The findings of the kitchen inspection, conducted 5/18/23, 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 5/18/23, conducted 8/9/23, 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 and interview, it was determined the facility failed to ensure the kitchen was maintained and person in charge (PIC) had appropriate knowledge in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

* Observations of the facility kitchen, food storage areas, food preparation, and food service on 05/18/23 revealed splatters, spills, drips, dust and debris noted on:

- Interiors of drawers and cabinets;

- Drip pan/drawer under stoves;

- Interior of microwave;

- Interior and exterior of reach in freezer located in dining room;

- Unused space between dishwasher and bottom cupboard storing food; and

- Wall and floor in dry storage closet.

* The following items were in need of repair:

- Multiple cupboards/drawers with damage to surface causing it to not be smooth/cleanable;

- Area under sink with holes;

- Paint on wood surfaces of shelves and cupboards peeling, chipped or missing; and

- Reach in freezer in dining room with large frost build up.

* Cutting boards were found with deep scoring and staining. Muffin baking pan was found with rust.

* Scoops or utensils were stored in coffee and ice. Coffee stored without lid exposing it to potential contamination.

* Multiple items found stored in reach in fridge were not dated when opened and/or prepared.

* Frozen ground meat product stored to defrost directly on top of shell eggs. Ground meat product was not appropriately sealed and frozen meat was on the outside of packaging.

* Plastic serving bowls found with scoring and scratching leaving them without a smooth and cleanable food contact surface.

* Kitchen did not have at least one sink dedicated for hand washing. Both sinks were filled with dishes for an extended period of time which did not allow an appropriate place for hand hygiene to be performed if and as needed. Staff 2 (Cook/Person In Charge) was asked how/where staff would wash their hands if needed and they indicated they would use the restroom which was not near the kitchen area.

* Staff 2 had pureed pizza and salad together for a resident needing pureed foods. Food product was not at correct pureed texture. Food item was not smooth and had chunks. Food was thin and dripping/flowing off the spoon. Staff 2 stated that they don't always puree all food items together but acknowledged it was a common practice and that the resident did not seem to mind having food items combined. As the texture was not appropriate for resident, Staff 2 prepared alternate items and served the vegetable and main dish separately. Facility staff acknowledged that the resident ate all of lunch stating s/he really enjoyed the items being separate. Texture of the original food products to be served was shown to Staff 1 (Administrator). S/he acknowledged it was not the correct texture being "too thin and had chunks." S/he agreed that food items should be pureed and served separately when appropriate for a dignified and quality meal experience.

* The facility had two dish machines. Both had a dedicated sanitizing cycle. Staff 2 stated that as far as she new and what she did was run on one hour wash with heated dry. Staff 2 was unaware of the required temperatures needed for sanitation and did not know if the dishwasher setting used met that criteria. Staff 1 (Administrator) was asked if she was aware the temperature or manufactures criteria for sanitizing dishes. S/he was unaware what the specifications were and did not know if the cycles commonly used met the needed 140 degrees to sanitize dishes. The surveyor was unable to verify or validate that the facility was effectively sanitizing dishes and utensils as required.

* The facility did not have any means to sanitize thermometers in between taking temperatures. Staff 2 was observed to rinse off the thermometers and dry with paper towel. Staff 2 also stated in between uses of knives and cutting boards, they were washed with soap and water but did not have any method to sanitize them other than running through the dishwasher. Facility was using Lysol sanitizer wipes for sanitizing counter tops in-between meals but had no other means or methods of surface sanitization for other items.

* Staff 2 was not aware that food needed to be served at 135 degrees Fahrenheit or above and after taking temperature of the pureed mashed potatoes, was about to serve them to a resident at 117 degrees F. Staff 2 was not aware of the required temperature of 165 degrees F for reheated foods prior to serving residents.

Staff 2 and the surveyor toured the kitchen. Staff 2 acknowledged the above findings.

The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator) and Staff 3 (Community Liaison). They acknowledged the findings.

1.) Interior kitchen drawers, cabinets, drip pans, freezer, and dry storage closet have been deep cleaned. Opening under sink will be patched. Wood surfaces have been repaired or repainted. Frost has been removed from freezer. Cutting boards and muffin pan have been replaced. Scoops are separated from food items. Food items are stored properly with open/prepared dates. Chipped dishes have been removed. Sink has been designated as handwashing sink, with bus tub purchased to hold dirty dishes.

Training provided to dietary staff on pureed textures and separating food items, as well as safe serving temperatures for foods, including reheated food.

Thermometer purchased for dishwashers, and temperature log will be maintained to show proper sanitizing temperatures.

Dietary staff will use chemical test strips to ensure proper bleach dilution to sanitize utensils between uses.

2.) Dietary Training Checklists will be completed by any new kitchen staff. Competency of kitchen staff will be evaluated by observation. Dietary Manager will inspect all dishes and utensils monthly to identify items needing replaced.

3.) Kitchen cleaning checklists will be maintained and evaluated weekly. Monthly audits will be reviewed by QA Committee no less than quarterly.

4.) Dietary Manager and/or Administrator will be responsible for compliance.

Based on observation 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 C 240.

Refer to C 240