The findings of the kitchen inspection, conducted 07/20/23, 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 first revisit to the kitchen inspection of 07/20/23, conducted 09/22/23, 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 maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

On 07/20/23 at 10:50 am, observations of the primary kitchen located in assisted living identified the following deficiencies:

a. An accumulation of food spills, splatters, loose food, dirt, and dust on or underneath the following:

* Upright refrigerator (near the entrance of the kitchen) had yellow colored liquid spilled on the lower shelf;

* Southbend oven had an accumulation of food matter buildup on the inside of the oven;

* Floor fan had a buildup of dirt and dust debris that was blowing directly on clean dishes; and

* Metal storage rack (near the warewash machine) that stored clean dishes had a buildup of dirt and dust debris.

b. The following areas were found in need of repair:

* Montague Grizzly oven was not operable;

* Grill next to the oven was not operable; and

* Walk-in freezer door had missing piece of gasket which caused ice buildup around the freezer door.

c. All staff working in the kitchen failed to have documented evidence of valid Oregon Food Handler cards.

d. Observations of the kitchenette located in the MCC identified the following deficiencies:

* Freezer pull out drawer had a buildup of white, pink and brown food matter on the lower shelf;

* Chemicals stored in unsecured cabinet above the stove;

* Spills, dirt and debris buildup inside multiple cabinets and drawers; and

* Improper storage of food items in cabinets (open bags of bread).

The kitchen was toured and the need to ensure the kitchen was maintained in accordance with Oregon food sanitation rules was discussed with Staff 1 (Director of Quality and Compliance) and Staff 2 (Director of Culinary Services) at 1:02 pm. They acknowledged the above findings.

C240

a.

1) Facility staff immediately did a deep clean of all kitchen and dining room areas including but not limited to all areas noted in the SOD.  

2) Plan of correction includes a Dietary Audit Sheet to be completed daily by dietary staff.  If an items needs to be referred to maintenance or housekeeping for deeper cleaning, a referral will be made through the maintenance workflow system, TELS with follow up by the Dietary Services Manager.  Inservice with all relevant employees completed on cleaning and sanitation protocols.  Protocols all posted in the kitchen area for reference.

3) Dietary Service Manager will audit weekly and provide additional inservice and training as needed.

4) Executive Director is responsible to see that the corrections are completed and monitored.

b.

1) Non-functioning Montague Grizzly oven and grill were removed from the kitchen. Gasket for freezer is on order.  Follow up email sent to vendor for estimated delivery date. Work order placed with maintenance for cabinet veneer door replacement.  

2) Plan of correction includes weekly walkthrough between DSM, Maintenance Director and ED and any areas of improvement needed, will be placed on a workorder for repair and/or removal.

3) Weekly walkthroughs will be completed.

4) Executive Director is responsible to see that the corrections are completed and monitored.

c.  

1) DSM immediately reached out to all kitchen staff to get copies of all Food Handler cards, that were not found in the personel files.  All are current and up to date.

2) Plan of correction includes audits conducted of certifications for all new hires and renewals for exisiting employees, using the training grid.

3) Review training grid and certifications at monthly CQI meeting.

4) Executive Director is responsible to see that the corrections are completed and monitored.

d.

1) Deep clean of kitchenette completed, cabinets were locked that contained chemicals, personal items were moved to another secured area.

2) Plan of correction includes an Audit Sheet to be completed by unit staff.  If an item needs to be referred to maintenance or housekeeping for deeper cleaning, a referral will be made through the maintenance workflow system, TELS with follow up by the Dietary Services Manager.  Inservice with all relevant employees completed on cleaning, sanitation and chemical safety protocols.  

3) Dietary Service Manager will audit weekly and provide additional inservice and training as needed.

4) Executive Director is responsible to see that the corrections are completed and monitored.  

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.

see C 240