The findings of the kitchen inspection, conducted 01/30/23, 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 of the kitchen inspection of 01/30/23, conducted 10/05/23, 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 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 facility main kitchen, Memory Care Unit kitchenette, food storage areas, food preparation, and food service on 01/30/23 revealed splatters, spills, drips, and debris on:

- Stand mixer;

- KitchenAid mixer;

- Interior of drawers and cupboards in the main kitchen and the Memory Care kitchenette;

- The exterior of cupboard in the Memory Care Kitchenette;

- Exterior and behind the gas range and oven;

- Interior of the ovens;

- Open shelving;

- Legs and underneath shelving; and

- Equipment throughout kitchen.

* There were undated and unlabeled foods in the walk in refrigerator.

* There was a leak in the walk in freezer creating a build up of ice above the door.

* The dietary staff person did not remove gloves and wash hands between scraping dirty dishes and putting away clean dishes.

* The thermometer in the reach in refrigerator in the Memory Care Unit was above 50 degrees. The protein based foods were discarded and the temperature turned down.

* There was a plastic up left in a container of brown sugar in the Memory Care Unit.

* The interior of the cupboard beneath the steamtable was damaged.

Staff 1 (Dietary Services Director) and the surveyor toured the kitchens. Staff 1 acknowledged the areas needing cleaning and repair.

1.) Stand mixer, KitchenAid mixer, can opener casing and blade, interior/exterior drawers, exterior/behind gas range/oven interior of main/activity kitchenette, open shelving, legs/underneath shelving and equipment throughout kitchen splatters, spills, drips, and debris were all deep cleaned. DSD has implemented daily cleaning tasks for dining team along with weekly audits of cleanliness; weekly audit will be reviewed with ED during weekly one on one meetings.

2.) Interior and exterior of drawers and cupboards in the Memory Care kitchenette; splatters, spills, drips, and debris were cleaned thoroughly and checked by MCD, DSD and ED for completed cleanliness. Nightly cleaning completed by NOC shift care team, with upkeep done after each meal by care team on duty. Weekly walk throughs completed by MCD and reported to ED during one on one meetings. Monthly sanitation audit implemented to be completed by MCD and reported at monthly quality assurance meetings.

3.) All undated and unlabeled foods were assessed and labeled/dated or thrown out appropriately. DSD completing daily checks to assure all foods are dated and labeled properly. Foods will be audited for labels along with sanitation audit weekly.

4.) The leak/ice buildup in the walk in freezer was the result of the freezer door not latching when closed. Latch repaired and leak/ice buildup eliminated.

5.) Training by DSD completed with all Utility Associates assuring that they are aware gloves must be changed between scrapping and loading dirty dishes and unloading clean dishes. DSD to complete annually shadowing audit for competency and compliance.

6.) The temperature of the MC refrigerator was adjusted and is now reading within range. Additional temperature check added to MC QMAR with two checks to be completed in 24 hours. Weekly QMAR audits completed by MCD reported in one on ones with ED.

7.) Removed container of brown sugar and replaced with single serve brown sugar packets for the MC for easy use and compliance.

Interior of cupboard beneath steamtable repaired on 2/7/2023.

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 POC for C 240