The findings of the kitchen inspection, conducted 05/24/24, 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 05/24/24, conducted 07/26/24, 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 Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility kitchen were made from 9:32 am to 11:55 am on 05/24/24. The following was identified:

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

* The kitchen walls;

* The floors under shelving and appliances;

* The open metal shelving and carts, and the white-coated shelving throughout the kitchen;

* The small appliances on the metal shelf to the left of the oven;

* The oven vent, knobs, interiors, and the sides of the ovens;

* The sink spray handle;

* The area between the sink backsplash and the wall;

* The kitchen drains;

* All utensil storage bins and trays;

* The lids and exterior of plastic dry storage bins in the dry good storage;

* The corrugated roll-up door over the kitchen pass;

* The exterior sides and interior floor of the freezer; and

* The ceiling, refrigerator, freezer, and ice machine vents.

b. Knives and spatulas were observed with taped handles, worn plastic, and/or missing pieces of the rubber part of the spatulas.

c. Multiple food items in the dry storage area and a bin on top of the microwave were open or not securely closed, as well as not dated when opened.

d. Multiple items were observed in the reach-in refrigerator that were not dated when opened and/or were not securely closed.

e. A watermelon in an open box was stored on the floor in the dry goods storage area.

f. Scoops and spoons were found stored in bins of raisins, brown sugar, and dry gravy mix.

g. There were baking trays and racks stored on the floor between the oven and the wall.

h. The shelf under the fryers to the left of the oven was covered in cardboard, creating a potential fire hazard and an uncleanable surface.

i. Multiple caregivers were observed serving food and assisting residents with feeding without protective barriers over their clothing. Aprons (clean barriers) are required for caregiving staff when preparing and/or serving food to residents, to prevent potential spread of infectious agents that could arise from caregiving tasks.

j. Eggs used for soft-cooked entrees were not pasteurized, and were stored above fruits and vegetables in the refrigerator.

k. The facility's policy for sick employees was requested at 9:55 am. Staff 1 (Assistant Administrator) provided a document which did not address facility guidelines for when an employee was to not work (e.g., with symptoms of illness such as cough and fever), and did not address guidelines for the employee returning to work (e.g., symptom-free for 24 hours).

The above areas were reviewed with Staff 1 on 05/24/24. He acknowledged the findings.

What actions will be taken to correct the rule violation for each example/resident?

The following corrections will be implemented to comply with the Food Sanitation Rules, OAR 333-150-000:

- Inspected areas, high-touch areas and appliances will be sanitized.

- Damaged or modified utensils will be replaced and stored properly.

- Food items will be stored approprietly and dated.

- The cardboard material between the shelf and the fryer will be removed and replaced with steel shelving.

- Caregivers serving meals will wear clean protective clothing such as aprons.

- Eggs used for soft-served dishes will be made from pasteurized eggs supplied by US Foods. Unpasteurized eggs will only be used as an ingredient in cooked dishes. This food item will be stored in proper order of storage.

- As part of the policy, managing sick employees

will be established, and will be acknowledged and

signed by all staff members.

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

- The administrator will conduct a comprehensive inspection to ensure the cleanliness and sanitization of

the entire kitchen area and will collaborate with its staff members to address any identified issues.

- The established policy will include clear guidelines on when employees should stay home, procedures for

reporting illness, and steps for returning to work. All staff members will be required to acknowledge and

sign this policy, ensuring that everyone is aware and adheres to the guidelines.

How often will the area needing correction be evaluated and who has been assigned to evaluate the

efforts?

- Bi-monthly kitchen inspections, conducted by the administrator, will ensure that the kitchen staff consistently fulfill their responsibilities in maintaining the area. Any identified damages and other issues in the kitchen environment and appliances will be promptly addressed.

- The policy's effectiveness and compliance will be evaluated on a monthly basis by the Human Resources Manager. During these evaluations, the HR will review staff adherence to the policy, and make necessary adjustments if needed to improve its implementation.

Who on your staff will be responsible to see that the corrections are completed and monitored?

- The head of the kitchen staff will be responsible for ensuring that all corrections are completed and monitored, following a checklist that includes daily, weekly, monthly, and quarterly tasks. The administrator

will conduct bi-weekly inspections to oversee the process and ensure compliance.

- The Human Resources Manager will be responsible for ensuring that the sick employee policy is properly implemented and monitored. This includes maintaining records of reported illnesses, ensuring staff compliance, and coordinating with department heads to

address any issues. The administrator will conduct periodic reviews to ensure overall compliance and

effectiveness.