The findings of the kitchen inspection, conducted 12/11/23, 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 first revisit to the kitchen inspection of 12/11/23, conducted 02/16/24, 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 second re-visit to the kitchen inspection of 12/11/23, conducted 05/28/24, 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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main kitchen on 12/11/22 at 10:30 am revealed the following:

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

* Ice machine with visible black substance on the inside;

* Kitchen drains;

* Ceiling fire sprinklers;

* Interior of microwave in small dining room;

* Stove/oven knobs, doors, interior;

* Cages to cooling fans and ceiling in walk-in cooler;

* Hood above stove/grill and above dish machine; and

* On, in, and around light fixtures.

b. The following areas were in need of repair:

* Multiple areas where pipes entered ceiling or walls with open areas and not sealed, allowing potential entry for pests; and

* Left oven not operational.

c. Dining room tableware was pre-set, and utensils were not covered to prevent potential contamination.

d. Multiple kitchen employees were observed to be working in the kitchen without hair restraints. This is a repeat concern from previous surveys.

e. Single service utensils and paper plates stored in dry storage were open to potential contamination. This is a repeat concern from previous kitchen surveys.

f. Two large packages of frozen hot dogs were observed thawing, but not according to approved methods. They were not fully submerged under running cold water.

g. The reach-in refrigerator in the small dining room did not have a thermometer to monitor cold food storage temperatures. A container of salsa for residents was observed in the refrigerator. There was no date indicating when it was opened and no label identifying to whom the salsa belonged.

h. Multiple rags for surface cleaning/sanitation were observed stored out of the sanitation buckets on random counters/areas throughout the kitchen.

i. Facility observed to have only a two-compartment sink. Staff 2 (Executive Chef) confirmed they did not have a three-compartment sink and had more than 16 residents.

Staff 2 toured the kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor and Staff 1 (Interim Executive Director) reviewed areas of concern. Staff 1 acknowledged the above areas needed to be cleaned and repaired and that there were practices that needed to be addressed.

In response to Assisted Living Kitchen Inspection conducted 12/11/2023:

1 - A) Deep clean of entire kitchen will be completed to bring into immediate compliance. This is to include; ice machine, drains, fire sprinklers, microwave,stove in it's entirety, walk-in cooler fan cages, hood cleaning, and light fixtures.

B) All repairs regarding where piping and ceiling/walls intersect have been completed by our Environmental Services Director. Oven replacement has been submitted to ownership for review and ordering.

C) Servers have been re-educated regarding pre-setting tableware without covering through inservice and demonstration.

D) Hairnets are readily accessible in the kitchen and staff have been inserviced on requirements of donning hairnets.

E) Single service utensils are now stored with coverage to prevent potiential contamination.

F) Kitchen staff has been in-serviced on proper thawing methods and in-services will continue for current and new staff.

G)Thermometer is now present and being monitored appropriately. No items are to be stored in the refrigerator without an open date and label.

H) Rags are being stored only in sanitation buckets. All staff have been in-serviced. Soiled/random rags will be taken out of rotation regularly.

I) Community is in contact with licensed plumbers to obtain bids for three compartment sink to ensure abililty to properly wash, rinse, and sanitize is in place.

2 - A) Kitchen staff are to utilize weekly/monthly cleaning logs to ensure all items are being cleaned regularly.

B) Environmental Services Director to include kitchen inspection on weekly plant audit to ensure repairs are effectively in place.

C) Ongoing education for current and new kitchen employees regarding the risks of potential contamiation and prevention processes.

D) Hairnets are readily accessible upon entry into kitchen and in well stock.  

E) Ongoing education for current and new kitchen employees regarding the risks of potential contamination and proper storage processed.

F) Ongoing education for current and new kitchen employees regarding proper thawing techniques and risks associated to improper thawing.

G)Thermometer is in place in the fridge and will be monitored via regular tempurature check log.

H) Sanitation buckets are to be readily available with clean solution for utilization of rags.

I) Temperatures to be monitored regularly to ensure meeting proper temp for sanitizing.   

All items are to be reviewed on a daily/weekly/monthly basis dependent on the task. Spot corrections to occurs when needed and identified through these daily/weekly/monthly audits for each item.

The Dietary Supervisor will be responsible for assigning such tasks to employees and ensuring tasks are done appropriately, as well as ongoing in-services. The Environmental Services Director is repsonsible for ensuring regular and preventative maintenace through weekly audits. The Executive Director will monitor to ensure scheduled completion of tasks is in compliance.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main kitchen on 02/16/24 at 11:30 am revealed the following:

a. An accumulation of food spills, dirt, dust, black matter, and grease were visible on or underneath the following:

* Kitchen drains;

* Ceiling fire sprinklers;

* Stove/oven knobs, doors, interior; and

* Cages to cooling fans and ceiling in walk-in cooler.

b. Single service utensils and paper plates stored in dry storage were open to potential contamination.

c. Two large packages of frozen chicken breasts were observed sitting in a sink with no water flowing onto the packages.

d. The reach-in refrigerator in the small dining room did not have a thermometer to monitor cold food storage temperatures. A container of salsa was observed in the refrigerator and there was no date indicating when it was opened.

e. Facility observed to have only a two-compartment sink.

Staff 2 (Executive Chef) and Staff 4 (Executive Director) toured the kitchen with the surveyor and acknowledged the areas identified.

In response to Assisted Living Inspection conducted 2/16/24:

1.  A. Deep clean of entire kitchen will be completed, to include dusting of the sprinkler heads, cages to fans in walk in  cooler, drains, microwave, stove.

B. Single service utensils are stored with appropriate covering over them.

C. Kitchen staff has been inserviced again regarding proper thawing methods and will continue to be inserviced on this.

D. New thermometer placed in small refridgerator and is being monitored daily.

2. A. Staff will have daily/weekly and monthly cleaning logs to ensure all items are being cleaned regularly.

B. Ongoing education  for new and current kitchen employees regarding the importance of proper storage processes regarding single service utensils.

C.Ongoing education for new and current kitchen employees regarding the importance of proper thawing techniques and the risks associated with improperly thawed food items.

D. New thermometer is in place in the refridgerator and is being monitored via regular temperature checks.

All items are to be reviewed on a daily/weekly/monthly basis dependant on the task. Spot corrections to occur when needed and identified through these daily/weekly monthly audits on each item.

The dietary supervisor will be responsible for assigning such tasks to employees and ensuring tasks are done appropriately, as well as the on-going in-services. The environmental Services Director is responsible for ensuring regualr and preventative maintenance through weekly audits.  The Executive Director will monitor to ensure scheduled completion of tasks is in compliance.

Based on interview and record review, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment. This included protocols to prevent the development and transmission of communicable diseases, including Norovirus and other gastrointestinal outbreaks. This failure had the potential to impact all residents residing at the facility. Findings include, but are are not limited to:

During the annual kitchen inspection survey, the facility was asked to provide their policy and procedures for identifying and responding to resident gastrointestinal outbreaks. At the time of survey the facility's internet was down, and Staff 1 (Interim Executive Director) acknowledged there was not a printed version of the policy and procedures available for review and they were only available online. The facility failed to provide the requested policy after multiple attempts to obtain it. Staff 1 acknowledged the facility should have a copy for staff to access if and when needed.

In Response to Assisted Living kitchen inspection conducted 12/11/2023:

1) The printed version of the policy and procedures for identifying and responding to resident gastrointestinal outbreaks is available in multiple locations; Kitchen, Nursing Station, and Communities Policy and Procedure binder.

2) In-service to be conducted with all staff on where to locate and how to interpret policies and procedures. To be held during next all staff meeting.

3) Upon hire, the employees are assigned infection disease in-services through Relias to complete, which educate on gastrointestinal outbreaks as well. Re-educating employees on a regular basis (upon hire/ annually) as to where to locate policies and procedures.

4) The Dietary Supervisor and the Executive Director will be responsible for assigning this education to employees and ensure this is completed, as well as hold in-services throughout the year. Executive Director is responsible for regular audits to ensure policy and procedures are updated and accessible to staff.  

Based on record review and interview, it was determined the facility failed to ensure 1 of 12 staff (#3) who prepared and served food had an active food handler's certificate. Findings include but are not limited to:

On 12/11/23 at approximately 12:30 pm, the surveyor reviewed employee records for active food handler's cards. Staff 3 (Cook) was found to have a Washington State food card that was expired. At 1:00 pm, Staff 1 (Interim Executive Director) and Staff 2 (Executive Chef) verified the staff did not have an Oregon food handler's card and that the Washington one was expired. Staff 2 verified Staff 3's duties did include preparing and serving food to residents.

In response to Assisted Living Kitchen Inspection conducted on 12/11/23:

1) Employee was removed from the role of preparing and serving food until completion of Oregon State food handles card. Employee now holds a current Oregon State food handler's card.  

2) This will be corrected in the future by ensuring that any staff member that will be handling food items will have a current food handler's card in place and in their employee file prior to being released to work in the kitchen upon hire.

3) Monthly audits for all employees who must maintain and active food handlers card.

4) The Dietary Supervisor and the Business Office Manager will ensure this document is in place prior to staff orientation beginning, and the Executive Director will monitor to ensure the completion of this. Monthly audits of employee files by Executive Director/Business Office Manager will ensure records are current.