The findings of the kitchen inspection, conducted 07/21/22, 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 07/21/22, conducted 08/24/22 through 08/25/22, 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 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 facility kitchen including food storage areas, food preparation, and food service on 07/21/22 identified the following:

a. Splatters, spills, drips, and debris build-up noted on:

* Shelving throughout kitchen;

* Grill vents had a build-up of grease;

* Interior of the ovens;

* Range tops;

* Sides and behind range;

* Blender, toasters on food prep table;

* Flooring drains under steam table, prep table and warewash machine;

* The wall behind the warewash machine had a small amount of black matter build-up in the far left corner; and

* Underneath the stainless steal shelf in the warewash machine area.

b. Food storage:

* Refrigerator 1 was consistently operating above 41 degrees F.

* Refrigerator and freezer bottom shelves were observed with food spillage;

* Undated, unlabeled, an uncovered foods were observed in the upright refrigerator;

* Open food containers and left over food items were stored in the refrigerator without proper label, cover and date; and

* Open package of rice was noted on the bottom shelf of the food prep table.

c. Food service:

* Cold food items were served from the tray line above 41 degrees F. (Waldorf salad was 52 degrees F.)

Staff 3 (Food and Beverage Director) and Staff 4 (Executive Chef) were observed removing the salad and threw it away. New salad was prepared and placed over ice in order to maintain proper temperature when served from the tray line.

d. Employee infection control:

* Inconsistent hand hygiene;

* Inconsistent glove use between dirty and clean tasks; and

* Multiple caregivers and other staff who assisted with food service from the tray line were observed not wearing food service aprons and failed to have hair restrained while in the kitchen.

The food storage, food service, infection control, and areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director), Staff 2 (Administrator), Staff 3 and Staff 4. They acknowledged the findings. Staff 2 further acknowledged they would remove the items from Refrigerator 1 to the other refrigerators until it could be fixed or replaced.

1.

    a. Splatters, spills, drips and debris build-up noted in the central kitchen:

Shelving throughout kitchen;

7/22/22

Food removed from shelves and into dry storage, and shelves de-cluttered and cleaned.

Server-side of line cleaned and containers labeled by Food & Beverage Director Kathryn, so that condiments and food items each have a specific spot and will not be cluttered. Signage posted to maintain, and training ongoing with cooks and caregivers.

Gril vents had a build-up of grease;

7/22/22

Kitchen deep clean of hood vents, stovetop, stove drip pans and gas hookup on stove by dishwasher Robin.

Plan for regular cleaning maintenance - dishwashers scheduled to go over each day for initial deep clean, then dishwasher scheduled to go over every Monday, Tuesday and Friday for 1 ½-2 hours to clean.

Interior of the ovens;

7/25/22

Cleaned by cook Archie - dishwashers will clean weekly

Range tops;

7/22/22

Kitchen deep clean of hood vents, stovetop, stove drip pans and gas hookup on stove by dishwasher Robin. Will make this part of regular cleaning schedule, and cooks have been instructed to wipe down each night.

Sides and behind range;

7/22/22

Kitchen deep clean of hood vents, stovetop, stove drip pans and gas hookup on stove by dishwasher Robin.

7/25/22

Deep cleaning by cook Archie: sides of oven

Blender, toasters on food prep table;

Cleaned and will be regularly maintained.

Flooring, drains under steam table, prep table and ware wash machine had a small amount of black matter build-up in the far-left corner; and

7/25/22

Deep cleaning by dishwasher Robin: Dish sink area

Food & Beverage Director spoke to Bargreen Chemical Rep and was advised to use "Natural 23", a hydrogen peroxide-based cleaning product, to remove the black matter build-up. This will be regularly maintained.

Underneath the stainless-steel shelf in the ware wash machine area

7/25/22

Cook removed trays from under dishwasher area, cleaned them and stored them out of kitchen, since they are no longer used.

Foodservice items will no longer be stored under the dish area.

a.Food Storage in the central kitchen:

Refrigerator 1 was consistently operating above 41 degrees F.;

7/21/22

All food removed from this refrigerator and discarded; out of order sign put up

Work order submitted to maintenance to repair kitchen refrigerator

7/22/22

Refrigerator repair came - could not fix - will return

7/25/22

Refrigerator repair vendor came - worked on fridge. Replacement refrigerator ordered. To arrive October, 2022. Until then will not be used for food storage.

Refrigerator and freezer bottom shelves were observed with food spillage;

7/22/22

Refrigerator and freezer bottom shelves cleaned - regular cleaning added to weekly cleaning list

Undated, unlabeled, and uncovered foods were observed in the upright refrigerator;

7/22,23,24/22 and ongoing

Food & Beverage Director went through refrigerators and spoke to cook about labeling, dating, wrapping, proper storage - inspections will occur daily.

Open food containers and left-over food items were stored in the refrigerator without proper label, cover and date; and

Food & Beverage Director went through refrigerators and spoke to cooks about labeling, dating, wrapping, proper storage of leftover foods- inspections will occur daily.

Open package of rice was noted on the bottom shelf of the food prep table.

7/22/22

Food removed from shelves and into dry storage, and shelves de-cluttered and cleaned.

b.Food service in the central kitchen:

Cold food items served from the tray line above 41 degrees F. (Waldorf salad was 52 degrees F.)

Method for serving cold food items moving forward:

Keep the cold food refrigerated until ready to serve.

Refrigerate plates/bowls that will be used for cold foods.

Keep cold foods on ice during service, and away from the hot line food items.

Temp foods before serving.

c.Employee infection control:

Inconsistent hand hygiene;

Handwash signs are posted in the kitchen at the hand wash sink. All-staff training will include proper handwashing.

Executive Chef presence during service - on going.

Inconsistent glove use between dirty and clean tasks; and

All-staff training will include proper glove usage

7/22/22

Follow up with cook Rich - overview of survey, and discussion of glove usage.

7/24/22

Food & Beverage Director spoke with cook Archie to go over survey points and discuss action plan. Reviewed glove usage.

Multiple staff who assisted with food service from the tray line were observed not wearing food service aprons and failed to have hair restrained while in the kitchen.

7/21/22

Aprons and hairnets are provided for staff - aprons and restrained hair and/or hairnets are required during food service.

d.Observations in the memory care kitchenette identified the following:

Inoperable dishwashing machine - work order placed to repair.

8/4/22

Bargreen Ellingson will repair dishwashing machine - Request sent by Maintenance Director

Steamer drawer - training staff on appropriate use of steamer drawer.

Multiple cabinet doors and interior shelves had a build-up of brown sticky matter.

8/4/22

Sticky cabinets were cleaned by dishwasher Dan. Regular cleaning of the cabinets and shelves will be on the weekly cleaning list.

2. Ongoing staff training and documentation.

3. Monthly and weekly review

4. Food & Beverage Director and Administrator.