The findings of the kitchen inspection, conducted 5/17/23, 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 revisit to the kitchen inspection of 05/17/23, conducted 07/21/23, 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, record review 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. Findings include, but are not limited to:

Observations of the facility kitchen food storage areas, food preparation, and food service on 5/17/23 revealed splatters, spills, drips, dust and debris noted on:

- Can opener blade and casing;

- Small table top mixer;

- Interior of drawer next to steam table holding hamburger buns;

- Grill/Oven/stove knobs; and

- Vents, fire sprinklers, and parts of ceiling with dust accumulation.

The following items/areas in the main kitchen were in need of repair:

- Corner of steam table area with plastic covering broken and pieces missing as well as areas of laminate surface chipped and missing exposing wood surface;

- Cabinets/shelves under steam table had multiple areas where wood was exposed;

- Ceiling around vent in dry storage in need of repair;

- Clock was broken with a large piece of plastic missing; and

- Multiple vents with rust build up.

* Slicer was observed to be uncovered and was not protected from potential contamination when not in use/stored.

* Cutting board on steam table was observed heavily scored and/or stained.

* Facility did not have a small diameter thermometer to accurately check/monitor temperatures of thin foods.

* Ice machine was found with large amount of mold type substance on the interior of the machine where ice was made. Facility was instructed to discard the ice and clean the ice machine immediately. Staff 3 (Maintenance Services Director) was interviewed and stated he did service the machine and cleaned all areas every 6 months. He did indicate that in-between his regular servicing of the machine the dietary department was responsible for cleaning the machine.

* Ware washing machine rinse cycle temperature was not reaching the required temperature of 180 degrees Fahrenheit as required for effective sanitization of dishes. Multiple observations during survey rinse temperatures ranged from 161-164 degrees F. Staff 2 (Executive Chef/Person in Charge) stated that the temperature of the final rinse had been at around 160 degrees F since they recently switched over to a new type of soap. Staff 3 was not aware that the temperature was not reaching 180 degrees F. The data plate on the machine confirmed the final rinse temperature needed to be 180 or higher for sanitization. Upon evaluating the machine, Staff 3 indicated a valve in the machine had failed and most likely was the cause of the temperature not reaching correct levels. The facility stated it would be sanitizing all dishes with 3 compartment method until the machine could be fixed by an outside vendor.

* Meal service was observed and there were multiple observations of kitchen staff using single service gloves incorrectly. There were multiple times where the staff had handled RTE (ready to eat) food items with gloves that were potentially contaminated from other tasks/items. One staff was observed to use gloved hands to serve food items (cooked carrots and potato wedges) not using utensils. Staff members gloves were contaminated by touching cooler door handles, meal delivery carts, rolling up his sleeves, and wiping gloved hands on his pants. Another staff was observed to touch BBQ sandwiches and tomato slices after touching cooler door handle and meal delivery carts with the same gloved hands.

Staff 2 toured kitchen with surveyor. At approximately 12:15 pm surveyor reviewed areas above with Staff 2. Staff 2 acknowledged the above findings.

At 12:30 pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

Community acknowledges that Facility areas were not maintained in occordance with the Food Sanitation rules and have been addressed as described below.

, Kitchen cleaning list has been updated and posted for daily, weekly and monthly cleaning duties. Each person will sign off on cleaning duties completed and Executive Chef will audit cleaning schedule weekly.

1. Areas of kitchen food starage, food prep and food service  revealed splatters, spills, drips, dust and debris

~Can opener and casing,

Can opener was replaced with new equipment. Equipment is scheduled to arrive on 6/10/2023 and will be installled my building maintainence and will be cleaned daily by kitchen staff on duty.

2. small table top mixer

Mixer cover has been ordered and will be here on or about 5/8/2023 and will be used to cover mixer when not in use. Kitchen staff will ensure that mixer is cleaned as needed and after every use and covered when not in use.

3. Interior drawer next to steam table that holds the hambuger buns.

Debris was removed from kitchen drawer on 5/17/2023. Kitchen staff to wipe out drawer after each meal or as needed to prevent crumbs or debris from building up in drawer. This taskadded to daily cleaning schedule by kitchen staff  

4.Grill/oven/stove knobs and Vents, Fire sprinklers and parts of ceiling fan with dust accumulation.

Kitchen staff to remove items from the stove daily and clean and remove debris and dust per cleaning schedule daily. Vents, ceiling fan and fire system being cleaned by fire company on 6/23/2023 to remove the dust and grease build. Community setup routine cleaning with fire company for 1x each quarter.

Based on observation, record review 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.

5.Corner of steam table area with plastic covering broken and pieces missing as welll as areas of laminate surface chipped and missing exposing wood surface.

Broken pieces were removed and replaced with new plastice pieces. Exposed wood was cleaned and repaired with fresh paint 6/12/2023   

Cabinets with exposed wood were repainted by 6/12/2023 ensuring clean surfaces with no exposed wood

6.Ceiling around vent in dry storage in need or repair

Ceiling area and vent was cleaned and repainted on 6/2/2023 by building maintenance.

7.Clock was broken with large plastic piece missing and Multiple vents with rust buildup.

Clock was replaced with new clock on 6/2/2023, vents were moved cleaned and replaced with a fresh coat of paint on 6/2/2023

8. Slicer was observed to be uncovered and was not protected from potential contamination while not in use.

Slicer cover was ordered and is scheduled to be here about 6/23/2023. Staff using clean dry palstic bags until new cover gets here. Staff to ensure slicer is santitzed as needed and ensure cover is in place when not in use.

9. Cutting board on steam table was observed heavily soiled scored and stained.

Community will use bleach solution to wash and sanitize daily and as needed to ensure it is clean.Completed and as needed by 6/1/2023  

10.Facility did not have small diameter thermometer to accurately check or monitor temperatures of thin foods. Community ordered and received small thermometers  on 05/22/2023

11.Ice machine was found with large amount of mold type substance.

Facility was instructed while surveyor was still in the building to empty the ice machine and service. Ice machine was promptly emptied and cleaned and weekly cleaning has been added to cleaning schedule. Kitchen staff will ensure this gets done weekly.Ice machine will also be serviced every 6 months by maintenance director

12.Ware washing machine was not reaching temp of 180 degrees for effective sanitation Machine continued to not temp after maintenance supervisior checked it. Kitchen staff were instructed to do sanitation in the 3 compartment sink until it could be fixed. Machine tech determined thermostat was bad and part has been ordered.

Machine is temped daily by kitchen staff and if machine does not temp out to 180, maintenance is called and 3 sink sanitation is implemented.  

13.Meal service was observed and kitchen staff were using single service gloves incorrectly.

Kitchen staff have a training on 6/26/2023 to be retrained on handling food items with gloves and how to prevent cross contamination