The findings of the kitchen inspection, conducted 05/17/23, 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 05/17/23, conducted 07/19/23, 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 ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen, Memory Care Kitchenette, food storage, prep, and service on 05/17/23 revealed:

Spills, splatters, and debris were noted:

* The sides and interior of the range, grease build up on hood;

* Interior of drawers throughout the kitchen;

* The open shelving and shelving legs throughout the kitchen;

* The can opener blade and casing;

* Interior of reach in refrigerators;

* Knife storage box and bin;

* Food processor;

* Slow cooker;

* Surfaces of prepared food and food bins in dry storage;

* Hot cart used for food delivery;

* Floor throughout the kitchen.

* Staff 3 (Sous Chef) explained the facility used auto dispense Quaternary solution for the sanitizer bucket. There was no documented evidence it was monitored to ensure the correct solution. Staff 3 was unsure of how to test the sanitizer solution. The sanitizer bucket was tested and found to be at the required part per million.

* The high temperature dish machine was not monitored to ensure correct temperatures were reached to sanitize dishes.

* Multiple prepared food items in the walk in, deli, and reach in refrigerators were not covered, dated, or labeled.

* Multiple packaged food items in all refrigerators were not dated when opened.

* There was no evidence of the monitoring of refrigerator temperatures.

* Staff observed washing dishes did not remove gloves or wash hands between handling dirty and clean dishes.

* Staff preparing lunch were observed to not change gloves between tasks.

* Caregiving staff in the Memory Care Unit did not don aprons while serving food to residents.

* Staff 3 (Sous Chef) explained the facility did not use pasteurized eggs and served undercooked eggs.

The areas in need of cleaning, food storage guidelines, infection control, and hand hygiene were reviewed with Staff 1 (Executive Director), Staff 2 (Executive Chef), and Staff 3 on 05/17/23. They acknowledged the findings.

Spills, splatters, and debris:  an in-service was conducted by the Food Services Director (FSD) 5/26-5/30/23 with all Dietary staff covering cleaning and sanitizing including but not limited to areas outlined in this survey. Cleaning schedules will be posted in the kitchen and initialed by staff completing the task(s). Daily spot-checks by Executive Director, FSD, and other management team members will be conducted at random intervals.

An in-service will be completed by FSD regarding documentation of the following areas of concern:  Quaternary solution (for sanitary bucket) including testing the solution, monitoring the temperature on the dish machine.  In-service(s) was conducted re: covering, dating and labeling food items in refrigerated areas for ALL dietary staff.  A separate in-service conducted with all dietary staff for monitoring refrig temps.  These temps will be reviewed as a part of the daily spot-check by management team. Temps will be turned in to Exec Dir during daily stand-up meetings.  Note that all areas noted above reflect existing policy.  The written policies will be reviewed with the appropriate Dietary staff member(s) and the FSD and signed and dated by the individual staff member(s).

Glove usage: staff washing dishes will be required to use gloves when loading dishwasher OR unloading, unless hands are washed by the individual prior to handling clean dishes.  This process will be monitored by FSD and randomly by other members of management team.  This will be an in-service conducted by FSD between 5/26-5/30/23.  

Glove usage during food preperation will include the changing of gloves and/or hand-washing between tasks.  This, too, will be covered in this in-service period.

Cooking of pasturized eggs (and all foods) will be reviewed by the FSD with all cooks and this will be an on-going task.  Ensuring eggs(and all foods) are appropriately cooked will be continuously monitored by all members of the management team. Oversight of all POC will be the responsibility of the Executive Director. (continued)  

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 C 240.

Refer to C 240