The findings of the kitchen inspection, conducted 12/27/22, 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 12/27/22, conducted 03/30/23, 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, 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 12/27/22 revealed splatters, spills, drips, dust and debris noted on:

- Can opener blade and casing;

- Exterior of the range, range top, back of grill, and grease trap;

- Underneath shelving and equipment;

- Wire racks storing dishes;

- Plate warmer;

- Service/utility carts;

- Light switches;

- Dish machine;

- Floor and walls under and behind dish machine;

- Walls above and behind prep area;

- Hand washing sink;

- Corners/edges of door thresholds;

- Chemical storage room floors/edges;

- Hood above dish machine;

- Microwave exterior and interior;

- Plate warmer;

- Trays where clean dishes were stored;

- Pan where jugs were stored by the grill;

- Exterior of refrigerators/freezers;

- Walls and floors in chemical storage room; and

- Walls as you entered the kitchen across from the service area.

The following areas/items were found needing repair;

- Hole in the wall in the dry storage area next to an outlet;

- Under sink in dish washing area;

- Multiple areas in door thresholds with chipped paint exposing wood;

- Wood shelf where dishwashing chemicals were stored;

- Interior of dish machine with heavy mineral buildup;

- Wire racks storing dishes with areas of rust and ware; and

- Freezer in chemical storage room with heavy frost/ice build up.

* Cutting boards found with deep scoring and staining.

* Steam table with large wooden area that was deeply scored/damaged making it a non cleanable surface.

* Removable vents of hood above grill/stove with visible dust and build up.

* Multiple items in the cold storage were not dated when prepared or opened.

* Serving scoop was left in a dessert item and was stored uncovered in the refrigerator.  

* Prepared dessert items for service stored in fridge uncovered.

* Multiple items in dry storage not dated when opened.

* Brooms stored on floor.

* Facility was not using pasteurized eggs.

* Ice machine with visible black and pink substances on interior where ice was stored. There was a notable build up of dust on the intake vents on both sides of the ice machine.

* Beverage service area in dining room was found with drips and spills on the walls. Small refrigerator in that area also with items not dated and spills and food/beverage stains or debris.

* Kitchen staff observed touching ready to eat food products (fried chicken/lettuce for salads) with gloves that had touched other potentially contaminated items (service utensils, fridge door handles, knife).

* Dish machine was found not reaching necessary temperature for sanitization and thermometer was not working for rinse cycle. Facility discontinued use of dish machine and utilized alternated methods for sanitizing pots and pans and switched to use of paper products until dish machine could be fixed. Service company contacted by Staff 2 (Dining Service Manager) and Staff 3 (Maintenance) and indicated they would be out the next day to service/repair. Staff 2 and 3 indicated facility does have plans to replace dish machine in February related to ongoing repair issues with machine.

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

The areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

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

1. Deep clean of entire kitchen, chemical storage area, kitchen walls, ice machine and beverage service area will be completed on 2/8/23.  Initial cleanings occuring on a daily basis as of inspection date.

2. Updated monthly kitchen cleaning schedule to include all items listed on citation page 3, also including ice machine, beverage service area, chemical storage and small refrigerator. Ice Machine has been cleaned since inspection to resolve any immediate issues.

3. Dining Director will audit deep clean list at end of every month to ensure tasks are completed.

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

Plan of Correction for items that were found needing repair-

1. Maintenance requests were entered for all items and repairs to be completed by 2/13/23. The following items cannot be repaired and will be replaced- dishwasher, steam table, wire rack that stores dishes, cutting board, can opener and chemical storage rack. Replacement time is dependent on vendor availability and shipment time. (Facility is aquiring a new dishwasher. Until new dishwasher arrives we are using a santizier in replacement of high temp sanitizing. This will alleviate any inappropriate temperature issues.)

Once new machine arrives, Maintenance Director will  complete monthly temperature checks on dishwasher for on-going maintenance.  Currently dishwasher has been converted to a low temp chemical (chlorine based sanitizer) system as a temporary solution.

2. Dining Director and ED complete quarterly standard audits. At quarterly dining standard audits ED will submit maintenance requests for any items found to broken or inoperable. Dining Director will submit requisitions to ED when kitchen items have become inoperable beyond repair.

3.  Dining Director will complete monthly and quarterly audits. ED will complete quarterly audits.

4. Dining Director, Maintenance Director and ED will be responsible for monitoring and corrections.

Plan of correction for staff related issues- non-dated items, improper food storage, broom storage, food serving sanitation-

1. On 1/25/23 an all staff inservice will be completed to include food sanitation practices, cleaning and sanitizing protocols, proper food storage and proper serving protocols.  Documentation will be available upon request.

2. Dining Director will perform quarterly cook audits to ensure each cook is trained and knowledgeable on kitchen sanitation practices. This will include a skills checklist. ED will complete dining standards audit every quarter, to include observation of a meal service, meal preparation and food storage.

3. Dining Director is responsible for day to day monitoring of kitchen staff skills, education and conduct. Dining Director will perform quartely skills audit and ED will perform quarterly dining standards audit.

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