The findings of the kitchen inspection, conducted 10/25/23, 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 10/25/23, conducted 01/04/24, 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, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observations were made in the kitchen on 10/25/23, between 10:26 am and 1:15 pm, with facility staff. The following deficiencies were identified:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following:

*Industrial and counter top can opener and housing;

*Industrial mixer base and dough hook;

*Convection oven;

*Range top;

*Grout behind dishwashing area;

*Fans and ceiling in walk in cooler;

*Handwashing sink near dishwashing area; and

*Bottom two shelves of racks holding clean dishes.

b. Heating and cooling system vents in the food prep and tray line areas, as well as in cold storage, had a build-up of visible dust. The ceiling and walls around the vents also had a visible build-up of dust, risking potential contamination of food.

c. The coating on the blade of the large can opener was peeling off, leaving an uncleanable surface. The blade needed to be replaced.

d. Multiple cutting boards and utility carts were found heavily scored, stained, and/or missing chunks, and needed to be replaced.

e. In the dry storage area, multiple cans of food were observed dented/damaged.

f. Multiple carts were observed lined up against the wall in a hallway near a dining room at 10:20 am. The carts held covered food and uncovered utensils and were accessible by anyone passing the area, exposing them to potential contamination. The Dining Services Manager reported there was a lack of space in the kitchen area for tray set up, so food delivery carts were kept in the hallway until service.

g. Kitchen employee was observed to repeatedly handle RTE (ready to eat) food items with potentially contaminated gloves during tray line service.

h. Memory care kitchenette reach in refrigerator was found to be at 49 degrees Fahrenheit. This was the units resident snack fridge. Review of documentation of temperature sheet revealed 10 times since 10/12/23 that the refrigerator temperatures were at higher than 41 degrees (42-48 degrees). Milk and condiments were observed stored in that refrigerator. Facility administrative staff verified they were not informed of any temperature concerns with that refrigerator.

The findings were shared with the Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 10/25/23 at 1:00 pm. They acknowledged the findings.

C240: a. Action has been taken by refining our cleaning focus to delegate who and when the above-mentioned discrepancies will be cleaned. All tasks will be done by AM and PM kitchen staff. This cleaning focus will be checked daily by leads or designee.Weekly, a checklist with all state required regulations will be used by managers or designee. See attached cleaning focus (1.1) and checklist (1.2).

b. Maintenance will perform regular vent cleaning. A work order will reoccur on the first Monday of every month. The vents, walls, ceiling, and shelving will be checked for any buildup of dust. Wiping walls will be part of the cleaning focus. See attached cleaning focus (1.1). Weekly, a walkthrough performed by the leads or designee, will be performed. See checklist (1.2).

c. A new blade and inner mechanisms have been ordered and sent for immediate repair. See invoice (1.3). A task on the cleaning focus will be delegated by a team lead or designee to clean can openers. See attached cleaning focus (1.1). During the weekly walkthrough done by managers or designee, the can opener will be monitored for food debris or rust build up. See checklist (1.2).

Based on observation, record review and interview, 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 C240.

e. A designated area has been made in the dry storage to place any dented/damaged cans away from non-damaged cans. A memo has been made and training have been put into place to ensure all staff are aware of regulations and how to handle damaged goods on 12/16/23.  Staff that actively put stock away have been trained by leads.During the weekly checklist done by the manager or designee (see 1.2), the dry storage will be monitored to ensure no damaged cans are mixed in with non-damaged cans. Immediate disposal will be taken if damaged cans have been found. See attached notice and training summary (1.6, 1.7)

f. A new policy has been put into place to keep trays from potential contamination. All trays will be stacked and kept in the storage closet with no silverware until needed for tray service. We will no longer have trays set up and ready in the hallway. Moving forward, all food and utensil set up will be done in the kitchen 15 minutes before service starts in the dining room (7:15am, 11:15am, & 4:15pm). Silverware will be wrapped in the napkin to keep from exposure. Serving staff have been trained and a training meeting has been scheduled for 12/16/23. See attached training summary and tray notice (1.7, 1.8).

g. Training has been scheduled to remind all kitchen staff about safe food handling 12/16/23. We have purchased smaller, individual utensils to use for line service to prevent any contamination of ready to eat foods when serving. See invoice and training summary (1.4, 1.7).

h. Training has been scheduled on 12/16/23 to ensure staff are aware of safe refrigerator and freezer temperatures. Temp logs identify what safe temperatures are and to report to managers if temperatures are not safe. See training summary and temp logs (1.7, 1.9.)

C999: (1) All staff have been informed about Noro Virus and the symptoms associated with the virus. A policy has been posted and communicated to maintain infection prevention. Staff are aware of what to do and to contact direct supervisors when symptoms occur to prevent infection. See policy (1.10).

C370 A spreadsheet has been made to ensure that all staff have valid and up to date OR food handler's certificates. The dining service supervisor is to keep track of all food handler's certificates monthly to ensure compliance with regulations. See spreadsheet (1.11).

Z142: The above information applies for memory care.