The findings of the kitchen inspection, conducted 12/15/23, 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 12/15/23, conducted 04/03/24, 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 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 main kitchen and dining room service area were conducted on 12/15/23 from 11:30 am through 3:45 pm.

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:

* Multiple food carts, upright go carts and service carts throughout the kitchen;

* Multiple stainless steel racks throughout the kitchen;

* Walk-in refrigerator and freezer shelves and flooring;

* Dry food storage floor and shelving;

* Walls, floors and doors throughout the kitchen;

* Equipment stored underneath the prep table (back of kitchen);

* Wall behind the prep table in the back of the kitchen;

* Blender base, toasters, Hobart countertop stand mixer (not covered);

* The eyewash sink and eye protection station (back of kitchen);

* Exterior of the Ecolab wall mounted pest control system;

* Janitors closet wall and light switch (there was no door to the janitors closet);

* Prep table below microwave;

* Interior/exterior microwave;

* Behind the grill /ovens;

* Prep table and casters next to oven;

* Interior/exterior of ovens including oven handles and knobs;

* Oven hood vents and light fixtures;

* Multiple soiled oven mitts;

* Cabinets and shelving underneath steam table;

* Steam table drain;

* Robot coupe (used to puree food);

* Exterior white cabinet that stored clean dishes;

* Wire rack at entrance that stored single use food items;

* Wall behind wire rack at entrance;

* Exterior reach-in beverage refrigerator at entrance;

* Floor behind ice machine;

* Interior and exterior white cabinet below coffee counter;

* A bucket of used coffee grounds with a greenish colored substance was stored underneath the warewash counter; and

* The warewash machine area had a buildup of black matter around the caulking and on the walls above and below the warewash counter.

The following areas were in need of repair:

* The juice machine was broken;

* The hot water for the prep table (back of kitchen) was turned off due to a water leak;

* Caulk around the beverage counter sink;

* Beverage counter sink pipes leaked when they used the sink;

* Walk-in refrigerator door had black marks on the exterior;

* Seal around walk-in freezer door was broken causing a build-up of ice around the door and on the light switch outside the door;

* Back entrance door had gouges and scrapes;

* Multiple utensils were made of wood which created a porous and uncleanable surface;

* Multiple plastic utensils and scrapers were broken down and in need of replacement;

* Multiple food service trays were damaged with protective coating peeling off; and

* Dish sponges were not of commercial grade and had a buildup of food product and/or were damaged.

c. Food Storage:

* Multiple uncovered, unlabeled and undated food items in the reach-in refrigerator and freezer;

* Multiple food items in the walk-in were held past the manufactures expiration date;

* Multiple food items in the walk-in were held past the re-use expiration date for left-over food;

* Multiple opened food items in the dry storage area;

* Multiple scoops were stored inside dry food bins; and

* Perishable food items were stored on the floor (box of melons, bags of potatoes and onions).

d. Infection control:

* Chloride sanitizer bucket was not at proper concentration for surface sanitation;

* Staff 6 (Server) lacked an Oregon Food Handler card;

* On numerous occasions Staff 3 (Sous Chef) failed to change gloves between touching visibly dirty surfaces and returning to meal services and plating food;

* Staff 3 failed to clean prep table surfaces in the back of the kitchen and on the tray line between uses;

* Staff 3 failed to wash vegetables and fruit prior to cutting and serving;

* Staff 3 failed to change gloves after touching multiple different food items including ready-to-eat meats, cheeses, tomatoes, lettuce, and bread with the same gloved hands; and

* The facility lacked a written sick leave policy.

e. Food service:

The facility used styrofoam and other disposable paper products for meal service that was delivered to resident rooms verses residents who ate in the dining room were served meals on china, metal utensils and glassware.

At approximately 3:00 pm on 12/15/23, the kitchen was toured and the above areas of concern were discussed with Staff 2 (Dining Services Manager) and Designee in Charge, Staff 7 (Business Office Manager). They acknowledged the findings.

a) We have eliminated all accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and or black matter that was visible on or underneath the following:

1.  Actions taken:

*Current food/service carts have been cleaned

*Stainless steel racks througout the kitchen were pressure washed

*Walk-in refridgerator and freezer shelves were cleaned and organized.  Raising shelving 6" off the ground floor

*Dry food storage floor and shelving was cleaned

*Walls, floors, and doors thoughout the kitchen were cleaned and or painted

*All equipment being stored underneath the prep table in back of kitchen have been cleaned, and or organized with the proper coverings on the (blenders, toasters, and Hobart countertop stand mixer)

*The wall behind the prep table in the back of kitchen was cleaned.  

*The eyewash sink and eye wash station at the back of kitchen has been removed.  We are currently using the eyewash station in the bathroom at the back of the kitchen that is being cleaned and maintained daily

*The Ecolab wall mounted pest control system was removed

*Janitors closet wall and light switch were cleaned and a door was added to the closet

*Prep table below the microwave was cleaned and organized

*A new microwave was added to the kitchen and cleaning schedule was implemented

*Cleaning was completed behind the grill/oven

*Prep table and casters next to oven were cleaned as well as the interior/exterior of ovens, handles, and knobs

*Oven hood vents and light fixtures were cleaned

*New oven mitts were obtained

*Cabinets and shelving underneath steam table were cleaned and organized

*Steam table is being drained after every use and cleaned

*Robot coupe used to puree food was cleaned and covered

Exterior of white cabinet that stores clean dishes was cleaned

*Wire rack at entrance storing single use food items has been cleaned and organized

*Wall behind wire rack at entrance was cleaned

*Exterior of reach-in beverage refridgerator at entrance has been cleaned

*Floor behind the ice machine has been cleaned

*The interior and exterior of the white cabinet below coffee counter has been cleaned and organized

*The bucket of coffee grounds stored underneath the warewash counter has been removed

* The warewash machine area has been re-caulked and all black matter was removed and the walls above and below the warewash counter has been cleaned

2. The system will be corrected to ensure violations will not happen again:  A cleaning schedule has been implemented with a daily/weekly/monthly checklist for staff  to initial to ensure completion

3. The areas needing correction will be reviewed daily

4. The person that will be held responsible for the corrections being completed/monitored will be the Dining Service Manager as well as the Executive Director

b)All areas in need of repair have been completed:

1. Action taken

*The juice machine was in working order at time of survey but was not hooked back up to water line after flood on 12/24/23.  Juice machine has been removed entirely

*The hot water for the prep table at the back of kitchen is in working order and leak was repaired

*Caulking around the beverage counter was replaced

*Beverage counter sink pipes are no longer leaking when in use

*The walk-in refrigerator door has been cleaned and is free and clear of the black marks on the exterior

*The seal around walk-in freezer door was repaired and the build up of ice around the door was removed and the light switch outside the door was cleaned

*The back entrance door has been resurfaced and painted and is free of gouges and scrapes

*All wooden utencils have been replaced with stainless steel utencils and are in working order

*Food service trays were ordered and damaged ones were removed

*Dish sponges of commercial grade are in use and all other sponges that were not of commercial grade have been removed

2. Daily monitoring will be conducted to ensure this violation will not happen again

3. Monthly in-service training with the kitchen staff will be completed and documented to ensure no violations will occur in the future

4. The Dining Service Manager as well as the Executive Director will be resposible to further montior so future violations do not occur

c) Food Storage

1.Action Taken

*All food items that are being stored in the reach-in refrigerator and freeezer are being covered, labled, and dated

*All food items being stored in the walk-in are checked daily to ensure the re-use expiration dates are on all leftover food

*All food items will be monitored daily to ensure they are being used within their experation date

*All food items that are being stored in the dry storage area will be stored, dated, labeled accordingly

*All dry food bins no longer have scoops left in them

*All perishable foods are not left stored on the floor and stored appropriately

2. The food storage areas will have continuous monitoring

3.The food storage will be monitored daily

The Dining Service Manager as well as the Executive Director will be responsible

d) Infection Control

1. Action Taken

*All sanitizers in buckets are of proper concentration for surface sanitation and proper testing trips were ordered to ensure proper concentration

*All staff received additional in-service training to ensure they have reviewed proper hand higiene within a community based care setting

*Proper sanitation of work surfaces and prep tables were reviewed with kitchen staff for a in-service training

*All staff has had in-service training on when to change their gloves; either when providing food/care

*In -Service training with the kitchen staff was completed to ensure all kitchen staff wash all vegetables and fruit prior to cutting or serving

*Sick leave policy is being updated to reflect employee illness policy for all kitchen staff per OAR 333-50-0000

2. In-service training being held monthly with all kitchen staff to ensure all employees can recognize symptoms of foodborne illness and how to report to management if symptoms present as well as to exclude or restrict employees from food service, if diagnosed with any of the following; E.coli, Salmonella typhi, Shigella, Hepatitis A, and norovirus

3.This will be monitored daily

4. The Dining Service Manager and the Executive Director will be responsible to ensure correction and being completed and monitored

e) Food Service

1/2. Action Taken/How system was corrected:

* We are no longer using styrofoam and other disposable paper products for all meal services when providing meal trays. We have ordered two cambro 20-tray meal deiveray carts as well as extra china, glassware, and flatware to ensure the same dining experience as provided in the main dining room

3. All meals for both dining room and room trays are being served on china and will be monitored daily

4. The Dining Service Manager as well as the Executive Director will be responsible for furhter montioring to ensure this is happening at each meal