The findings of the kitchen inspection, conducted 02/22/24, 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 02/22/24, conducted 05/08/24, 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 and OARs 411 Division 57 for Memory Care Communities.

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 facility main kitchen, kitchenettes, food storage areas, food preparation, and food service on 02/22/24 noted a buildup of splatters, spills, drips, and debris on:

- Exteriors and interiors of reach-in refrigerators and freezers on each unit;

- Exterior of cupboards and walls in unit refrigerator areas;

- Floor of the walk-in refrigerators and reach in freezer in the main kitchen;

- Can opener casing; and

- Lids and sides of garbage cans.

* Multiple packed food items were not dated when opened.

* Raw eggs were stored over vegetables.

* Scoops and spoons were left in bulk bins of foods.

* Significantly dented canned food item noted in the dry storage.

* There was not a small diameter probe thermometer to measure thin foods.

* There was no evidence of monitoring the sanitizing solution to ensure it was at the correct ratio.

* There was no evidence of monitoring temperatures of refrigerators, cooked foods, or the ware washer.

* High temperature ware washer was not reaching the required water temperature. Staff 1 (Executive Director) and Staff 2 (Dietary Services Director) agreed to sanitize dishes in the triple pot sink until the issue was resolved.

* Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food.

Staff 1 (Executive Director), Staff 2, and the surveyor toured the kitchens on 02/22/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintaned in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility main kitchen, kitchnettes, food storage areas, food preparation, and food service on 2/22/24 noted a buildup of splatters, spills, drips and debris on:

- Exteriors and interiors of reach-in refrigerators and freezers on each unit;

- Exterior of cupboards and walls in unit refrigerator areas;

- Floor of walk-in refrigerators and reach-in freezer in the main kitchen;

- Can opener casing; and

- Lids and sides of garbage cans

POC: ED added kitchenette cleaning to NOC shift assignment and reviewed standards/expectations for cleaning the kitchenettes. Care staff to clean nightly and Dining Services Coordinator to check weekly to ensure it is being cleaned thoroughly. Can opener casing, walk-in refrigerator and reach-in freezer cleaned immediately and added to weekly/monthly cleaning list for Dining Services Team to ensure they are on regular cleaning schedule.

- Multiple packed food items were not dated when opened.

POC: DSC reviewed this with cooks, disposed of undated items and ED reviewed with care staff during February all staff meeting. This will be part of daily end of shift check to ensure all items are dated and prevent reoccurrence.

- Raw eggs were stored over vegetables.

POC: Eggs were immediately moved to the bottom shelf. DSC reviewed this with cooks. To prevent reoccurrence, DSC/cook to check walk-in daily for temperatures, dates, and product placement (e.g. eggs on bottom shelf) at the end of each shift.

- Scoops and spoons were left in bulk bins of foods.

POC: Scoops and spoons removed from bulk bins. This was reviewed during February's all staff meeting with care staff, but signs have also been placed on bins reminding all staff not to store scoops/spoons in bulk bins and this will be part of the end of shift checklist for Dining Services.

- Significantly dented canned food item noted in the dry storage.

POC: Item moved to a separate storage location immediately to be returned to vendor. During each shipment, DSC and cooks to check for significantly dented items and to notate immediately that item is to be returned to prevent staff from accidentally using item before being returned.

- There was not a small diameter probe thermometer to measure thin foods.

POC: DSC located small diameter probe thermometer to use for measuring thin foods. Dining Services Team aware and will utilize moving forward.

- There was no evidence of monitoring temperatures of refrigerators, cooked foods or the ware washer.

POC: Temperature logs were replaced immediately. To prevent reoccurrence, Dining Services Team to take food, refrigerator and freezer temps and log them for each meal. ED to check for compliance weekly.

- High temperature ware washer was not reaching the required water temperature.

POC: EcoLab was contacted immediately to service machine and Dining Services Team sanitized dishes in the triple pot sink until the issue was resolved. To prevent reoccurrence, Dining Services Team to check temperature daily to ensure temps are falling within the requirements.

- Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food.

POC: Aprons purchased and in-service held on 2/29/24 to communicate this requirement for all care staff who are serving food after providing incontinent care to residents. Management team rotating days on the floor during mealtimes to ensure compliance.

Based on observation, interview, and record review, 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 C 240.

Refer to C 240