The findings of the kitchen inspection, conducted 01/11/24, 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 revisit to the kitchen inspection of 01/11/24, conducted 05/16/24, 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, 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 and dining room beverage service, food  storage, preparation areas and service  on 01/11/24 revealed splatters, spills, drips, dust and debris noted on:

- Interior of cabinets, drawers;

- Walls under ware washing machine;

- Interior of microwave;

- Open stainless steel shelving throughout kitchen;

- Fan blades and cage;

- Metal storage racks throughout kitchen;

- Ovens;

- Interior of refrigerators and freezers;

- Utility room walls and floors;

- Floors under major appliances;

- Windows and portable AC unit behind microwave; and

- Canned goods in dry storage room.

The following areas/items were found needing repair:

- Reach in refrigerators in kitchen not registering 41 degrees;

- Ware washing machine wash cycle temperature gauge not registering 150 degrees;

- Ware washing machine rinse cycle temperature gauge not consistently registering 180 degrees;

- Freezer with evidence of temperature irregularity and damaged seal; and

- Multiple small holes around pipes or conduit were found. Areas needing sealing to prevent entry points for possible pests.

* Dining room beverage area found with areas of chipped paint and cabinetry in disrepair.

* Main kitchen cabinetry with interior and exterior areas of exposed wood edges resulting in a surface that is not smooth or cleanable. Hinges on multiple cabinets were not operating correctly. Many shelves in cabinets/cupboards with damage and not smooth, cleanable surfaces.

* Dry storage room door was unsecured for several hours. Door opened to resident care area hallway where entry by non-kitchen/authorized staff could occur.

* Multiple cutting boards were found with deep scoring and staining.

* Multiple sauté pans were found with deep scoring and flaking of non-stick surface material.

* Multiple items in refrigerators/freezers were not covered and/or dated when prepared or opened. Mayonnaise container was found expired.

* Items in freezer not stored to allow for adequate air circulation. Multiple items were found with visible signs of freezer burn.

* Multiple items in dry storage were observed not securely sealed and/or not labeled and/or not dated. Multiple items were found expired and/or removed from manufacturer packaging without labeling or date marking. Several dry goods bins were found with lids ajar and scoops left in food product.

* Ware washing machine was found below 150 degrees during multiple wash cycles between 10:15 am and 11:15 am. Ware washing machine was found below 180 degrees during multiple rinse cycles between 10:15 am and 11:15 am

* Multiple kitchen staff found without hair or facial hair restrained as required.

Staff 2 (Dietary Services Director) and the surveyors toured the kitchen. Staff 2 acknowledged the above findings.

At approximately 2:00 pm, the above areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). S/he acknowledged the findings.

1)Interior of cabinets, drawers, walls under and around washing machine, interior of microwave, open stainless steel shelving, the fan blades and cage, metal storage racks, the right side oven interior, the interior of the refrigerators and freezers, the utility room walls and floors, the floors under the major appliances, the windows and portable AC units and the canned goods in the dry storage room will be deep cleaned.

2) A cleaning schedule will be put in place for daily, weekly, and monthly cleaning.

3) Weekly meetings with the ED and the kitchen manager will review the cleaing schedule and the kitchen manager will do a daily walk through to ensure complaince with the schedule.

4)The kitchen manager will be responsible for the oversight of the cleaning with reports to the ED for compliance.

1)Reach in refrigerator not registering at 41degrees was services by a technician and found to not have the fan turned on. Fan was turned on on 1/12/2024.

2) Staff educated on which buttons on refrigerator need to be turned on at all times and temp logs for refrigerators in place.

3). Temp logs reviewed by kitchen staff daily and any inconsistancies will be reported to kitchen manager.

4) Temp logs maintained and reviewed daily for compliance by the kitchen manager and reported to the ED during the weekly meeting.

1).Ware washing machine was services by Ecolab 1/12/24 and shown to be maintaining 150 and 180.

2).Temp logs in place to monitor the machine temps two times per shift.Staff educated to only run machine when the temps register at 150 and 180.

3) Temp logs will be reviewed by kitchen staff daily and any inconsistanceis will be reported to kitchen manager

4)Temp logs maintained and reviewed weekly for complinace by the kitchen manager and reported to the ED during weekly meeting.

1)The freezer with damaged seal and and evidence of temperature irregularity was emptied and will be disposed of.

2). Freezer room added to weekly maintenance and ED building walk through.and to the kitchen cleaning schedule. Any concerns will be reported to the kitchen manager.

3).Maintenance Weekly walk through to identify needed repairs

4).Kitchen manager will be maintaining the cleaning schedule where issues can be identified and repairts to be done by maintenance.

1)Small holes identified around pipes were sealed on 1/23/24.

2)Weekly ED and maintance walkthrough to identify repair needs.

3). Weekly walkthroughs

4). Maintenace Manager will be responsible for repairs and monitoring for effectiveness.

1). Cabinets in the dining room and the kitchen identified to have chips and uncleanable surfaces and hinges that need  repair will be repaired to be smooth, cleanable, and functionable state.

2).Cabinet surfaces will be added to the ED and Maintenance manager walkthrough for observation

3).Weekly during the walkthrough

4). The maintenance manager will be responsible for making sure the itegrity of the cabinets is maintained and during the weekly ED and Maintenace meeting this will be discussed.

1). Signage was placed on the dry storage door that that door is to remail closed and locked at all times. Kitchen staff educated on the necessity of keeping this door closed and locked at all times.

2). Management team also educated on the door needing to be closed and locked. Any violations to be reported to the kitchen manager. The kitchen manager will be including this door on his daily walk through for compliance.

3). Daily and weekly

4).The kithcen manager is responsible for making sure the staff are closing this door during and after use.

1)Cutting boards and pans that had deep scoring and staining were disposed of.

2). New cutting boards and pans were purchased. Staff educated on using non-metal tools on the non-stick pans and when to report to kitchen manager the need for replacing them.

3).The kitchen staff to report any concerns with deep cuts and scratches and condition of equipment will be added to the weekly walkthrough for the kitchen manager.

4). The Kitchen manager is respsonsible for making sure the equipment is in good working order.

1) Items found to be opened and not dated, expired, soiled, or freezer burned were disposed of.

2).Kitchen staff to be educated on FIFO principles and how to properly date and store opened food.

3). The weekly walkthrough for the kitchen will include auditing the dry storage, freezers, and refrigerators for properly labeled food and expired food.

4)The kitchen manager is responsible for ensuring all food products are properly stored.

1). Kitchen staff not wearing hair/beard nets or head coverings - Beard and hair nets were purchased. Staff given the opportunity to wear a hat.

2). The kitchen manager will lead by example and ensure that all staff wear the approporiate head and face gear. Staff training on the necessity of wearing hair covering items.

3)The Kitchen manager will ensure the staff is following this directive daily.

4). The kitchen manager and the ED are responsible for making sure the staff are complying with hair covering as required.