The findings of the kitchen inspection, conducted 12/06/23 through 12/07/23, 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 to the kitchen inspection of 12/06/23, conducted 02/08/24, 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 and interview, 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 facility kitchen and the memory care unit kitchenette on 11/6/23 from 10:00 am through 2:30 pm and 12/07/23 from 9:30 am through 11:00 am and revealed the following deficient practices.

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:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath and on top of the dish machine;

* Kitchen drains;

* Electrical outlets and light switches;

* Trash cans;

* Ceiling vents and light fixtures;

* Walls throughout kitchen;

* Stove, oven and grill knobs, doors, and exteriors;

* Grill top and interior of ovens;

* Open shelving throughout kitchen;

* Shelving above try line;

* Industrial mixer;

* Base holding mixer;

* Large can opener and housing;

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges;

* Rack shelving in walk in cooler and freezer;

* Reach in cooler;

* Rack shelving in dry good storage;

* Rack shelving storing equipment and dishes;

* Under and behind shelving in dry good storage;

* Utility racks;

* Legs and wheels of equipment, steam table, carts, shelving, prep spaces;

* Meal service delivery carts;

* Plastic bulk bins and lids;

* Go racks and;

* Interior and exterior of ice machine.

b. The following areas needed repair:

* Caulking in ware washing area with black matter debris buildup;

* Nozzle to sprayer in dish machine area sink with leak.

* Dispensing tubing of chemicals in ware washing area with build up of black matter.

* Multiple areas in walls near counter top and serving area in memory care kitchenette was damaged.

* Caulking around counter top in kitchenette was missing/cracking.

* Metal cart storing dirty dishes in memory care was worn and rusted in some areas.

* Memory care unit serving glasses found damaged and stained

c. Multiple food items/packages/containers found in cold food and dry food storage that were open to potential contamination.

d. Dirty dishes were found stored on clean dish side of dish machine area, along with observed food debris. Piles of dishes were observed stacked up along the dish washing area and overflowing into, on and around the three compartment sink area.

e. Multiple dry good food items were not dated when opened.

f. Multiple cooking pots, pans and utensils were found in poor repair needing replaced.

g. Multiple containers of bulk dry goods were found to have cups or scoops stored in them.

h. Multiple items in freezer and refrigerator were not dated or labeled when opened or prepared.

i. A large pot of dirty/rancid oil was observed stored in kitchen area. There was no lid and staff were not able to clearly state approved method of disposal of fryer oil.

j. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. A staff member was observed to handle utensils, touch handles, and other potentially contaminated items with his/her gloves and then touch ready to eat items. The staff member was observed to not change gloves or wash hands when appropriate.

k. Kitchen staff was observed to prepare a hamburger to order and serve to a  resident without checking temperature to ensure it reached the appropriate safe temperature prior to serving. Surveyor stopped the process and requested the food item be tested prior to service.

l. Multiple rags were observed lying about the kitchen prep areas and not in appropriate sanitizer buckets with sanitizer at appropriate concentrations.  Staff was observed to wipe gloved hands with these rags and then handle RTE food items.

m. multiple kitchen staff did not have facial hair or hair restrained as required.

n. Dining area was observed to have preset silverware and service ware that was not protected from potential contamination as required.

o. Silverware was observed stored with food contact surfaces pointing up and memory care staff observed removing them to set the table and noted handling the food contact surfaces with their hands.

p. Memory care staff did not have on aprons for meal service to protect food/equipment from potential contamination from care giving tasks. Not all staff were observed with their hair restrained in memory care unit during meal service.

q. Memory care kitchenette did not have chemical test strips available to validate concentration of sanitizing solutions to ensure they were at appropriate levels.

In an interview on 12/06/23 at 12:45 pm, Staff 1 (Executive director) and Staff 2 (Dining Services Manager) were informed of concerns found. They acknowledged the concerns and presented a plan to address identified issues. The facility had recognized areas of concern prior to kitchen survey and were implementing measures to correct deficient practices. A new interim (Dining Services Manager) was brought in to assist facility in implementing corrective actions.

- Documented training provided to all kitchen staff on food temping requirements, hair/beard net/ hair up requirements, sanitation requirements, oil disposal protocol, and food storage requirements.

- Cleaning task lists implemented to ensure kitchen remains above sanitation requirements and turned into MCD daily by DSM. Additional cleaning parties held as needed to retain excellent sanitation expectations.

- New DSM hired and trained on protocols.

- Additional support weekly from the company Dietician on all protocol matters.

- MCD or DSM to walk kitchen 3x daily to ensure sanitation, cleanliness, and all protocols are being followed and properly trained on.

- MCD to audit trainings provided weekly

- MCD/DSM daily

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 C240.

- Aprons provided and worn by all care staff that are serving food.

- Testing strips provided and used for santizing solution to ensure that they are at appropriate levels.

- MCD will provide written training to all memory care staff.

- MCD/DSM will check for implementation of training daily.

- MCD/DSM