The findings of the kitchen inspection, conducted 05/08/24 through 05/09/24, 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 revisit to the kitchen inspection of 05/08/24, conducted on 07/18/24, are documented in this report. The facility was determined to be 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 maintain the kitchen in good repair, in a sanitary manner or have a qualified person in charge in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility ALF kitchen was completed 05/08/24 from 9:45 am through 2:30 pm and again on 05/09/24 from 9:45 am thru 11:00 am and the following was identified:  

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease and/or black matter was visible on or underneath the following:

* Dining room floors near tables, table bases;

* Ceiling vents above beverage service area;

* Ceiling vents above prep and service areas;

* Juice machine;

* Outlets and light switches;

* Floors throughout kitchen and beverage service area;

* Interior of ice machine;

* Walls throughout kitchen;

* Multiple utility carts;

* Exterior of robot coupe;

* Fans and metal cages of fan by serving area;

* Open shelving throughout kitchen and beverage service area;

* Large metal pan holding bag of onions;

* Interior and exterior of microwave;

* Exterior of bulk food bins;

* Cover for baking (Go) racks;

* Baking (Go) racks;

* Interior and exterior of convection ovens;

* Exterior and interior of steamer;

* Range top, grill top;

* Knobs of ranges/ovens/grill and steam table;

* Metal shelves storing pots/pans/dishes;

* Steam table wells;

* Industrial can opener and housing;

* Steamer interior and exterior;

* Industrial mixer;

* Interior and exterior of reach in deli cooler;

* Door thresholds with food debris/splatter;

* Plate warmer;

* Interiors and exteriors of stainless steal drawers;

* Flooring in under and around dishwashing area;

* Walk in cooler fans and cages;

* Walk in cooler ceiling;

* Metal racks in walk in cooler;

* Kitchen and beverage area drains.

* Three compartment sink area;

* Can rack in dry storage;

* Metal racks storing clean dishes; and

* Stainless steal service area on tray line.

b. The following areas were in need of repair:

* Corners of walls with chips, nicks and gouges;

* Multiple tile pieces upon entry to kitchen with cracks with visible debris build up;

* Caulking behind three compartment sink with black debris build up; and

* Approximate one inch gap observed by ceiling vent by prep area.

c. Staff 2 was observed to prepare hamburger and sandwich with lettuce that was not washed. Staff was observed to leave the line, walk into walk in cooler, and remove green leaf lettuce from box, exit walk in and put directly on to hamburger that was served to resident. Lettuce was then put in deli fridge. Surveyor returned to walk in and reviewed box lettuce which indicated the product needed to be washed and trimmed before service/use. Surveyor immediately informed Staff 2 that lettuce was to be washed prior to service per the box instructions. Staff 2 stated that they usually did not wash that product as it "looks very clean and looked prewashed." Surveyor reiterated that the box indicated it needed to be washed and trimmed. Staff 2 verbalized understanding but did not remove lettuce and wash or trim as directed and was observed placing it on a deli sandwich and served to residents.

d. Staff 2 was observed during tray line to leave line several times and touch door handles, and other items including a rag with sanitizer solution with gloved hands. Staff 2 did not change gloves or wash hands, when switching tasks or potentially contaminating gloves and preceded to handle ready to eat foods such as garlic bread, hamburger buns, and make deli sandwiches.

e. Staff 2 was observed to wipe several plates with a rag stored on the tray line counter. Staff wiped the counter with this rag as well as other plates. The rag was then placed in sanitizer bucket and taken back out to be used to wipe plates and surfaces during tray line.

f. Multiple food items were found in walk in cooler without proper labels and/or prepared/opened or use by dates as required. Multiple food packages were found opened in walk in, exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler.

g. Multiple food packages were found opened in dry storage without open dates. Multiple food items found not securely closed and/or open to potential contamination in dry storage.

h. Staff 2 was observed to not check temperature of service line products including scrambled eggs. Surveyor intervened before delivery and asked staff to check the temperature which was found to be at required levels.

i. Multiple kitchen staff were observed without hair or beard/facial hair restraints. Staff 2 was alerted of the need however staff continued to not restrain hair while working with food and clean equipment per rule.

j. Dining room was observed with preset tableware that was not covered or inverted and exposed to potential contamination.

k. Staff 2 was not able to demonstrate adequate person in charge knowledge for prevention of cross contamination, kitchen employee hygienic practices, proper temping of food items, handling of potential hazardous food items, and proper cleaning methods/procedures.

On 05/08/24 at approximately 12:30 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 5 (Memory Care Administrator), who acknowledged the findings.

On 05/09/24 from 9:45 am to 10:45 am,  the surveyors observed that significant cleaning had occurred with also noted improvements in other identified areas from previous days observations. Staff 4 was interviewed and was able to verbally demonstrate adequate knowledge in most areas with the exception of employee illnesses for exclusion and reporting.

Staff 3 (Dining Service Manager) was interviewed on 05/09/24 at 10:00 am. S/he said areas identified in kitchen review were not at their standards of what they would expect the designated Person In Charge to maintain. Staff 3 stated s/he had not at been at facility consistently in PIC role since November 2023.

On 05/09/24 at approximately 10:45 am, completed survey findings were reviewed with Staff 1 and Staff 5. They acknowledged the areas in need of correction.

1. Dining manager and team will be completing the following:

a.  thorough cleaning of kitchen, which will include floors, vents, ceilings, appliances, walls, utility carts, shelves, bins, countertops, coolers, freezer, sinks, steam tables, juice machines, drink station, and any other area not mentioned.

b.  repairs of chipped corners, cracked tile on floor, caulking behind sinks, and any other area not mentioned.

c.  Inservice for all dietary staff reviewing infection control, cross contamination, proper glove use, proper hand washing, proper washing of produce, proper labeling of food items, proper temperature checks, and proper hair restraints.

d.  All kitchen staff are to re-do and complete food handler's card.

e.  Designated kitchen manager while Dietary Services Manager is away.

f.   Cleaning party done weekly (Thursdays) for the next 30 days and then done once monthly.

g.  Management present during each meal service for the next 30 days to ensure compliance and good practice.

2. Management present during all meals to ensure compliance and good practice.

b. Retraining for staff/inservice regarding infection prevention, hand washing, food handler

3. Evaluation of kitchen will be done daily

4. Dietary Service Manager, Executive Director, and Person in Charge will oversee compliance and good practice.