use of aprons for caregivers serving food, hand hygiene during food preparation, hand hygiene between dirty and clean tasks, and use of gloves.

(scheduled date of in-service for all dietary staff is 4/17/2024)

Plan of Correction / Infection Control

1. Director of Health Services to do "hands on" infection control training with each member of the dietary team and the staff will be expected to demonstrate skill to get signed off.

2. Scheduled 10-minute review on a weekly basis with all dietary staff.

3. This is monitored daily, weekly and monthly

4. Dietary Supervisor, licensed nurse, and Administrator.

Based on observation 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. This is a repeat citation. Findings include, but are not limited to:

On 06/27/24 at 1:00 pm, the facility's kitchen was toured and food service was observed.

The following areas were in need of repair:

* The conveyor toaster had a broken leg and was covered in food debris and grease build-up;

* Steam table needing repair;

* Walk-in freezer door was broken with frozen condensation lining the exterior edges of the door; and

* Walk-in walls, doors, floors and ceiling including fire sprinkler system were rusting.

At 1:15 pm in an interview with Staff 2 (Food Services Director), he stated he was getting bids to replace the steam table completely.

The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 06/27/24. They acknowledged the findings.

Based on observation and interview, 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 and Z 142.

1. Review response to tag 240.

2. By adapting a more comprehensive cleaning schedule, we are also hiring an additional staff member to focus more on cleaning. We are currently getting bids on purchasing replacement equipment and repair in order to maintain the kitchen according to licensing standards once we are back in compliance to better maintain practices going forward.

3. Daily, weekly and monthly according to cleaning schedules.

4. Dietary Supervisor and Administrator

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

Refer to C240 and Z142.

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 C240.

Refer to C240

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 240.

Please refer to tag C 240 and tag C 455

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C240.