The findings of the kitchen inspection, conducted 05/02/24, 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 Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/02/24, conducted on 07/02/24, are documented in this report. The facility was found to be 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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

On 05/02/24 at 11:00 am, the kitchens were observed with the following:

* The dishwashing machines in the Ponderosa and Beechwood cottages did not have data plates to indicate proper temperature and chemical levels for sanitation;

* The dishwashing machine in the Ponderosa cottage failed to properly sanitize dishware, the temperature gauge did not reach the minimum temperature of 120 degrees Fahrenheit and the chemical sanitation test strip was below the required 50 - 100 parts per million for chlorine. Staff 1 (Food Service Director) contacted service vender to request onsite visit;

* The dishwashing machine in the Beechwood cottage failed to reach minimum temperature of 120 degrees Fahrenheit; and

* The hood vents in the Ponderosa cottage had accumulation of dust and grease.

The areas of concern were observed and discussed with Staff 1 and discussed with Staff 2 (Executive Director) on 05/02/24. The findings were acknowledged.

On 5/7/24-The data plates for dishwashing machines were provided by manufacturers and adhered to each machine by the CSD/Designee. On 5/7/2024-ED conducted an in-service with dietary team regarding data plates and accurate temperature checks. CSD/Designee will review weekly to ensure data plate is still intact and document any changes as needed. Results of audit results will be reported to the QAPI committee at the monthly CQI meeting.

On 05/08/24-Maintenance Director adjusted incoming water temperature to meet 120 degrees. The dish washing machine was checked by manufacturer to ensure temperature adjustment was correct and temperature gauges were repaired, this included both dishwashing machines for Ponderosa and Beechwood. On 5/8/24 -ED/CSD conducted an in-service with dietary staff on how properly use of chemical tabs to ensure proper sanitation has occurred. CSD/Designee will check temps daily to ensure temperatures are within range and document on daily log, ongoing. Results of audit results will be reported to the QAPI committee at the monthly CQI meeting. On 5/6/24- The vents hoods were cleaned of dust and grease buildup on 5/6/24. On 5/6/24-ED/CSD conducted in-service with staff regarding vent cleanliness weekly. Vent Pro manufacturer is scheduled to complete cleaning of vents every 3 months, CSD/Designee to ensure this occurs every month. CSD/Designee will ensure cleaning is completed daily and weekly according to posted cleaning schedule for daily and weekly checks Results of audit results will be reported to the QAPI committee at the monthly CQI meeting. Refer to POC for C240

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.

see C 240