The findings of the kitchen inspection, conducted 10/05/22, 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 of 10/05/22, conducted 12/13/22, 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 the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 10/05/22, the operation of the dish machine was observed.

The dish machine utilized a low temperature rinse cycle with chlorine to sanitize dishes. The sanitizer was tested with the available strips and the chemical level was noted below the required range. There was no documented evidence of monitoring of the sanitizing solution. The sanitizer solution bottle was observed to be empty.

Staff 2 (Dietary Manager) replaced the empty bottle of sanitizer.

The dish machine did not reach the required temperature of 120 degrees Fahrenheit.   

A fan located in the dish machine area was noted with dust and debris on the cage blowing into the kitchen.

During observation of meal service, staff did not change gloves between tasks and were touching ready to eat foods. Staff were noted to not remove gloves when entering the kitchen.

Hand hygiene and the areas in the kitchen needing cleaning and repair were observed and reviewed with Staff 1 (Executive Director) and Staff 2 on 10/05/22. They acknowledged the findings.

1. Tag C 240 requires policy & procedure updating and enforment to correct staff actions and monitoring, and an outside professional plumbing company to address the mechanical issues of the plumbing system and dish sanitizing machine.

2. The kitchen policies & procedures will be updated and enforced to routinely test temperature and sanitation chlorine levels and log approprietly, and to check the sanitizer solution bottle for adequate solution. The stand-alone fan was removed from the kitchen.

The plumbing company will fix the low water pressure that was causing the dish machine to underperform both in reaching the required operating temperature and in distributing the chlorine used to sanitize the dishes.

The kitchen dish machine temperature and sanitation logs will be monitored by the Food Services Manager.

Kitchen staff will be montiored by the Food Services Manager, Administrator, Assistant Administrator, Infection Prevention Control Manager, or Clinical staff during meals to ensure glove change and hand sanitation procedures are being adhered to.  

3. Kitchen logs of sanitzer temperature and chlorine potency for the dish sanitizer will be monitored at least weekly.  Hand hygiene (washing and glove changing) will be monitored periodically throughout each week to instill proper hand hygiene and glove changing practice.

4. The Food Service Manger and the Executive Administrator will be responsible for seeing that all corrections are completed. The Food Services Manager will continue with ongoing monitoring of these corrections to prevent the issues from reoccurring.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Observations of staff during the survey on 10/05/22 revealed multiple staff failed to wear medical face mask, wear masks correctly, or wore no face mask at all.

The need to ensure staff consistently wore a medical face mask was reviewed with Staff 1 (Executive Director). She acknowledged the findings.

1. All staff will wear protective procedural masks at all times except when in a room alone.

2. Masking procedures will be reiterated at the All Employee Meetings each month to re-inforce the mandate to all employees. These meetings occur the last Wednesday of each month. Monitoring will be ongoing and proper instruction of wearing the masks will be given as needed.

3. The proper wearing of masks will be evaluated nearly continuously since the masking mandate calls for nearly consistant wearing of the masks. The Infection Prevention Control Specialist will inform management and staff when any changes occur to the masking and/or face shielding mandated guidelines by OHA SOQ and/or CDC.

4. The Executive Administrator, Infection Prevention Control Specialist, Assistant Administrator, and RCC will continually monitor all staff for proper masking (and face shield if/when necessary) to control the spread of COVID-19.