The findings of the kitchen inspection, conducted 04/29/24, 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 04/29/24, conducted 07/17/24, 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 and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility kitchen was reviewed on 04/29/24 from 11:30 am through 2:45 pm and the following was noted:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Outside freezer interior; and

* Kitchen flooring.

b. The following areas were in need of repair:

* Gaps in wall by electrical outlet under sink; and

* Small hole in pantry wall by floor.

c. Staff 3 (Cook/Person in charge) was not able to correctly identify cook to temperatures for ground meats, proper reheat temperatures, or identify illnesses needing exclusion and reporting. Staff 2 (House Manager) was not able to correctly identify illnesses needing exclusion and reporting.

d. Multiple items in reach in refrigerators did not contain open and/or use by dates. One item (potato salad) was found past the manufactures use by date.

e. Differing meat/proteins were found in same pan defrosting creating the potential for the thawing fluids from each meat product to potentially contaminate the other. These proteins had different cook to temperature requirements. The pan these items were thawing in was also too small for the products creating the potential for thawing fluids to contaminate other areas of the refrigerator.

f. The facility had two sinks in the kitchen, neither was designated for a handwashing sink. Both sinks had dirty dishes in them, Staff 3 was observed to wash their hands in the sink where dirty dishes were located. There was no dedicated sink for handwashing throughout the duration of the kitchen survey. Facilities must designate a hand washing sink that was not used for other purposes while utilized as a hand washing sink.

g. During the tour, the facility was not sanitizing dishes. Staff 3 stated the items s/he used for cooking were washed and rinsed by hand then air dried. They acknowledged there was no sanitize step. Residential dishwasher being used had a light display to identify when dishes were "clean" and when they were "sanitized". Upon entry to kitchen the cycle of dishes was finished and the light for "clean" was activated and no light was on for "sanitized". Staff 3 validated that the fastest cycle was used for the dishwasher that usually took one hour. Staff 2 and Staff 3 were not able to identify how they could validate the dishes were sanitized. After consulting the manufactures manual, the manual indicated the light would illuminate if the rinse cycle met the sanitized requirements. The stipulation was that the hot water inlet to dish washer needed to reach at least 120 degrees Fahrenheit and the sanitize selection made for the cycle. Facility staff were not aware of this process to ensure dishes were effectively sanitized.  Surveyor and Staff 2 validated water source closest to dish washer did reach at least 120 degrees so that per the manufacture would be able to sanitize the dishes when the correct cycle was selected. The sanitize cycle would add 60 min to the regular cycle length so that the quick 60 min cycle would not "sanitize" the dishes. Staff 1 (Administrator/Owner) and Staff 2 stated they would ensure the correct cycle was used for washing dishes to include the extra sanitizing cycle time.

h. Multiple disposable delivery service items (spoons/forks/straws) were not stored covered or inverted as required to protect from potential contamination.

i. Surface sanitizing solution was tested utilizing strips from the facility. The concentration was well over the reading ppm for Quat solution. The effective and desired range for Quat sanitation is between 200-400 ppm. Upon review of dilution of the chemical used staff were under diluting the product producing a much stronger solution.  Staff were not testing the solution with the strips to ensure the liquid was at the correct ppm for effective sanitation of surfaces. Over concentration of chemical can be potentially harmful if ingested.

j. Care staff were observed serving and assisting residents with their meals without aprons on to protect residents' meals from potential contamination from care giving tasks.

k. Multiple bulk dry good bins were noted to have scoops stored inside the food product potentially contaminating the food product.

Staff 1, 2, and 3 toured the kitchen areas with the surveyor and acknowledged identified areas needing attention.

C240

A. New fridge for staff is being ordered that will be replacing old facility freezer. Kitchen floors are mopped after every meal to ensure clean floors. This will be fully corrected by June 5,2024.

B. Replaced the outlet cover under the sink and replaced the one in the party with a new one. This was corrected on 5.9.2024

C. New policy with correct illnesses needing exclusions and reporting has been made. This was corrected on 5.10.2024

D. Fridge is gone through twice a week to ensure nothing is past use by date or expiration date. This is done by Head Cook and admin.

E. Separate pans are used for thawing out meat in the fridge. All cooks were retrained in proper defrosting techniques. This was corrected on May 1, 2024, with head kitchen cook and admin team.  

F. Kitchen staff are to use the left side of the sink for dirty dishes, leaving the right side open for hand washing. This was corrected immediately.

G. Kitchen staff are using the sanitized button on the dishwasher to ensure proper cleaning of dishes is done and retrained all other staff. This was corrected that same day by the admin team.

H. New holder for plastic wear is now in use to ensures that they are safe from contamination. This was corrected 5.8.2024

I. New proportioning system is being installed so that there are no errors with mixing of cleaning products and testing strips used to make sure those solutions are correct. This is being corrected by 5.20.2024

J. New aprons were ordered and are in use for any/all care staff to wear when helping serve meals to residents. Corrected 5.2.2024

K. Dry goods scoops are placed on the top of the bens and not left in them and are checked daily by kitchen staff and admin team to ensure they are not in the bens. This was corrected the day of 4.29.24

Admin team and head cook will make sure all these things stay in compliance weekly to enusre these never happen again.