The findings of the kitchen inspection, conducted 02/15/24, 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 first re-visit to the kitchen inspection survey of 02/15/24, conducted 05/02/24, 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, food storage areas, food preparation, and food service on 02/15/24 revealed:

a) splatters, spills, drips, dust and debris noted on:

- Can opener casing;

- Industrial can opener;

- Interiors of drawers;

- Walk-in freezer floors;

- Service/utility carts and wheels;

- Smoke detector near/above a dishwashing area;

- Interior of oven;

- Interior and exterior of microwave;

- Food contact and non food contact surfaces of the industrial slicer;

- Food delivery cart;

- Screen door with dust build up; and

- Shelf under microwave.

b. The following areas were in need of repair:

- Caulking near hand washing was missing, cracked or found with black matter;

- Walls and caulking around dish machine area with build up of black debris;

- Industrial slicer not working;

- Left oven not operational and;

- Screen door to outside not latching/handle broken off.

* Kitchen staff observed to handle ready to eat foods with potentially contaminated gloves. Staff wearing same gloves that handled fry pan and spatula cooking chicken breast, open refrigerator door, touching container of ranch dressing and sour cream and then handling flour tortillas, shredded lettuce and shredded cheese.

2. Memory care unit (Expressions) kitchenette was observed at 11:40 and revealed:

a) splatters, spills, drips, dust and food/debris noted on:

- Exterior of food delivery cart;

- Clean dish storage cart;

- Interior of reach in refrigerator and freezer;

- Interior and exterior of microwave;

- Exterior of oven;

- Behind sink;

- Cabinet under sink;

- Wall behind trash can; and

- Kitchenette flooring.

b) Multiple cold food items were found without use by or open dates. A carton of unpasteurized eggs found multiple days past the used by date. Containers of food items for residents without dates or resident identifier information.

c) Previously frozen cartons of nutritious shake beverages found thawed without a use by date for their thawed state.

d) Care staff were not wearing aprons or other protective layer during meals service to prevent potential spread of infectious agents on clothing from care giving tasks. One staff member was observed in the kitchenette area without their hair restrained.

e) Multiple dry food items were not dated or securely closed after opening to ensure they were protected from contamination.

f) Staff did not properly sanitize thermometer probes between checking temperatures of multiple food items potentially contaminating the food products.

g) Recyclable items were not stored in appropriate receptacles as required.

h) A serving utensil was found stored in the ice bin in the reach in freezer. A spoon was found in the container of brown sugar.

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

Areas found to be out of compliance referenced in section A.  have all been cleaned as of 3/4/24.  Dietary director will continue to monitor cleanliness of kitchen daily and will be doing weekly audits per prestige policy of quality assurance to ensure ongoing compliance with OAR 333-150-000.  

ED will be responsible for continued compliance through weekly meeting with dietary manager, kitchen walkthroughs and quality assurance audits.

Items referenced in need of repair in section B.  have been repaired.  Dietary manager will continue to oversee kitchen appliances and will alert ED and Maintenance department in timely manner of any items in need of repair.

Employee inservice to be held 3/26/24 to provide re-education on food handling, glove usage, apron & hair restraints, food beverage labeling, use by dates, food storage, cleaning checklist and expectations.

Expressions memory care kitchen, deep clean of kitchen and repair of drawer have been completed as of 3/6/24 that include all items referenced in section 2. a.  Dietary manager to check for continuing compliance of cleaning checklist and proper food storage weekly per prestige quality assurance policy.  ED to meet with dietary manager weekly and do weekly kitchen walkthroughs to ensure policies being followed.   

Section 2.b.  Fridge contents labeled with item, and opened date, staff to receive retraining on this on 3/26/24.  Continued compliance will be monitored by dietary manager and executive director per quality assurance policy.

Section 2.C. Staff have been educated on marking nutrtional shakes with use by date when they are thawed.  Continued compliance will be monitored by dietary manager and executive director per quality assurance policy.

Section 2.D.  Staff have been re-educated on apron and hair restraint usage for kitchenette area.  Expressions director, dietary manager and executive director will ensure continued compliance via weekly checks and quality assurance program.

Section 2.E.  Dry storage in kitchenette cabinet has been organized and all food items labeled.  Staff to receive retraining on this process on 3/26/24 and continued compliance will be monitored by dietary manager, expressions director and executive director following quality assurance policy and program.

Section 2.F  Staff have received retraining and coaching on proper sanitizing of thermometer probes and have probe covers as well as acohol cleansing wipes to ensure this policy can be followed.  Dietary manager and Executive Director to do weekly walkthroughs during meal service to ensure this process is being followed.

Section 2.G.  Recycling receptacle bin placed in kitchenette for proper disposal of items.

Section 2.H  Staff receiving retraining on proper storage of utensils on 3.26.24.  Weekly audits will occur by dietary manager and executive director per quality assurance program to ensure continued compliance.    

Based on observation, record review, and interview, 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.

 Areas found to be out of compliance referenced in section A.  have all been cleaned as of 3/4/24.  Dietary director will continue to monitor cleanliness of kitchen daily and will be doing weekly audits per prestige policy of quality assurance to ensure ongoing compliance with OAR 333-150-000.  

ED will be responsible for continued compliance through weekly meeting with dietary manager, kitchen walkthroughs and quality assurance audits.

Items referenced in need of repair in section B.  have been repaired.  Dietary manager will continue to oversee kitchen appliances and will alert ED and Maintenance department in timely manner of any items in need of repair.

Employee inservice to be held 3/26/24 to provide re-education on food handling, glove usage, apron & hair restraints, food beverage labeling, use by dates, food storage, cleaning checklist and expectations.

Expressions memory care kitchen, deep clean of kitchen and repair of drawer have been completed as of 3/6/24.  Dietary manager to check for continuing compliance of cleaning checklist and proper food storage weekly per prestige quality assurance policy.  ED to meet with dietary manager weekly and do weekly kitchen walkthroughs to ensure policies being followed.