The findings of the kitchen inspection, conducted on 07/05/22, 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.

The findings of the revisit to the kitchen inspection, conducted on 11/23/22, 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, 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:

The annual kitchen inspection was conducted on 07/05/22 and revealed the following:

* Black substance on the ceiling tiles above food prep areas;

* Two severely dented cans of Marinara sauce;

* Black substance and food particles on the wall underneath the dish washer;

* Staff not changing gloves between kitchen tasks such as; touching different items in the sandwich bar, going into the refrigerator and grabbing different food items and prepping other foods and, opening the garbage can lid wearing the same gloves and returning to work;

* Side of stove had dried grease and food particles; and

* Thermometer was not sanitized between taking the temperature of different foods.

A tour of the kitchen was conducted on 07/05/22 with Staff 1 (Executive Director) and Staff 2 (Executive Chef). Staff 1 and Staff 2 acknowledged the areas of kitchen needing cleaning.

The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 and Staff 2 on 07/05/22. They acknowledged the findings.

1.) The Environmental Services Director will remove all soiled ceiling tiles and replace with new ones.

Light covers and areas surrounding tiles will be cleaned by dietary employees. Contractors will be consulted regarding potential for revision of kitchen ceiling using non porous materials to allow for better ease of cleaning moving forward.

2.)The kitchen cleaning schedule will be revised to increase cleaning of ceiling tiles and light fixtures to weekly and as needed.

3.)The kitchen cleaning will be audited and evaluated weekly by the Executive Director and Dietary Manager.

4.)It will be the responsibility of the Environmental Services Director and Dietary Manager to assure corrections are completed with Executive Director Monitoring for compliance.

Cont. Tag C240

1.) Cooks will be trained to inspect product when checking in and putting stock away. Kitchen food products will be audited to assure any damaged/dented food items are removed from stock and returned or disposed of.

2.)Training will be provided for all dietary staff to review the

OHA Food Sanitation Rules and Company Policy and Procedure. Monthly culinary meetings will be scheduled for continued education and training moving forward.

3.) Weekly audits of all food storage will be completed weekly by the Dietary Manager and audited monthly by the Executive Director.

4.) It is the responsibility of the Dietary Manager and Executive Director to ensure that the corrections are made and systems are monitored for compliance on a regularly scheduled basis.

Cont. Tag C240

1.) Black substance and food particles were immediately cleaned and removed from underneath the dish washer.

2.) The Kitchen Cleaning schedule will be revised/updated to include Daily cleaning of the dishwasher and surrounding areas.

3.) Cleaning of the dishwasher and surrounding areas will be audited weekly by the Dietary Manager and monthly by the Executive Director.

4.) It will be the responsibility of the Dietary Manager and the Executive Director to ensure that the corrections are completed and monitored.

Cont. Tag C240

1.) Immediate implementation of use of tongs at individual food item containers on sandwich bar. Assurance that gloves are kept in stock at work stations.

2.) Scheduled training for all dietary staff for review of OHA Food Sanitation Rules and Company Policy and Procedure. Random competency observations will be documented for all dietary staff. Ongoing monthly dietary staff meetings with continued training.

3.) Employee performance will be audited monthly with ongoing observation and competencies competed weekly.

4.) It is the responsibility of the Dietary Manager and Executive Director to assure all corrections are completed and monitored for ongoing compliance.

Cont. Tag C240

1.) Immediate cleaning of stove to remove grease and food particles.

2.) Review cleaning schedule and ensure that Stove Cleaning is indicated as daily task.

3.) The area needing correction will be monitored weekly by the Dietary Manager and audited monthly by the Executive Director.

4.) It is the responsibility of the Dietary Manager and Executive Director to ensure the corrections are completed and monitored for ongoing compliance.

Cont. Tag C240

1.) Immediate review of Food Sanitation Rules with employee. Documented verbal warning with review of policy and procedure.

2.) Scheduled meeting with all dietary staff to review OHA Food Sanitation Rules as well as policy and procedure. Observations and competencies will be completed weekly.

3.) The area needing correction will be monitored weekly with audits completed monthly.

4.) It is the responsibility of the Dietary Manager to assure that the corrections are completed. It is the responsibility of the Executive Director to assure that monthly audits are completed.