The findings of the kitchen inspection, conducted 09/08/22, 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.

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The findings of the revisit to the kitchen inspection of 09/09/22, conducted 11/04/22, 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, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

On 09/08/22, multiple staff members were observed not wearing face masks and/or were below their nose while inside the kitchen.

On 09/08/22, the need to ensure staff fully and consistently complied with masking requirements was discussed with Staff 1 (Executive Director), Staff 2 (Executive Chef), and Staff 3 (Dining Supervisor). They acknowledged the findings.

New signage was posted at the entrances to the kitchen and the inside of the kitchen.

Disciplinary action will be imposed on employee members who have violated the policy on safety.

Department managers are accountable and responsible to ensure compliance with safety protocol.

Infection prevention training was added to the New Employee Orientation. This training will also be added to all staff meeting each quarter.  Staff Development Coordinator and Administrator will be responsible to ensure that this is done.

The Health Services Administrator will be responsible to make sure that corrections are completed and being monitored.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 09/08/22, the facility kitchen was observed and the following deficiencies were identified:

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

* Walls and back splashes;

* Freezer and refrigerator;

* Ceiling;

* Floors;

* Doors and door frames; and

* Warming carts.

b. The following areas were in need of repair:

* Floors;

* Multiple cabinets and shelves; and

* Black splashes.

c. Standing water was observed inside of and at the bottom of the refrigerator.

d. Multiple food and beverage items were observed inside the freezer and refrigerator without covers, labels, and/or dates.

On 09/08/22, the areas which required cleaning and repair were observed and discussed with Staff 1 (Executive Director), Staff 2 (Executive Chef), and Staff 3 (Dining Supervisor). They acknowledged the findings.

Cleaning on the ceilings, floors, doors and back splashes were completed.

Regular weekly deep cleaning will be done including the walls, back splashes, freezer, refrigerator, ceilings, floors, doors, door frames and warming carts.

Exposed woods, cabinets and shelves will be protected and painted by the maintenance team.   

Standing water inside of and the bottom of the refrigerator has been cleaned and being monitored.  New refrigerator was ordered.

The Exec Chef and dining room supervisor will ensure that food items are labelled and covered. Meeting and educational training with staff to reinforce compliance on food labeling and covering will be completed. Dining Room Supervisor will do daily rounds to ensure that these are implemented.

The Health Service Administrator will be responsible to see that corrections are completed and will do a weekly checks and walk through in the kitchen areas.