Print Inspection: YU9H

The findings of the kitchen inspection, conducted 08/16/24, 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 first re-visit to the kitchen inspection of 08/16/24, conducted 11/01/24, 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 08/16/24, conducted 02/07/25, 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 main facility kitchen on 08/16/24, from 10:30 am through 1:30 pm, revealed the following deficient practices:

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:

* Ceiling vents and light fixtures;

* Sprinkler heads;

* Interior of microwave;

* Interior and exterior of commercial toaster;

* Range top;

* Sides of industrial equipment (oven/range/grill);

* Top shelf of service line;

* Industrial mixer;

* Floors throughout the kitchen had black matter build-up, food debris, and grease in corners and behind, in between, and under equipment;

* Walk-in cooler floor;

* Walk-in freezer door threshold;

* Utility carts;

* Floor and walls of entry way to kitchen/dining room; and

* Cabinets storing clean dishes.

b. The following areas needed repair:

* Multiple utility carts with cracks/damage;

* Gas range top flame causing excessive carbon build up/damage to pots and pans;

* Baseboards and walls near kitchen entry way and dining room beverage area with scrapes, gouges, and other damage.

c. Multiple food items/packages/containers found in cold food storage that were not covered or properly closed/sealed and were exposed to potential contamination.

d. Multiple food items were not dated when opened and/or prepared. Multiple food items found past their use-by dates.

e. Single service utensils and plates found in dry storage area open/exposed to potential contamination.

f. Multiple pans, pots, and/or cutting boards were noted to be heavily worn, stained, scratched, and/or damaged.

g. Cook was observed preparing and serving food with facial hair not restrained. A staff member was observed serving soup with long acrylic nails that were not covered by gloves as required.

h. Dining room was observed with tables pre-set at 10:30 am for lunch service at noon. Food contact surfaces of utensils and tableware were not covered or inverted to protect from potential contamination.

Staff 2 (Dining Service Director) toured the kitchen with surveyor and acknowledged areas of concern.

At 1:30 pm, surveyor reviewed identified issues with Staff 1 (Administrator), and they acknowledged the areas needing correction.

A.

   1. Dietary Services Director to preform weekly cleaning inspection of all areas in Kitchen and where food preperation or storage occurs.

  2. Weekly cleaning inspection to be preformed by Dietary Services Director, then followed up by a monhtly cleaning inspection to be preformed by Administrator to ensure complaince standards are continuously met.

  3. Inspections moving forwardwill be conducted weekly by DSD, then monthly by Administrator.

  4. The Dining Services Director will be responsible for maintaining oversight of cleaning scheduleds, process, and execution.

B.

  1. Broken utility carts have been removed and replacments are to be ordered ofr dietary use. Quotes for the gas range replacemtn have been submitted for approval to the ownership group to eliminate the possiblity of future damage to pots and pans. The baseboards and walls near kitchen have been reviewed with regional director of enviromental services and a plan to repair the damaged areas has been established with the enviromental services director.

  2. All items/ effected areasare to be added to the weekly inspection for the Dietary Services Director weekly inspection to ensure all aspects of Kitchen/ Dining room remain in good repair.

  3. These items will be monitered weekly and reviewed monhtly with the Administrator to ensure continued compliance.

  4. The Dietary Services Director will be responsible for monitering and mainiting all aspects of Kitchen and Dining room.

C.

  1. Dietary staff are to retake Oregon Care Partners training regarding food sefty storage and labeling to ensure compliance and safe practices. All single serving items will be stored appropriatly in closed cabinets moving forward. All damaged or worn pots, pans, and cutting boards are to be replaced immediately. All dietary and care staff are to retake food handling training course on Oregon Care Partners to ensure proper use of hair nets and glove protocol. To esnure that presetting tables is done appropriately, dietary aides will begin prewrapping utentsils that will sit out before service to ensure they are not exposed to contaminents and cups/ glassware will be inverted to ensure cleanliness.

  2. All trainings will be monitered by Business Office Manager to ensure compliance. All purchasing of replacement items in kitchen will be overseen by Dietary Services Director and monitered monhtly to ensure continued compliance. Dietary Services Director will oversee table setting procedures to ensure compliance moving forward and will correct as needed.

  3. All areas of correction will be reviewed weekly by Dietary Services Director and reported to Administrator monthly upon inspection. The Business Office Director will audit for training compliance quarterly.

  4. The Business Office Director will be responsible for training and education compliance moving forward. The Dining Services Director will be responsbile for continued compliance in dining room and to ensure that all cooking tools and untesils are in adequette condition. The Administrator will provide a monthyl inspection to ensure standards are being met and upheld moving forward.  

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 main facility kitchen on 11/01/24, from 12:30 am through 2:00 pm, revealed the following:

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:

* Interior of microwave;

* Interior of commercial toaster;

* Range top;

* Sides of industrial equipment (oven/range/grill);

* Top shelf of service line;

* Industrial mixer;

* Floors throughout the kitchen had black matter build-up, food debris, and grease  in between, and under equipment;

* Walk-in cooler racks;

* Cook utility cart;

* Industrial can opener and housing;

* Spice racks;

* Speed rack;

* Walls by prep and beverage spaces; and

* Cabinets storing clean dishes.

b. The following areas needed repair:

* Blue utility carts with cracks/damage; and

* Baseboards and walls near kitchen entry way and dining room beverage area with scrapes, gouges, and other damage.

c. Multiple food items/packages/containers found in cold food storage that were not covered or properly closed/sealed and were exposed to potential contamination. Speed rack with lunch side items with all food items not covered and exposed to potential contamination.

d. Multiple food items were not dated when opened and/or prepared. Multiple food items found past their use-by dates.

e. Single service cups and plates found in dry storage area open/exposed to potential contamination.

f. Multiple pans, pots, and/or cutting boards were noted to be heavily worn, stained, scratched, and/or damaged.

g. Dirty cleaning rags were found stored on service line and prep areas on counters and not in sanitation buckets. Multiple dirty/used rags were found in a green bucket with no visible liquid. The red sanitation bucket was empty.

h. Multiple dishwashing racks were found stored on the floor next to the dirty drain.

Staff 2 (Dining Service Director) toured the kitchen with surveyor and acknowledged the findings.

At 1:40 pm, the surveyor reviewed identified issues with Staff 1 (Executive Director), and Staff 2 (Dining Services Director). Both acknowledged the areas needing correction.

1. For items a,c,d,e,g,h, Dietary Services Director to preform weekly cleaning inspection of all areas of kitchen and where food preperation or storage occurs.

For item b, new utility carts will be ordered. The baseboards and walls near kitchen entry way and dining room beverage area will be repaired.

For item f, equipment that is noted to be heavily worn, stained, scratched, and/or damaged will be replaced with new items.

Dining Services staff will be assigned training through Oregon Care Partners regarding  proper food handling, food storage and sanitation practices.

2. Weekly cleaning inspection to be preformed by Dietary Services Director, then followed up by with a weekly kitchen sanitation inspection to be preformed by Administrator until compliance has been achieved. The Business Office Manager will monitor completion of assigned trainings.

3. Inspections moving forward will be conducted weekly by DSD, then monthly by Administrator. Training requirements will be monitored by the Business Office Manager.

4. The Dining Services Director will be responsible for maintaining oversight of cleaning scheduleds, process, and execution. Training requirements will be monitored by the Business Office Manager.

Based on record review and interview, it was determined the facility failed to ensure 2 of 7 staff (#s 2 and 3) who prepared food had active food handler's certificates. Findings include, but are not limited to:

On 08/16/24 at 10:30 am, employee records were requested and reviewed to ensure staff had active food handler's cards. Food cards for Staff 2 (Dining Service Director) and Staff 3 (Cook) could not be located. Staff 1 (Administrator) stated she would continue to look for documents and forward to surveyor if/when found.

On 08/16/24 at 3:45 pm, surveyor received copies of Staff 2 and Staff 3's food handler's certificates, which were dated effective 08/16/24. Staff 1 (Administrator) was interviewed and acknowledged that there was no documented evidence located that Staff 2 and Staff 3 had active food handler's certificates upon kitchen survey entrance as required. Staff 1 validated that the duties of Staff 2 and Staff 3 did include food preparation, that the facility should have had current food handler's cards on file, and that both employees obtained their required certificates after surveyor had identified them as missing.

1.All cooks, including the Dietary Services Director, have provided up-to-date copies of their food handlers card and will maintain these certifications moving forward.

2. An aduit will be preformed by Business Office Director on a quarterly basis on all employee files to ensure that all certifications remain in good standing.

3. Audits will be preformed every 3 months beginning September of 2024 to ensure comtinued compliance.

4. The Business Office Director will be preforming audits to ensure continued compolaince for training and certification.

Based on interview, observation, and review of records, 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.

1. The Dining Services Director and Administrator will create a POC binder to track progress on areas identified in the POC to ensure that the community is in compliance by 1/17/2025

2. The Dining Services Director and Administrator will meet twice weekly to ensure the items identified in the POC are addressed and procedures implemented are effective.

3. The area needing correction will be evaluated twice a week until compliance is achieved.

4. The Administrator is responsible to see that the corrections are completed/monitored.