The findings of the kitchen inspection, conducted 11/15/22, 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 of 11/15/22, conducted 2/10/23, 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 11/15/22, conducted 4/3/23, 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 main facility kitchen, food storage areas, food preparation, and food service on 11/15/22 revealed splatters, spills, drips, and debris noted on:

- Interiors of drawers; and

- Stand mixer.

* Staff 2 (Cook) stated residents were provided soft cooked eggs. Pasteurized eggs were not available for undercooked eggs entrees.

* The stand mixer bowl interior was damaged and flaking.

* A dented can was noted in the dry food storage.

* Undated food items were observed in the walk in refrigerator.

* The Quaternary sanitizer was not monitored to ensure correct solution.

Staff 1 (Executive Director), Staff 2, and the Surveyor toured the kitchen. They acknowledged the findings.

1. Spill splatter, drips and debris will be cleaned on the interior of drawers and the stand mixer will be cleaned.  Pasteurized eggs will be purchased.  A new mixing bowl will be purchased.  The dented can was removed, all new dented cans will be returned to vendor.  All items will be dated in the walk in refrigerator.  The quaternary sanitizer will be check at the beginning of each day.

2. Review of kitchen will be conducted by administrative staff quarterly, and will review most recent surveys to ensure compliance.

3.  Imeediate action has been taken, and quarterly there after.

4.  Kitchen staff, cooks, servers, dishwashers, and administrative staff.

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. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility kitchen, food storage areas, food preparation, and food service on 2/10/23 revealed splatters, spills, drips, and debris noted on/in:

- Interiors of drawers;

- Interior of microwave;

- Walk in cooler floor;

- Pan holding spices;

- Reach in freezer and coolers;

- Grill/oven/stove knobs and handles;

- Floor in between grill and fryer;

- Pan storing plates for service on steam table;

- Sides and geese trap of grill; and

- Wall where fire extinguisher was stored.

* Stand mixer was observed not covered and kitchen staff validated it did not have a cover when not in use.

* Container of employee food stored in walk in cooler with resident food.

* Multiple undated food items were observed in the walk in refrigerator.

* When asked to check the sanitizing solution, Staff 1 had to go to the locked janitor closet to get out a new and unopened test strip. Staff 1 acknowledged there were none readily available in kitchen area at time of inspection.

* Cutting boards were observed heavily scored and stained.

* Heavy ice/frost build up was noted on the reach in freezer.

* 2 Light fixtures were observed out and/or damaged/cracked.

* Fryer oil had a degraded smell and had floating debris indicating need for draining and cleaning.

* Walk in cooler observed with dust build up on ceiling next to and on cooler fan grates.

Staff 1 (Executive Director) and the Surveyor toured the kitchen. He acknowledged the findings.

1. Interior of drawers and drawers will be cleaned in debris.  Interior of microwave will be cleaned.  Walk in cooler floor will be scraped and cleaned of all debris.  Pan holding spices was cleaned while inspection ocured.  Reach in freezer will be cleaned and wiped down of all debris spills, drips, and splatters.  Stove knobs will be cleaned of buildup.  Floor in between grill and fryer has been cleaned and will be kept clean.  Pan storing plates for service on steam table, had some debris which has been removed and cleaned.  We will make sure it stays that way.  Sides and greese trap of grill will be cleaned out.  Unfortunately the grill is a bit older and has some character to it.  Wall where fire extinguisher is has been wiped down and cleaned.  Was not aware that mixer had to have a cover, this was not mentioned at last inspection.  A cover will be purchased and installed.  Will discuss with staff at next staff meeting to make sure staff meals are kept in staff fridge, or in the break room.  No staff meals should be in the kitchen.  Dating opened items is a must, will do an audit weekly, or even daily for awhile until staff get back into the routine of dating items.  Sanitizing solutions are available and will be used on a regular basis.  Staff have already been instruced on this procedure again.  test strips are readily available.  New cutting boards have been purchased and will be installed shortly.  Ice frost and build up on freezer has been removed.  Will keep an eye on it for further build up.  Due to upgrading to new LED bulbs staff complained it was too bright in the kitchen, so not all fixtures have bulbs in them.  Damaged and cracked lenses will be replaced.  Fryer oil was dumped on day of inspection, pressure washed and cleaned.  New oil has been installed.  Walk in cooler will be cleaned of the dust build up next to the fan and the grates.  

2.  Weekly or even daily kitchen audits by administration staff.  Staff training will be provided.  Relias course REL-PAC-0-ICK Infection control in the kitchen, and REL-SRC-0-SK Safety in the kitchen.  These trainings will be provided at the next two staff meetings for March and April.

3.  Weekly and even daily until new habits begin to form, self audits show that areas have improved and stay within compliance guidelines.

4.  Administration, and kitchen staff

Based on interview, observation and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.

1. Due to current staffing issues (turnovers), and quality of applicants. Lots of burden has been placed on administration.  I'm sorry surveyor felt we are not back in compliance.  Items noted will be addressed again to ensure compliance to the best of our ability.  Your patience and understanding would be greatly appreciated during this time.

2.  Weekly or even daily kitchen audits by administration staff.

3.  Weekly and even daily self audits until new habits begin to form, self audits show that areas have improved and stay within compliance guidelines.

4.  Administration, and kitchen staff