The findings of the kitchen inspection, conducted 03/14/24, 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 Sanitation Rules OARS 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/14/24, conducted 05/16/24, 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 ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The facility kitchen was toured on 03/14/24 at 10:37 am.

a. The following areas needed cleaning and/or repair:

* Kitchen entrance door leading to the dining room had peeling paint;

* There was multiple small holes in the wall by the juice/coffee counter and sink;

* Laminate veneer on the bottom and corners of the juice/coffee counter were missing with exposed wood, which created an uncleanable surface;

* Coffee cups and other glassware housed in the cabinet beneath the juice/coffee counter were not stored in a manner to prevent cross contamination and the clean dishes were observed to have spillage from coffee and/ or juice;

* The juice machine had sticky residue buildup on the nozzles and exterior of the machine;

* The handwashing sink between the ice machine and juice machine failed to have splash guards;

* The window sill at the kitchen entrance had exposed wood rendering the surface uncleanable;

* White three drawer plastic bins to the left of the entrance door (that housed single use food items) were visibly dirty on the interior and exterior;

* The ice machine had a brown substance buildup around the interior seal and interior electrical cables;

* The floor underneath and behind the upright beverage refrigerator, behind the ice machine and Hobart mixer had a build up of food debris and dust;

* The spice rack and spice jars hanging on the wall next to the Hobart mixer were visibly dirty and jars were left open to air;

* Galaxy conveyor toaster on the steam table was not cleaned and sanitized after use;

* The electrical outlet on the steam table was burned out and in need of repair;

* The back of the equipment, wall and floor underneath and behind the Vulcan ovens had a build up of food debris and grease;

* The legs of the stand holding the Cleveland steamer had buildup of debris and oxidation;

* The counter mounted can opener housing and blade had a buildup of food debris;

* A large white wire rack hanging on the wall (to left of the steam table) had multiple areas of protective coating that had peeled off and was rusting;

* The electrical power strip in the dry food storage area (shared space with managers office) was burned out and need of replacement;

* The floor and shelving in the dry food storage area had a build up of food debris, dust and food was housed with personal belongings such as shoes, clothing and purses;

* The reach-in freezers had spillage and food debris buildup on the interior shelves and the exterior front and door handles;

* Prep table next to the walk-in refrigerator was pulled off the wall bracket and the caulking between the table and wall was missing;

* Spice jars on the shelf above the prep table (next to the walk-in refrigerator) were left open to air and were visibly dirty and the black microwave had food debris buildup on the interior;

* Walk-in refrigerator door paint on the exterior and interior was peeling off, the door handle was broken and the door was unable to securely close, and the door's gasket surrounding the door was coming off;

* The floor and walls of the walk-in refrigerator had a build up of food debris, splatters and an unknown liquid substance;

* The caulk adjoining the stainless-steel ware washing area and the wall above and beneath the warewash area had a buildup of black and brown matter and the caulk was deteriorating which caused water to saturate the wall beneath the ware wash counter;

* There was a broken drainpipe in the dishwashing area;

* A wire rack in the dishwashing area that housed cleaning chemicals was rusted;

* A stainless-steel cart in the dishwashing area had areas of rust, including rust on the casters; and

* Approximately 12-inch X 12-inch square floor tiles were missing on the floor underneath the sprayer sink in the dishwashing area; and

* Multiple food service racks (stainless steel and plastic) had a buildup of debris and were not sanitized prior to use.

Observations of food storage identified the following:

*The dry food storage area had multiple packages that were left opened to air and items removed from the original packaging that were left open to air without a label or date (jasmine rice, table salt, split peas, various grains etc.);

* The walk-in refrigerator had expired produce (multiple heads of lettuce, onions etc.); and

* Fish was improperly stored above and next to butter and eggs.

Observations of the food preparation and food service identified the following:

* Cold food items (milk-based products, fresh cut vegetables, ready to eat meats and cheeses) plated for food service had temperatures above 41 degrees F. when served from the tray line; and

* Approximately 22 blocks of butter that contained soy and milk product was stored on a shelf and not maintained below 41 degrees F.

Review of infection control practices identified the following:

* Staff 1 (Dining Services Coordinator) failed to ensure hair was effectively restrained;

* Staff 1, Staff 2 (Cook) and Staff 5 (Dishwasher) failed to have valid Oregon Food Handler cards;

* Multiple kitchen staff and direct care staff observed during meal service failed to consistently perform hand hygiene and change gloves between tasks;

* Direct care staff assisting during meal service failed to consistently use aprons;

* Staff were observed using the eyewash station as a hand washing station;

* Staff failed to have and use test strips for testing sanitation buckets used for sanitizing surfaces and failed to change the sanitation buckets at least every two hours or when the water was visibly dirty; and

* Trash cans, including compost bins and a recycling bin with food containers that contained food debris lacked covers when not in use.

The kitchen was toured, and the above areas were discussed with Staff 1 and Witness 1 (RN Consultant) on 03/14/24 at 1:32 pm. They acknowledged the findings.

1. Kitchen doors were painted. Holes in wall behind juice/coffee counter and sink will be patched and wall will be painted. Counter holding the juice and coffee maker will be replaced. Temporary covers for the glassware in place, with permanent covers to be installed with new counter.

Juice machine was cleaned including cleansing the nozzles and exterior of the machines. Splash gaurds for handwashing sink will be installed. Windowsill at kitchen entrance will be repainted. White three drawer plastic bins were cleaned, both interior and exterior. Ice machine was cleaned. Floors will be deep cleaned throughout the kitchen. Spice rack was cleaned, all spice jars were cleaned, and all spices will be covered. Toaster was cleaned and sanitized. Electrical outlet on the steam table will be replaced. Vulcan overs will be deep cleaned including the back of the machine, the wall, and the floor underneath the ovens. Legs of the steamer stand were cleaned. Can opener was cleaned. Wire rack to left of steam table will be replaced/repaired. Power strip in the food storage office was replaced. Dry food storage area was deep cleaned, including the floors and the racks. Personal items were removed from food shelving.  Reach in freezers were cleaned, both interior and exterior. Prep table next to walk in was pushed back against wall and chaulking replaced. Food removed from microwave and disposed of. Walk in walls painted and floors cleaned. Walk in door will be repaired or replaced.  Chaulking around dishwashing area was replaced. Drainpipe in dishwashing area will be replaced or repaired. Wire rack in the dishwashing area will be replaced or repaired. Rust removed from the stainless steel dishcart and casters replaced. Tile will be replaced in dishwashing area. All food service racks cleaned. Dry stored foods will be stored in containers with lids with open dates and labels. Expired food removed from walk-in and food arranged properly on shelves. Cold food items will be stored in the walk-in and only removed when it is time to serve them. Butter will be stored in refrigerated unit. Properly fitting hair nets were obtained. Re-education will be provided to all staff regarding hand hygiene, gloves, aprons, and hair nets by 4/25/24. All kitchen staff will maintain current food handlers cards. Soap dispenser and papertowel dispenser will be removed from eyewash station to prevent it from being used as a handwash station. Test strips will be used for testing sanitation bucks at least every two hours. Trash cans, recycling, and food bins will all have covers when not in use.  

2. ED and dietary director to distribute daily, weekly, monthly cleaning checklist. Daily walk through by dietary director, ED, or designee.

3. Dietary director or designee will review checklists daily. ED will also do a daily walkthrough of the kitchen until all is in compliance, then weekly walk throughs. ED to review survey checklist with dietary director during 1:1 weekly meeting.

4. Dietary director and Executive director are responsible for meeting and mainting compliance.