The findings of the kitchen inspection, conducted 02/14/23, 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 Sanitization Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 02/14/23, conducted 04/11/23, 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 and interview, it was determined the facility failed to ensure the kitchen was clean and appropriate food storage practices were in accordance with the Food Sanitation Rules OARs 333-150-0000.  Findings include, but are not limited to:

On 02/14/23 at 11:00 am, the facility kitchen was observed with the following concerns:

* Reach in refrigerator had an open package of sliced cheese and open container of shredded cheese;

* Walk in refrigerator had an uncovered bowl of grapes, pans of uncovered leaf lettuce and heads of cabbage;

* Uncovered light fixture in the dry food storage area;

* Ceiling vent outside of dietary manager office had a heavy buildup of dust/grease; and

* Two boxes of parchment pan liners were stored underneath the piping of a sink,  creating a potential for cross contamination if pipes leaked and boxes were observed to have wet drips/splashes.  

The areas of concern were discussed with Staff 1 (Food Service Director) and Staff 2 (Nursing Home Administrator) on 02/14/23. The findings were acknowledged.  

1. Each of the items mention in tag C240 have been addressed in the following way:

- The sliced cheese was appropriately covered and dated

-The grapes, leaf lettuce, and cabbage were covered and dated

-The light fixture was placed in TELS for Maintenance to address, a new cover was been ordered for replacement and installed

-The ceiling vent cover was taken down and cleaned

-The pan liners were removed from under the sink to an adjacent area that does not risk contamination from a potential sink leak

2. The follow systems will be put in place to prevent these issues happening again:

- The dietary staff will be retrained by the Food Service Director to address correct food and equipment storage and maintenance reporting practices.

- The Food Service Director, Administrator, and Maintenance Director will conduct an audit of the kitchen to make sure that all maintenance issues are added to our TELS system and addressed

3. A monthly audit of food and equipment storage and maintenance needs will be used to ensure that proper procedures are being followed and kitchen needs are being met and maintained

4. The following people will be responsible for monitoring compliance:

- The Food Service Director is responsible for monthly audits to ensure all food and equipment storage and maintenance needs meet compliance. Audits will be brought to the quarterly QA meetings to determine if additional actions are required.

- The Food Service Director, Administrator, and Maintenance Director will be responsible for making sure all maintenance needs are identified and addressed.

For tag Z 142, please see the following Plan of Compliance:

- Actions taken to address tag C 240 as set out in this Plan of Correction will be taken to address the concerns set out in tag Z 142

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240.