The findings of the kitchen inspection, conducted 04/27/23, 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 333-150-0000.

The findings of the first re-visit kitchen inspection of 04/27/23, conducted 06/27/23 through 06/29/23, 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 second re-visit kitchen inspection of 04/27/23, conducted 11/06/23 through 11/07/23, 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.

Based on observation and interview, it was determined the facility failed to ensure equipment was clean and appropriate food preparation practices were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

On 04/27/23 at 11:05 am, the facility kitchen was observed to have the following concerns:

* The residential type refrigerator did not have a thermometer to monitor the temperature;

* The walk in refrigerator had uncovered/undated food items: cake, sausage links, Jello, muffins and box of cranberries;

* One garbage can located near the steam table and coffee maker was uncovered when it was not in use; and

* The microwave oven interior had food splatter/debris. The concerns were observed and discussed with Staff 1 (Dietary Manager) and Staff 2 (Executive Director) on 04/27/23. The findings were acknowledged.

Thermometers were purchased and placed in all refrigerated locations on 5/2/23. Staff in kitchen were educated on taking fridge and freezer temps on 5/2/23 and appropriate temp logs were initiated. Dietary Manager will audit temp logs for compliance routinely per Sapphire QA process.

A full audit of all uncovered or mislabled food items was compelted on 4/27/23 and issues corrected. Staff were retrained on covering and dating all foods appropriately. The Dietary Manager was given and educated on use of self auditing tool to ensure food items are covered and labled. Dietary Manager will audit for ongoing compliance per Sapphire QA process.  

Garbage can lid was placed on top of container on 4/27/23. A new garbage can with self closing lid was purchased on 4/27/23 and placed in kitchen. Dietary Manager auditing appropriate lid use ongoing through Sapphire QA practices.

Microwave was cleaned out on 4/27/23. Staff were trained on the importance of cleanliness and micowave cleanliness on 4/27/23. Micowave cleaning was added to cleaning task sheet and staff retrained on use of cleaning task sheet. Dietary Manager will audit micowave cleanliness and task sheet ongoing through Sapphire QA practices.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 06/27/23 through 06/29/23, the facility kitchen was observed to have the following concerns:

* The walk-in refrigerator temperature was observed on 06/27/23 at 49 degrees Fahrenheit at 10:03 am, 48 degrees Fahrenheit at 11:21 am, and 39 degrees Fahrenheit at 2:00 pm; and

* Temperatures were taken on three protein-based food items on 06/29/23 at 12:50 pm;

- Mayonnaise: 51 degrees Fahrenheit,

- Leftover ground meat: 51 degrees Fahrenheit, and

- Cream cheese: 54 degrees Fahrenheit.

Per Food Sanitation Rules, protein-based foods must be held at a temperature of 41 degrees Fahrenheit or less.

The concerns were discussed with Staff 2 (Administrator), Staff 3 (Dietary Director), and Staff 4 (Senior Regional Director of Operations) on 06/29/23. Staff 4 confirmed the above mentioned items were higher than 41 degrees Fahrenheit by obtaining the temperatures herself.

#1) Any food item temping out of range was immediately discarded and removed from facitlity. Vendor was brought in on 6/29 to conduct walk-in cooler repairs and was repired same day.

#2) New thermomters were purchased on 6/29 and installed in walk-in cooler, in addition, a digital alarming termostat was purchased and installed. Staff were re-educated on how to read themostat and how to document holding temps and system in place to capture accurate temps.Staff were educated as to what do when temps are out of range.

#3) Kitchen Audits will be completed weekly for four weeks then monthly as a part of our ongoing QA program.

#4) Dining Manager and Executive Director will be responsible for ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 240.

See C240