The findings of the kitchen inspection, conducted 07/05/22, 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 07/06/22, conducted 10/04/22, 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 food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the main facility kitchen, food storage areas, food preparation, and food service on 07/06/22 revealed:

* Splatters, spills, and drips noted on:

- Food storage bins under the tray-line;

- Exterior of the range;

- Interior of the microwave;

* Black matter noted on the can opener blade;

* Dust and debris was built up on metal storage shelves throughout the kitchen;

* Dust and debris noted on cage of two rotating fans blowing onto the tray line and into the dish washing area;

* Two bottles of opened mustard noted to require refrigeration were left in an un-refrigerated food storage area;

* Undated food items and food items with dates older than seven days were noted in the reach in refrigerator;

* The cove-base flooring was damaged in corners creating an un-cleanable surface; and

* The back entrance to the kitchen was left open allowing the entrance of flies and pests.

The commercial high temperature dish machine was observed in operation three times. It was not reaching the specified temperature required for the sanitizing rinse cycle.

Observations of the Tuscany House kitchen and food storage areas on 07/06/22 revealed:

* Spills, splatters, and debris noted in drawers and on shelves;

* Splatters noted on the interior of the microwave;

* Garbage can lacked a lid;

* Damage to entry door frame by the refrigerator seating area island around kitchen;

* No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored; and

* Food dated past seven days noted in refrigerator.

Observations of the Ranch House kitchen and food storage areas on 07/06/22 revealed:

* Spills, splatters, and debris noted in drawers and on shelves;

* Garbage can lacked a lid;

* Damage to seating area island around kitchen; and

* No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored.

The kitchens were toured with Staff 1 (Administrator) and Staff 2 (Dietary Manager). Disposable dishes were in use.

The areas in need of cleaning and repair were reviewed with Staff 1 and Staff 2. They acknowledged the findings.

***Commercial Kitchen

This Rule is not met as evidenced by: Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation

1. Splatters, spills, and drips noted on: - Food storage bins under the tray-line; - Exterior of the range; - Interior of the microwave;  

Actions: All of the Splatters, spills and drips were cleaned the day of the inspection.

System Correction: On going cleaning has been added to the daily cleaning task list to be completed by kitchen staff by the end of the day and as needed during the day as spills occur.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect all areas daily Monday - Saturday for compliance.

2. Black Matter noted on the can opener blade.  

Actions: The can opener was taken apart, cleaned and sanitized. The cleaning of the can opener was put on a daily and as needed sanitizing list.

System Correction: The on going cleaning has been added to the daily cleaning/sanitizing task list to be completed by kitchen staff by the end of the day and as needed during the day as needed. It is also taken apart, cleaned and sanitized after the dinner prep has occurred.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect the can opener daily Monday - Saturday for compliance.

3. Dust and debris was built up on metal storage shelves throughout the kitchen;

Action: The metal shelves throughout the kitchen were cleaned the day of the inspection.

System Correction: The on going cleaning of the shelves was put on the weekly cleaning task list to be completed by the kitchen staff on Fridays.

Audit/Follow Up/ Responsible Party: Dietary management will inspect weekly that the cleaning has been done.

4. Dust and debris noted on cage of two rotating fans blowing onto the tray line and into the dish washing area;

Action: The fans were taken apart and cleaned the day of the inspection.

System Correction: The on going cleaning of the fans will be put on the weekly cleaning task list to be completed by the kitchen staff on Fridays.

Audit/Follow Up/ Responsible Party: Dietary management will inspect weekly that the cleaning has been done.

5. Two bottles of opened mustard noted to require refrigeration were left in an un-refrigerated food storage area;

Action: The mustard was discarded immediately. All Staff will be in-serviced on food safety with a focus on refrigeration, dating food items, and discarding items that are out of compliance.

System Correction: Daily checks have been added to the task list for the kitchen staff to be checking every kitchen for un-refrigerated food that requires refrigeration, Out dated food, and un-dated food items.

Audit/Follow Up/ Responsible Party: Dietary management will do ongoing monitoring of the kitchen areas for any violations.

6. Un-dated food items and food items with dates older than seven days were noted in the reach in refrigerator;

Action: Out dated food and un-dated food were discarded immediately during inspection. All Staff will be in-serviced on food safety with a focus on refrigeration, dating food items, and discarding items that are out of compliance.

System Correction: Daily checks have been added to the task list for the kitchen staff to be checking every kitchen for food that requires refrigeration, out dated food, and un-dated food items.

Audit/Follow Up/ Responsible Party: Dietary management will do ongoing monitoring of the kitchen compliance.

7. The cove-base flooring was damaged in corners creating an un-cleanable surface; and

Action: Maintenance inspected the areas noted and we determined that a full replacement of the Rose Arbor kitchen flooring would be required to bring the condition back in compliance. A request for bids was made on 7/6/2022. As of 7/19/2022 they have yet to come in to the facility.

System Correction: Flooring will be monitored daily by kitchen management to note condition changes after the new floor has been installed. Any noted damage or areas of disrepair will be reported to the Administrator and the maintenance director immediately and submitted for repair.

Audit/Follow Up/ Responsible Party: Dietary management will do ongoing monitoring of flooring.

8. The back entrance to the kitchen was left open allowing the entrance of flies and pests.

Action: The back door was immediately closed and not proped open until a screen door could be installed. A screen door was purchased and it was installed on 7/19/2022. Staff were in-serviced on the importance of closing the door to avoid pests and bugs to enter the kitchen. When the staff needs to prop the door open the screen must be in place.

System Correction: Kitchen staff and dietary management is responsible for monitoring and ensuring that the screen is in place during times that the door is proped open.

Audit/Follow Up/ Responsible Party: Dietary management will do a weekly and as needed check on the screen for damage and replace as needed.

9. The commercial high temperature dish machine was observed in operation three times. It was not reaching the specified temperature required for the sanitizing rinse cycle.

Action: The use of the commercial dish machine was discontinued until it could be inspected and repaired by our vendor. The three sink sanitizing system was started and will continue until the dish machine comes up to temp.

System Correction: A tempature will be taken twice daily (morning and evening) by kitchen staff and recorded in their temp log. Kitchen staff in-serviced on the required tempature and what to do in the event that the dish washer is not reaching the required temp.

Audit/Follow Up/ Responsible Party: Dietary management will audit the temp logs daily.

*** Observations of the Tuscany House kitchen and food storage areas on 07/06/22 revealed:

1. * Spills, splatters, and debris noted in drawers and on shelves; * Splatters noted on the interior of the microwave;

Actions: All of the Splatters, spills and debris on and in the drawers and on shelves were cleaned the day of the inspection.

Action: All cleaning was completed by the end of the work day on 7/6/2022.

System Correction: On going cleaning has been added to the Night shift care staff's cleaning task list to be completed as needed throughout the day, by caregivers and dietary staff.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect all areas daily Monday - Saturday for compliance. Reporting any deficency to the Resident Care Coordinator for staff intervention, training, and educational support.

2. Garbage can lacked a lid;

Action: Commercial garbage cans were ordered and received with foot operated lids for both memory care homes.

System Correction: Kitchen staff will do daily checks for lids, or damage and report any findings to the dietary management.  

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator.

3. Damage to entry door frame by the refrigerator seating area island around kitchen;

Action: The administrator and the maintenance director met and reviewed the repairs that would be required. A plan was put in motion with the highest priority.

System Correction:  Dietary management will note any damage in their daily audit of the kitchens and report to the Administrator and Maintenance director.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator.

4. No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored;

Action: Dietary management created a temp log for each house and care staff training was completed.

System Correction: Care staff in the memory care homes are now responsible for completing a temp check on the refidgerator, freezer and sanitizer twice daily, at breakfast and dinner, and logging it in the temp log binder in each home. Staff has been in-serviced on their responsibility, temp requirements and who to report to when the temps are out of range. Staff will have continued education during food safety in-services.   

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. non compliance will be reported to the Administrator for additional education and or corrective action. The regional Dietitcian will also complete routine spot checks, and complete monthly continued education with the dietary, leadership, and direct care staff on food safety, survey preparedness, system auditing, and competency compliance.  

5. Food dated past seven days noted in refrigerator.

Action: Any food that was beyond the 7 days or unlabeled was discarded immediately.

System Correction: Care staff are responsible for checking the dates on items or discarding items as they use them.   Kitchen Staff will check daily while in the homes serving meals for dated or unlabled food to make sure that there is nothing out of range. Regular food safety education will be included in the in-service schedule.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Non compliance will be reported to the Administrator for additional education and or corrective action.

***Observations of the Ranch House kitchen and food storage areas on 07/06/22 revealed:

1. Spills, splatters, and debris noted in drawers and on shelves; * Splatters noted on the interior of the microwave;

Actions: All of the Splatters, spills and debris on and in the drawers and on shelves were cleaned the day of the inspection.

Action: All cleaning was completed by the end of the work day on 7/6/2022.

System Correction: On going cleaning has been added to the Night shift care staff's cleaning task list and will be done as needed througout the day by dietary and direct care staff.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager will inspect all areas daily Monday - Saturday for compliance. Reporting any deficency to the Resident Care Coordinator for intervention, training and educational support.

2. Garbage can lacked a lid;

Action: Commercial garbage cans were ordered and received with foot operated lids for both memory care homes.

System Correction: Kitchen staff will do daily checks for lids, or damage and report any findings to the dietary management.  

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator.

3. Damage to entry door frame by the refrigerator seating area island around kitchen;

Action: The administrator and the maintenance director met and reviewed the repairs that would be required. A plan was put in motion with the highest priority.

System Correction:  Dietary management will note any damage in their daily audit of the kitchens and report to the Administrator and Maintenance director.

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. Any damage noted or replacement needed will be reported to the Administrator.

4. No documented evidence the temperatures of the dish sanitizer or the refrigerator were being monitored; and

Action: Dietary management created a temp log for each house and care staff training was completed.

System Correction: Care staff in the memory care homes are now responsible for completing a temp check on the refigerator, freezer and sanitizer twice daily, at breakfast and dinner, and logging it in the temp log binder in each home. Staff has been in-serviced on their responsibility, temp requirements and who to report to when the temps are out of range. Staff will have continued education during food safety in-services.   

Audit/Follow up/Responsible Party: The dietary manager and assistant manager have added checks daily Monday - Saturday for compliance. non compliance will be reported to the Administrator for additional education and or corrective action.

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 C240.