The findings of the kitchen inspection, conducted 07/12/22, 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 first revisit to the kitchen inspection of 07/12/22, conducted 10/03/22, 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 second revisit to the kitchen inspection of 07/12/22, conducted 12/13/22, 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, interview, and record review, 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 facilities kitchen, food storage areas, food preparation, and food service on 07/12/22 revealed:

* Splatters, spills, debris, and drips noted:

- Surfaces an underneath storage shelves, cabinets, and drawers throughout the kitchen;

- Metal storage shelves throughout the kitchen and walk in refrigerator;

- Walls throughout the kitchen;

- Floors and drains;

- The vents, outer surface, and underneath the ice machine;

- The dishwashing area walls, floors, and equipment;

- Both sides and the interior of the range, grill, and oven;

- The range hood;

- Food storage bins;

- Behind and underneath appliances;

- The surface and underneath the tray line steam table;

- The plate warmer;

- Food preparation counters;

- Interior of the microwave;

- The stand mixers;

- Garbage cans and lids;

- The mop bucket storage area; and

- A radio on the counter by the stand mixer.

* The walk in freezer had a leak creating a build up of ice build from the ceiling to the floor.

* Food was stored on the floor of the freezer.

* Multiple dented cans of food were noted in they dry storage area;

* Bagged food items were stored on the floor of the dry storage area; and

* A Styrofoam cup was left in a bag of rice.

* Dust and debris noted on cages of three fans blowing onto the tray line, preparation areas, and into the dish washing area.

* Undated food items and food items with dates older than seven days were noted in the refrigerators.

* The back entrance to the kitchen was left open allowing the entrance of flies and pests.

* The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million.

* Staff were observed to not change gloves between tasks or sanitize hand upon entering the kitchen.

* Staff in the kitchen did not have hair restrained; and

* Caregiving staff assisting with meal service and delivery were not using aprons.

A box of frozen Halibut fillets was observed to be left on the kitchen counter at 8:45 am. It was still on the counter at 9:15 am. Dietary staff stated it was to be used for lunch, and they were waiting to get the number of fillets needed. The need to thaw items on the lowest shelf in the refrigerator or under cold running water was explained. Staff acknowledged the information. The Halibut was not moved to the refrigerator or under cold running water. Staff 1 (Executive Director) was requested to intervene. The fillets were still frozen.

The Surveyor and Staff 1 toured the kitchen, and the areas in need of cleaning and repair were reviewed. He acknowledged the findings.

1. For the areas identified in the deficiency, the areas with splatters, spills, debris and drips were cleaned immediately including fans.

In addition, all food is properly stored, labeled and all cans with dents were destroyed. The repair for the walk freezer has been scheduled.

Aprons have been purchased and staff will be in-serviced on proper infection control, sanitation and safe handling of frozen and defrosted food.

2.All areas noted in the deficiency will be added to the cleaning schedule in the kitchen. Dining Service director will review cans weekly for damage and remove cans with damage

Safe handling of foods, sanitation and infection control will be added to our monthly in-service meeting for all staff.

3. It will be reviewed monthy in the sanitation audit

4. The Dining Service Director and Exeutive Director will be responsible.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

Observations of the facilities kitchen, food storage areas, food preparation and food service on 10/03/22 revealed:

* Splatters, spills, debris, and drips noted on the following:

- Metal storage shelves throughout the kitchen and walk in refrigerator;

- Racks in walk in refrigerator;

- Cart used for food delivery;

- Walls throughout the kitchen;

- Flooring throughout the kitchen;

- Drains;

- Underneath the ice machine;

- Behind and beside the range;

- Interior of the microwave;

- The stand mixers; and

- Garbage cans and lids.

* The walk in freezer had a leak creating a build up of ice from the ceiling to the floor.

* Dented can noted in the dry storage area;

* A scoop left in the bin of sugar.

* Dust and debris noted on cage of fan blowing into the dish washing area.

* Undated food items in the refrigerator.

* Staff were observed to not change gloves between clean and dirty tasks or sanitize hands upon entering the kitchen.

* Staff in the kitchen did not have hair and beards restrained.

The Surveyor and Staff 2 (Dietary Services Manager) toured the kitchen, and the areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director). They acknowledged the findings.

1. For the areas identified in the deficiancy, the areas with splatters, spills, debris, dust and drips were cleaned immediately.

In addition, all food is properly stored and labeled, utensils properly stored and all cans with dents were destroyed; excess ice removed;

All kitchen staff have hair and breard restrained and covered.

2. All areas noted in the deficiency will be added to the cleaning schedule in the kitchen. Dining Service director will review cnas weekly fir damage and remove cans with damage

Safe handling of foods, sanitation and infection control will be added to out monthly in-service meeting for all staff.

3. It will be reviewed weekly and monthly in the sanitation audit.

4. The Dining Service Director and Executive Director will be responsible.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Observations of staff during the survey on 10/03/22 revealed multiple staff failed to wear a face mask.

The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (Executive Director). He acknowledged the findings.

1. For the area identified in the deficiency the following was inplmeneted immediately;

Signs were posted in the kitchen for reminders to wear mask at all times;

Masks were placed in the kitchen readily available to all staff;

Dining Director monitor daily for mask compliance

2. Mask wearing will be added to the monthly sanitation audit;

staff are to take a infection control training is Relias by 10/31

3. Daily, Weekly and monthly for compliance.

4. Dining Director and Executive Director

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C240.

1. The plan of correction noted in C240 will be immediately implemented. See C240

2.The violations and plan will be audited weekly for compliance.

3.Weekly and Monthly

4. Dining Service Director and Executive Director.