Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and food was prepared and served 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 kitchen was inspected and the following was identified:1. The kitchen was observed to need cleaning and repair in the following areas:a. Food spills, splatters, debris, dust, dirt, rust, and black matter was observed on, inside, around or underneath the following: * Walls and ceilings throughout the kitchen and dry storage area;* Sprinklers and smoke detectors on the ceilings throughout the kitchen;* Stainless steel shelving throughout the kitchen;* Stainless steel cabinets throughout the kitchen; * Legs of stainless steel shelving throughout the kitchen;* Two fans affixed to the walls;* Warewasher;* Ceiling lights;* Handles and exterior of dry goods bins;* The turquoise cart holding jams;* Shelving, drawers, and heat lamp frame in the grill area;* Pipes, walls, and shelving in, under, and around the warewasher;* Kitchen light switches on the wall near the back office;* Toaster; and* Ceiling vent.b. The following equipment was found in poor repair:* Dishwasher racks;* Metal bread rack with brown trays;* The floor between the dishwashing area and pot storage had a large crack, exposing subflooring;* A piece of laminate baseboard next to the garbage can in the food prep area was peeling away from the wall and had food debris on it;* The freezer pipe on the ceiling had a large stalactite hanging from it;* The ice machine was leaking on both bottom front corners; and* The white spatulas had pieces chipped off.2. Staff were observed preparing and serving food and the following was identified:* Scoops were stored inside the dry goods bins;* The hobart and stand mixers were uncovered;* The eggs were stored on the top shelf above other food in the refrigerator;* Staff 3 (Cook) observed to wear the same pair of single-use gloves while completing a number of tasks including making sandwiches, throwing expired food away, and retrieving food from the refrigerator;* Staff 7 (CG) and Staff 8 (CG) were observed serving and feeding residents without wearing a protective barrier over potentially contaminated clothing; and* Staff 7 was observed delivering uncovered plates and beverages to resident rooms.During an interview at 10:30 am on 12/07/23, Staff 2 (Kitchen Manager) confirmed eggs were used for soft preparations and could not confirm the eggs used were pasteurized.The need to ensure the kitchen was clean and in good repair and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ALF Administrator) on 12/07/23. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair and food was stored in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 02/21/24 at 1:33 pm, the kitchen was inspected and the following was identified:1. Food spills, splatters, debris, dust, dirt, rust, and black matter was observed on, inside, around or underneath the following: * Fire sprinklers on the ceilings throughout the kitchen;* Pipes and walls, underneath the warewasher and sprayer sink;* Walls in the dry food storage area and janitor's closet;* Knife storage racks and knives stored on the wall in the dry food storage area; * Kitchen light switches on the wall near the back office and janitors closet; and* Walk-in freezer floors had an accumulation of food debris.2. The following equipment was found in need of repair:* The floor throughout the kitchen had large cracks and exposed subflooring in multiple areas;* Laminate baseboard throughout the kitchen was peeling away from the wall;* The ice machine was leaking on both bottom front corners; * The "Heated Holding Cabinet" (next to the stove) was inoperable;* The painted finish on the walk-in refrigerator was peeling off;* Multiple refrigerator/freezer shelving was rusted;* The hinges and door handle on the walk-in freezer door were rusted;* The freezer pipe on the ceiling had a large stalactite hanging from it and exposed electrical wire; and* The wooden janitor's closet door had chipped and exposed wood rendering the surface uncleanable. 3. Observations of food storage identified the following:* Food product in the walk-in freezer was stored on the floor, was improperly shelved and food was left open to air creating a situation for the potential of environmental cross contamination and freezer burn;* There were multiple unlabeled, undated food items in the walk-in refrigerator; and* Multiple food items in the dry food storage area were left open to air. The need to ensure the kitchen was clean and in good repair and food was stored in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ALF Administrator), Staff 6 (MCC Administrator) and Staff 7 (Community Coordinator) on 02/21/24. They acknowledged the findings.
Plan of Correction:
Resident Services Meals, Food Sanitation Rule: 1.) The following areas have been deep cleaned and dust/food/debris removed: a. Walls & ceilings throughout in kitchen and dry storage area, b. sprinklers and smoke detectors on the ceilings throughout the kitchen, c. stainless steel shelving throughout the kitchen, d. stainless steel cabinets throughout the kitchen, e. legs of stainless steel shelving throughout the kitchen, f. fans affixed to the walls, & warewasher; g. ceiling lights, h. handles and exterior of dry goods bins, i. the turquoise cart holding jams, j. shelving, drawers, and heat lamp frame in the grill area, k. pipes, walls, and shelving in, under, and around the warewasher, l. kitchen light switches on the wall near the back office, m. toaster, & n. ceiling vent.2.)A daily, weekly, & monthly cleaning log with instructions will be followed by kitchen staff and will include all deficiencies listed above. The kitchen staff will maintain/clean all areas of kitchen based on cleaning schedule implemented.3.) Community Admin & Dietary manager will review the kitchen, including all deficiencies above, once weekly during walk-throughs of the kitchen. 4.) Community Admin & Dietary Manager will be responsible to ensure all corrections are made and maintained.Resident Services Meals, Food Sanitation Rule: 2a.) The folloiwing equipment will either be repaired or replaced if repair isn't possible, a. dishwasher racks, b. metal bread rack with brown trays, c. the floor between the dishwashing area and pot storage had a large crack, exposing subflooring, d. a piece of laminate baseboard next to the garbage can in the food prep area was peeling away from the wall and had food debris on it, e. the freezer pipe on the ceiling had a large stalactite hanging from it, f. the ice machine was leaking on both bottom front corners, & g. the white spatulas had pieces chipped off.2b.) As part of the weekly walk-through of the kitchen, the dietary manager and admin will identify equipment that is in need of repair or replacement. The administrator will work with the dietary manager on an on-going plan & timeline of repairs or replacements needed. 2c.) The admin and dietary manager will do once weekly walk-throughs of the kitchen to better identify cleaning & repair needs.2d.) The dietary manager and admin will responsible for ensuring oversight & compliance in this area.Resident Services Meals, Food Sanitation Rule: 3a.) The scoops were removed from the dry storage bin, hobart and stand mixers have been covered, & eggs are now stored in the appropriate spot in the refrigerator (removed from top shelf to reduce risk of contamination to food underneath eggs). All dietary and universal staff are scheduled to receive infection control & prevention training. This training will include: washing hands and the use of gloves in the kitchen secondary to cross contamination, the imortance of wearing clothing protectors/aprons when assisting with feeding and/or delivering food, and all kitchen staff will be trained on the importance & requirement that all eggs must be pasteurized. Staff have been educated on covering beverages and plates when delivering meal trays to resident rooms.3b.) As a part of the weekly walk-through of the kitchen, the admin and dietary manager will observe dry storage areas & equipment to ensure appropriate storage of mixers and scoops. During weekly walk-through of the kitchen, the admin and dietary manager will observe dietary and universal staff when delivering food and/or when assisting residents with feeding to ensure appropriate infection control measures are in place at all times. Dietary staff will continue required on-going education on infection control & cross contamination, as required. 3c.) Dietary manager and admin will conduct once weekly walk-throughs of the kitchen to ensure compliance with the above citations as well as complete visual observation of dietary staff to mitigate risk of infection or cross contamination. 3d.) The dietary staff and admin will be responsible for ensuring oversight and compliance into all above cited areas. C 240 SS=FOAR 411-054-0030 Resident Services Meals, Food Sanitation Rule01. Immediate actions taken to correct the rule violation include: The main kitchen has been deep cleaned, addressing cleanable surfaces. A plan is in place to repair items/areas that were unable to be resolved immediately. Plan of correction was created ensuring that all areas noted on the SOD are to be resolved, cleaned and repaired. All items requiring replacement have been ordered/scheduled for replacement.a. Food spills, splatters, debris, dust, dirt, rust, and black matter was observed on, inside, around or underneath the following:i. Fire sprinklers on the ceilings throughout the kitchen- cleaned, removing dust/dirt & replacement of sprinkler heads that were uncleanable.ii. Pipes and walls, underneath the warewasher and sprayer sink-were scrubbed clean removing food debris/dust/dirt.iii. Walls in the dry food storage area and janitor's closet- cleaned and repainted dry storage, install of FRP to reinforce and provide cleanable surfaces on/in janitor closet and on refrigerator wall in dry storage.iv. Knife storage racks and knives stored on the wall in the dry food storage area- cleaned & moved to meal prep area wall for safety. Disposed of all knives that had porous handles.v. Kitchen light switches on the wall near the back office and janitors closet- removed and replaced with clean/new plates. vi. Walk-in freezer floors had an accumulation of food debris- shelving units moved and floors have been cleaned.b. The following equipment was found in need of repair:i. The floor throughout the kitchen had large cracks and exposed subflooring in multiple areas- flooring is being replaced throughout the entirety of the kitchen. Supplies ordered, scheduled install date between April 15-26th 2024, due to supplies ordered delivery expectation. ii. Laminate baseboard throughout the kitchen was peeling away from the wall- baseboards throughout the kitchen will be replaced with install of new flooring. iii. The ice machine was leaking on both bottom front corners- machine is being replaced, ordered pending delivery estimated 3/18/24. To be installed upon delivery.iv. The "Heated Holding Cabinet" (next to the stove) was inoperable- cabinet is being removed and replaced, ordered pending delivery estimated 3/18/24. To be installed upon delivery.v. The painted finish on the walk-in refrigerator was peeling off- surface area has been cleaned, removed peeling finish, scheduled to repaint the surface week of 3/12/24.vi. Multiple refrigerator/freezer shelving was rusted- shelves cleaned, removed rust and painted with rustoleum. vii. The hinges and door handle on the walk-in freezer door were rusted- areas to be scrubbed/removed rust and sealed with rustoleum paint.viii. The freezer pipe on the ceiling had a large stalactite hanging from it and exposed electrical wire. - Closure of box with exposed wire replaced, pipe is now covered w/pipe insulation. To be monitored daily, if issue arises again, repair of pipe to be completed by refrigeration specialist.ix. The wooden janitor's closet door had chipped and exposed wood rendering the surface uncleanable- door replaced.c. Observations of food storage identified the following:i. Food product in the walk-in freezer was stored on the floor, was improperly shelved and food was left open to air creating a situation for the potential of environmental cross contamination and freezer burn.--- all food items moved, placed on shelving unit off of floor. Containers closed- proper storage/sealed units purchased for storage of opened food itemsii. There were multiple unlabeled, undated food items in the walk-in refrigerator- thorough review and removal of all food products with no open date and or unlabeled. Re-training of kitchen/dietary personnel provided and direction/guidelines posted for staff reminders/review.iii. Multiple food items in the dry food storage area were left open to air - thorough review and removal off all food products with no open date and or unlabeled. Re-training of kitchen/dietary personnel provided and direction/guidelines posted for staff reminders/review.02. The system will be corrected so this violation will not happen again by : coaching and teaching kitchen staff proper cleaning and utilizing the Kitchen weekly cleaning schedule checklist for staff to use as a guide. The checklist has been updated to incorporate all required components to ensure the kitchen is clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-00003. The cleaning schedule checklist which includes review of proper food storage and labeling, will be reviewed weekly ongoing by the administration team and quarterly with internal company mock survey environmental audits.04. The Executive Director or designee will be responsible for reviewing/monitoring the weekly cleaning schedule to ensure the corrections remain in compliance.