The findings of the kitchen inspection, conducted 04/25/24, 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 first revisit to the kitchen inspection 04/25/24, conducted 06/25/24 through 06/27/24, 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, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the memory care kitchen area as well as the food storage building on 04/25/24 at 1:25 pm through 3:30 pm revealed the following:

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

* Interior of large outdoor grill; and

* Sponge/green scratch pad used to clean dishes.

b. The following areas were found in need of repair:

* Two holes greater than 1/4 inch were found in food storage building where electrical wiring entered/exited the building;

* Flooring in food storage building with multiple large cracks causing non smooth surface.

c. A female resident was noted to enter the kitchen area, open the utensil drawer to remove spoon, open the reach in refrigerator where all resident food was located/stored and remove a container of creamer to serve her/himself coffee. Resident was not observed to wash hands. No facility staff intervened in this event. Staff 1 acknowledged that this was an infection control and contamination concern. There was no barrier to deter or prevent residents to enter and exit kitchen at will.  

d. Multiple food items in dry storage and cold storage areas were observed not dated when opened or did not contain appropriate use by dates. Multiple items were found open and not securely closed.

e.  The reach in refrigerator in the food storage room was observed to have unpasteurized whole shell eggs in cardboard cartons stored above milk and next to strawberries, container of ready to eat salad mix, package of avocados and 2 bags of cooked chicken.

f. The reach in refrigerator in the resident house had a small container holding home raised chicken eggs. Staff 2 (Caregiver/Person in Charge) acknowledged these eggs were used for breakfast foods for residents. Staff 2 stated that staff prepared eggs cooked to order per resident preference including eggs with yolks that were runny (not fully cooked). Staff 1 (RN/admin designee) acknowledged that the eggs found were from her chickens and acknowledged they were used for resident food. Staff 1 acknowledged those eggs were not pasteurized.  Staff 1 was not aware residents could not have eggs from an unapproved (home raised) source.

g. Per interview with Staff 2, facility staff were not checking refrigerator temperature readings. Staff 2 indicated maintenance checked refrigerator temperatures weekly. Weekly checks of temperatures storing food items was not adequate to monitor food was stored at correct temperatures.

h. Resident dishes were observed being washed on the fast cycle on the dish machine. Staff 2 validated this was the typical cycle used. Staff 2 was unable to validate that the cycle used was effectively sanitizing dishes. At approximately 2:40 pm, Staff 3 (Maintenance) was contacted via phone. He was unable to validate what temperatures the fast cycle was washing/rinsing. Surveyor requested the manufactures information on cycles and any evidence that the facility was monitoring and evaluating effective sanitation of the dishes. Surveyor contact information was provided but no further information/documentation was supplied. Staff 3 was interviewed regarding maintenance of ice machine in reach in freezer. Staff 3 indicated he did not have a system to maintain the ice machine.

i. Staff 2 (Person in charge) was not able to list illnesses that require exclusion from working with food per Oregon food code. Staff was not able to correctly identify different cook to temperatures for food items, nor able to state correct re-heat temperature required to ensure safe food. Staff 1 was also not able to state the illnesses needing exclusion.

j. Ready to use items (straws) were observed stored open to potential contamination.

k. Dishwashing cleaning device was noted to be in poor repair along with being an unapproved material for effective cleaning (sponge).

The surveyor reviewed the above areas with Staff 1 (RN/Admin designee) and s/he acknowledged the identified areas.  

The grill has been cleaned, a new cleaning tool was purchased and staff have been instructed to clean the grill after each use. Added checking the grill for cleanliness to the weekly maintenance checklist to ensure it is clean. All staff and maintenance is responsible for cleaning the grill.  See attached maintanance checklist.

Discontinued the use of sponges.

The cracks in the concrete have been filled with apoxy concrete crack filler and the entire floor has beed sealed with apoxy sealer. See picture included. Maintenance is responsible for maintaining the area.

Purchased a "Do Not Enter" retractable belt to deter residents from entering the kitchen without staff assistance. Instructed staff to assist residents with getting items out of the kitchen. All staff are responsible to ensure residents receive assistance and the kitchen sanitation is maintaied.  See attached policy, pg. #30.

All food items not labeld properly have been discarded. Staff have been retrained regarding proper food labeling, including use by dates. See attached memo. All staff are responsible for labeling food properly.

Discontinued the use of farm fresh eggs. All eggs will be fully cooked unless pasterized. Added a label in the refridgerator stating "Store eggs on bottom shelf only". Instructed staff of proper procedures. See attached memo.

Implemented a refridgerator temp. log. Temps will be taken 3x a day and documented on the log. The PIC working in the kitchen is responsible for checking the tempratures and reporting tempratures out of range. Continue weekly checks by maintenance to ensure temps are being taken.

Staff have been instructed to always use the sani cycle on the dishwasher. Posted a label on the dishwasher stating "Must Use Sani Cycle". Instructions on how to set the sani cycle are posted on the dishwasher as well.  Purchased a new dishwasher temprature guage that will be used on a weekly basis. Added checking the temprature to the weekly maintenance checklist. All staff are responsible for using the sani cycle and maintenance is responsible for checking the temprature to ensure it is reaching the proper temprature.

Added changing the refridgerator filter and cleaning ice machine to the maintenance checklist. Manufacturer reccomends doing this every 6 months. Maintenance is responsible for changing the filter and cleaning the ice machine.

Cook to temp and reheat tempratures are now posted on the refridgerator to remind staff of proper cooking tempratures. See attached photo.

Discontinued use of ready to use straws. Purchased straws that are individually wrapped. The Administrator is responsible for purchasing the correct straws.

Based on interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases including Norovirus and other gastrointestinal/ food related outbreaks. Findings include, but are are not limited to:

During the annual kitchen inspection survey, the facility staff was asked to provide policy and procedures for staff exclusion for food workers related to illness. Facility staff was also asked to provide the facility's policy and procedure on resident gastrointestinal outbreaks. The policies provided did not effectively address methods for preventing and addressing possible gastrointestinal outbreaks at the facility.

On 04/25/24 at 3:00 pm Staff 1 (RN) was interviewed and acknowledged the facility did not have specific policies on exclusion of sick/ill food workers as required. Staff 1 also acknowledged the facility did not have a policy addressing identifying and responding to communicable gastrointestinal outbreaks.

Updated Infectous Disease Prevention policies to include sanitation guidelines, and employee sick policies. See attached policy. The Administrator is responsible to see that the policies are followed. See attached policy page #45.

Based on observations and interviews, 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 C240 and C295.

Refer to POC for C 240 and C 295 for corrections. The Licensee/Administrator is responsible for ensuring compliance with the licensing rules. The Administrator will check all areas out of compliance on a random basis, no less than weekly to ensure on-going compliance.