The findings of the kitchen inspection, conducted 2/1/23, 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 02/01/23, conducted 04/09/23, 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, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen and dining areas, food storage areas, food preparation, and food service on 2/1/23 from 10:10 am through 12:45 pm revealed the following:

a. Splatters, spills, drips, dust, dirt and/or debris noted on:

- Wall near kitchen entrance;

- Inside drawers and cupboards;

- Inside of microwave;

- Interior and exterior of oven and range top;

- Corners and edges of shelving in dry storage;

- Ice dispenser of reach in refrigerator;

- Interior of reach in refrigerator;

- Fire sprinkler heads;

- Outlet and light switch covers; and

- Phone.

b. The following areas were in need of repair:

- Contact paper on shelving in dry storage with peeling or missing areas;

- Areas of wood shelving in dry storage with wood exposed;

- Damage to wall behind retractable door to water heater;

- Damage to wall under cupboards next to entrance door; and

- Tape on dishwasher handle.

c. Multiple cutting boards and food storage containers were found with deep scoring and/or staining.

d. Scoops were found stored in coffee and sugar containers.

e.  Multiple items in refrigerator were observed to be passed their use by dates.  A bag of grapes had evidence of rotting fruit.

f. Staff 2 (Universal worker/Person in Charge) did not check the temperature of egg salad before preparing sandwiches for lunch service.

g. Person In Charge (PIC) observed touching RTE (Ready To Eat) foods with potentially contaminated gloves.

h. The PIC was not able to demonstrate adequate knowledge of the following:

- proper reheating temperature requirements;

- proper cooling procedures and temperatures;

- procedure for validating or checking sanitation concentration for surfaces; and

- procedure for validating dishwashing sanitation.

i. Staff 2 was observed entering kitchen area after care giving tasks without donning an apron or sanitizing hands. Other care giving staff also observed entering and exiting kitchen area without donning aprons or washing or sanitizing hands.

j. A resident was observed to be allowed to set tables with silverware for other residents. Facility staff provided resident with container of utensils with food contact surfaces upright making them accessible to touch the food contact surfaces while distributing. The resident was then observed to cough in her gloved hand and touch handles of walker and then touch the food contact surface of the silverware with potentially contaminated gloves. The resident was not adequately supervised to prevent potential cross contamination of silverware.

On 2/1/23, Staff 2 and the Surveyors toured the kitchen. Staff 2 acknowledged the above findings.

At 12:15 pm, the Surveyor reviewed findings with Staff 3 (Owner). Staff 3 acknowledged the areas of concern.

a.

1. These areas will be on a weekly checklist where staff will have to sign when cleaned.

2. A weekly schedule will prompt the staff with tasks they need to do to make sure that these area are clear of splatters, spills, drips, dust, dirt, and debris.

3. Weekly and will be added to the monthly quality assurance program.

4. Administrator will make sure that this is monitored by assigned staff

b.

1. Contact paper will be replaced to cover exposed wood shelving in the dry storage area, damage to the wall behind the water heater has been fixed with plaster and will be painted. The wall next to the entrance door has been repaired with plaster and will be painted. The tape has been taken off the handle of the dishwasher.

2. This will be checked weekly and with monthly maintenance quality assurance schedule.

3. Weekly and monthly quality assurance program.

4.  Administrator will make sure that this is monitored by assigned staff

c.

1. Cutting boards and storage containers have been thrown out and replaced with new cutting boards and storage containers.

2. This will be added to the weekly checklist and added to the monthly quality assurance schedule.

3. Weekly and monthly quality assurance program.

4.  Administrator will make sure that this is monitored by assigned staff

d.

1. Scoops have been taken out of the coffee and sugar. All staff have been instructed to not to put scoops in containers that hold these such foods.

2.This will be added to the weekly and added to the monthly quality assurance schedule.

3. Weekly and monthly quality assurance program.

4.  Administrator will make sure that this is monitored by assigned staff

e.

1. Items in the refridgerator will be on a weekly check list. Staff will need to look at all the dates and fruit in the refrigerator to make sure that the items are not out of date and food is rotated to have oldest date in front to be used first.

2. A weekly checklist will be used to make sure that food is being checked for dates and rotated out.

3. This will be checked weekly and added to the monthly quality assurance program.

4. Administrator will make sure that this is monitored by assigned staff

f,g,h,i.

1. All staff will be retrained on proper cooking temperatures, reheating, cooling procedures, kitchen procedures upon entering the kitchen, i.e. washing/sanitizing hands, putting on an apron and when to take off, cross-contamination of food, proper procedure and chemical concentrations for sanitizing surfaces and procedure for dishwasher sanitizing.

2. Administrative team will observe staff in kitchen and ask questions to make sure staff are able to answer questions about proper kitchen procedures. Training will be added to our monthly staff meetings three times each year to ensure all staff are knowledgable and will be added to the monthly quality assurance program.

3. Three times a year and monthly

4. Administrator will make sure that this is monitored by assigned staff

j.

1. Staff will put the utensils out when residents are served their meals rather than allowing residents to help.

2. The risk of potential cross contamination was explained to the resident and staff. Staff will be the ones to give silverware to residents when serving at meal times.

3. Daily

4. Administrator will make sure that this is monitored by assigned staff