Print Inspection: ZYE6

The findings of the kitchen inspection, conducted on 05/10/24 and 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 first revisit to the kitchen inspection of 05/13/24, conducted 09/19/24, 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 in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main kitchen, basement and refrigerator room outside of the main kitchen on 05/10/24 at 11:18 am identified the following:

The following areas were in need of repair:

* Multiple floor tiles and grout were broken, including a corner baseboard tile behind the turbofan appliance;

* There was a leaking pipe beneath the three compartment sink;

* Commercial refrigerator in the main kitchen had rusted shelves and a broken door seal;

* The upright side-by-side residential style refrigerator/freezer combo located in a room outside of the main kitchen was not cooling/maintaining temperatures;

* Two upright freezers located in a room outside of the main kitchen had a build-up of ice and frost on the interior walls;

* One white upright freezer located in a room outside of the main kitchen had a damaged door seal;

* The floor inside the refrigerator room located outside of the main kitchen had multiple areas of torn floor covering which exposed the wood floor beneath;

* Two dorm room size refrigerators in the basement were not cooling/maintaining temperatures; and

* Two chest style freezers in the basement had a build-up of ice and frost around the interior walls.

The need to ensure the kitchen was maintained in good repair in accordance with the Food Sanitation Rules was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 (Culinary Director) on 05/13/24. They acknowledged the findings.

"Two upright freezers & chest freezers ice build up"

What actions will be taken to correct the rule violation? We defrosted all freezers on 5/11/24 and 5/12/24 and are now working with Recipes and Rotations to minimize our frozen foods.  We have also increased our delivery schedules.  

How will the system be corrected so this violation will not happen again?

CSD is checking freezers every 2 weeks to ensure that ice is not building up.  

o How often will the area needing correction be evaluated?

Every two weeks

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

CSD, Administrator

o Date facility alleges compliance- 5/13/2024

"Leaking pipe beneath the three compartment sink"

What actions will be taken to correct the rule violation? We are repairing the leak at the same time that we repair the flooring to ensure leveling.

How will the system be corrected so this violation will not happen again?

Maintenance Tech will inspect plumbing on a monthly basis and staff will report any water issues in the interim to maintenance tech or administrator.

o How often will the area needing correction be evaluated?

Monthly

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

Regional Director of Facilities, Administrator, Maintenance Tech

o Date facility alleges compliance- 7/12/2024

1. What actions will be taken to correct the rule violation for each example/resident?"Commercial Fridge rusted shelves, broken seal"

What actions will be taken to correct the rule violation? We are sanding and using a product to paint the shelves (manufacture approved) as replacement shelves are no longer made. We have orderd a new seal and will replace upon arrival  

How will the system be corrected so this violation will not happen again?

CSD will inspect shelves and seals on a 2 week schedule

o How often will the area needing correction be evaluated?

Every two weeks

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

CSD, Maintenance Tech

o Date facility alleges compliance- 7/12/2024

7/12/2024

"Dorm Fridges"

What actions will be taken to correct the rule violation? All non working appliances have been recycled.   

How will the system be corrected so this violation will not happen again?

Staff have been inserviced on using appropriate appliances  

o How often will the area needing correction be evaluated?

Annually

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

CSD, Administrator

o Date facility alleges compliance- 7/12/2024

What actions will be taken to correct the rule violation? We are replacing all flooring in the kitchen and refrigeration area.  

How will the system be corrected so this violation will not happen again?

Staff have been instructed to immediately report any abnormalities or repair needs to the administrator or maintenance tech.

o How often will the area needing correction be evaluated?

Daily

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

CSD, Administrator, Maintenance Tech, Culinary Team

o Date facility alleges compliance. 7/12/2024

"White upright Freezer damaged door Seal"

What actions will be taken to correct the rule violation? We are ordering a replacement freezer and have modified ordering schedules in the interim.   

How will the system be corrected so this violation will not happen again?

CSD is checking appliance seals monthly  

o How often will the area needing correction be evaluated?

monthly

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

CSD, Administrator

o Date facility alleges compliance- 7/12/2024

"Residential Type Fridge not temping"

What actions will be taken to correct the rule violation? We have put an out of order sign on the fridge and are ordering more frequent deliveries to accommodate the space that we have with our current refrigeration.  We are working on recycling all non working appliances.   We are ordering new refrigeration to deliver at the completion of flooring.  

How will the system be corrected so this violation will not happen again?

We have update our temperature monitoring and inserviced staff.

o How often will the area needing correction be evaluated?

Daily

o Who on your staff will be responsible to see that the

corrections are completed/monitored?

CSD, Administrator

o Date facility alleges compliance- 7/12/2024