The findings of the kitchen inspection, conducted 05/09/23, 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 first revisit for the kitchen inspection on 05/09/23, conducted 06/20/23, 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 of the annual kitchen inspection on 05/09/23, conducted 08/23/23, 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, interview and record review, 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 main kitchen, food storage areas, food preparation, and food service on 05/09/23 revealed the following:

* Open packages of dry cereal stored on a shelf above clean dishes in the main kitchen food service area;

* Garbage barrels used for food disposal did not have covers available when not in use;

* Build up of food material on the grill surface and overflow drawer of the grill top;

* Sanitizer buckets with cleaning cloths were tested using test strips and were shown to have a lower concentration of sanitizing chemical than the acceptable range on the test strip instructions;

* The sanitizing solution distributed by the "Ecolab" dispenser installed above the three compartment sink was tested by kitchen staff, using the test strips, and showed the chemical sanitizer was below the acceptable range;

* Cooked fish being stored in a warm oven, prior to serving, measured 120 degrees with a probe thermometer, (below the required temperature of 135 degrees Fahrenheit); and

* One kitchen staff was observed without properly restrained hair while washing dishes and performing food preparation.

The following areas/items were in need of repair:

* Exposed wood surfaces, scuffs and blackened areas on the doors exiting the kitchen into the dining room;

* Exposed wood surfaces and damage to the cabinets below the coffee and juice service areas in the dining room; and

* The hot water setting in hand washing sinks in the main kitchen needed an extended period of time, in excess of three minutes, for the water to get hot (temperature obtained was a maximum of 112 degrees Fahrenheit).

During an interview on 05/09/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed ten kitchen staff did not have a current food handler's card. Staff 2 acknowledged the findings.

At 11:15 am, the above areas were discussed with Staff 1 (Kitchen Manager). She acknowledged the findings.

1. A full audit of the kitchen was done to ensure all food was being stored appropriately and all containers securely closed. Lids have been ordered for keeping the garbage cans covered when not in use.

A professional cleaning company came in on 5/23/23 to degrease and deep clean the stove, flat-tops and ovens to remove all buildup. Eco lab has been called out to test the dispensers to ensure the chemical levels are set correctly, and staff will test chemical levels with each meal.

Copies of food handler certification cards have been obtained for all staff who work in the kitchen.

Hot water will be repaired in kitchen to ensure proper temperature is reached timely. Doors and cabinets will be repaired to eliminate all exposed wood surfaces and scuffs. A meeting has been scheduled with all kitchen staff to provide re-education on the following processes:

*proper food temps

*proper food storage

*The use of hair nets if hair not tightly pulled back in a bun

*Temping of the sanitation buckets with each meal

2. To prevent recurrance, staff will be required to provide copies of their food handler certification prior to beginning their employment in the kitchen. Staff will also be fully trained utilizing the job specific training checklists to ensure competency.  Temperature logs and cleaning schedules will be utilized, including documentation of food temps prior to food being served and documentation of the chemical levels of the sanitation buckets 3 times a day. Dietary Manager and Executive Director will spot check cleaning schedules and tem logs to ensure they are being completed appropriately

3. This system will be reviewed monthly during the Continuous Quality Improvement (CQI) meeting, which includes a review of the kitchen documentation records and a kitchen sanitation audit

4. The Executive Director and Dietary Manager are responsible for maintaining this system.

Based on observation, interview and record review, 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:

a. Observations of the main kitchen, food storage areas and food preparation on 06/20/23 revealed the following:

* Garbage barrels used for food disposal did not have covers available when not in use;

The following item was in need of repair:

* Two ceiling tiles above the three compartment sink were damaged.

b. During an interview on 06/20/23, Staff 2 (Human Resources Manager) provided copies of food handler certification cards for kitchen staff. A review of the records showed Staff 5 (Dietary Server) did not have a current food handler's card. Staff 2 acknowledged the findings.

At 11:40 am, the above areas were discussed with Staff 4 (Executive Director) and Staff 3 (Administrator in Training). They acknowledged the findings.

* Garbage barrels used for food disposal

did not have covers available when not

in use;

POC- Properly fitting trash can lids purchased and implemented on 6/20/23. Dining manager will ensure continual compliance and use of covers in daily operations.

* Two ceiling tiles above the three

compartment sink were damaged.

POC- Replacement tiles located and ordered 6/29/23, arrived and installed 7/10/23. Executive Director provided the link to the tiles for future ordering needs to the Maintenance Director who will now oversee the replacement of damaged tiles on a as needed basis.

Staff 5 (Dietary Server) did not

have a current food handler's card.

POC- Employee 5's Food Handlers card was completed. All kitchen employees current with expectation that no new hire will start without current certs. Business office Manager will monitor for continued compliance going forward.  

Based on interview, observation and review of documentation, 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.

Interim Executive Director reviewed the clerical error of the stated compliance date with the Administrator in training. The Executive Director will review all POC's prio rot submission.