The findings of the kitchen inspection, conducted 12/18/23, 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 revisit to the kitchen inspection of 12/18/24, conducted 04/10/24, 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.

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 12/18/23 revealed splatters, spills, drips, dust and debris noted on:

- Dining room floor underneath tables;

- Interior of ovens;

- Tray where clean dishes were stored;

The following areas/items were found needing repair;

- Interior of dish machine with heavy mineral buildup;

- Floor underneath dish machine and ice machine with heavy mineral buildup;

- Reach in refrigerator in dining room not maintaining appropriate temperatures for cold storage.

* Ice machine with visible black substance on interior where ice was stored. There was a notable mineral build up on exterior and interior of ice machine.

* Reach in refrigerator in the dining room was found at 48 degrees Fahrenheit. Milk and other protein items noted stored in refrigerator. Milk temperatures was found at 48 degrees. It was determined kitchen staff were not consistently monitoring the temperature of that refrigerator and it was unknown how long those items were above 41 degrees. Staff 2 discarded all potentially hazardous food items.

* Kitchen did not have a 3 compartment sink as required.

* Dishwashing racks were observed overloaded with dishes/equipment not allowing all items unobstructed access to sanitizing agent.

* Kitchen staff without restraint for facial hair.

* Countertop mixer and equipment were not covered when not in use.

* Scoops were observed stored in bulk food bins/containers.

Staff 2 and the Surveyors toured the kitchen. Staff 2 acknowledged the above findings.

At 1:20pm, the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Wellness Director). S/he acknowledged the findings.

Plan of correction for splatters, spills, drips, dust and debris-

Dining room floor underneath tables, interior of ovens, tray where clean dishes are stored

1. All areas with splatters, spills, drips, dust and debris will be deep cleaned by kitchen staff  by 1/15/24. Initial cleanings occuring on a daily basis as of inspection date.

2. Updated cleaning schedule to include bi-weekly cleaning of oven and trays instead of monthly. Staff implementation of push broom after each meal.

3. Dining director will audit deep clean list at end of every month to ensure tasks are completed. Prior to leaving each shift, cook on duty will ensure dining room has been swept.

4. Dining Services Director, Executive Director and Residents Services Director will be responsible for monitoring and corrections.

Plan of correction for items that were found needing repair- Interior of dish machine with heavy mineral buildup; - Floor underneath dish machine and ice machine with heavy mineral buildup; - Reach-in refrigerator in dining room not maintaining appropriate temperatures for cold storage.

1. The following items cannot be repaired and will be replaced: reach-in refrigerator in dining room. Replacement time is dependent on shipment time. Once arrived, Dining Director will check temp logs daily. Plant Operations Director has descaled the following areas with a descaling agent: interior of dish machine, floor underneath dish machine and ice machine.

2. Descaling of dish machine and ice machine will be added to the monthly cleaning checklist. Plant Operations Director and Dining Director will complete monthly walk-thru of kitchen and dining area to identify items needing repaired or replaced.

3. Dining Director will audit cleaning list monthly for completion. Plant Ops Director will verify proper working order of kitchen and dining monthly.

4. Dining services Director and Plant Ops Director

Plan of correction for ice machine with visible black substance on interior where ice was stored.

1. Dining services director will deep clean ice machine, draining entire machine monthly and ensuring all interior areas are cleaned and sanitized.

2. After monthly deep clean, plants ops director will second initial that ice machine has been thoroughly cleaned.

3. Executive Director will review ice machine cleaning record and check ice machine cleanliness quarterly.

4. Dining services director and Executive Director

Plan of correction for staff not consistently monitoring the temperature of reach in refridgerator in dining room

1. Broken refrigerator was unrepairable and disposed of immediately.

2. When new fridge arrives, cook-on-duty will check temperatures daily with all other temp logs.

3. Daily

4. Dining services Director will review temp logs weekly

Plan of correction for kitchen not having three compartment sink as required.

1. Facility has received an exception for not having a three compartment sink

2. Two sink system policy will be implemented in the event dishwasher is not in good working order.

3. Exception is good until 1/3/2026

4. All staff will be trained on two sink system policy on 1/24/24. In this event, Dining services Director will ensure two sink system policy is followed.

Plan of correction for dishwashing racks being overloaded with dishes/equipment not allowing all items unobstructed access to sanitizing agent

1. Dishwashing racks will be loaded so that all items have access to sanitizing agent

2.All staff meeting to provide training and demonstration on proper loading of racks in order to achieve proper sanitation requirements and observe return demonstration.

3. Weekly- Dining Director to do spot checks weekly to ensure appropriate method is being used

4. Executive Director and Dining Services Director.

Plan of correction for kitchen staff without restraint for facial hair

1. Any cook with facial hair will wear beard net

2. Beard nets will be worn ongoing by all cooks with facial hair

3. Dining service Director to complete weekly spot checks

4. Dining Services director

Plan of correction for countertop mixer and equipment not covered when in use-

1. Plastic bag was placed over countertop mixer when not in use

2. After each use and cleaning, a new plastic bag will be placed over countertop mixer while not in use

3. Daily

4. Cook on duty

Plan of correction for scoops stored in bulk foodbins/containers-

1. Scoop in food bin was removed

2. All staff will be trained on expectation of scoops being stored in foodbins at all meeting on 1/24/24.

3. Daily

4. Cook on duty