The findings of the kitchen inspection, conducted 12/06/23 through 12/07/23, 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 12/06/23, conducted 02/08/24, 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 facility kitchen on 11/6/23 from 10:00 am through 2:30 pm and 12/07/23 from 9:30 am through 11:00 am and revealed the following:

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

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath and on top of the dish machine;

* Kitchen drains;

* Electrical outlets and light switches;

* Trash cans;

* Ceiling vents and light fixtures;

* Walls throughout kitchen;

* Stove, oven and grill knobs, doors, and exteriors;

* Grill top and interior of ovens;

* Open shelving throughout kitchen;

* Shelving above try line;

* Industrial mixer;

* Base holding mixer;

* Large can opener and housing;

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment and around perimeter edges;

* Rack shelving in walk in cooler and freezer;

* Reach in cooler;

* Rack shelving in dry food storage;

* Rack shelving storing equipment and dishes;

* Under and behind shelving in dry food storage;

* Utility racks;

* Legs and wheels of equipment, steam table, carts, shelving, prep spaces;

* Meal service delivery carts;

* Plastic bulk bins and lids;

* Go racks; and

* Interior and exterior of ice machine.

b. The following areas needed repair:

* Caulking in ware washing area with black matter debris buildup;

* Nozzle to sprayer in dish machine area sink with leak.

* Dispensing tubing of chemicals in ware washing area with build up of black matter.

c. Multiple food items/packages/containers found in cold food and dry food storage that were open to potential contamination.

d. Dirty dishes were found stored on clean dish side of dish machine area, along with observed food debris. Piles of dishes were observed stacked up along the dish washing area and overflowing into, on and around the three-compartment sink area.

e. Multiple dry food items were not dated when opened.

f. Multiple cooking pots, pans and utensils were found in poor repair needing replaced.

g. Multiple containers of bulk dry goods were found to have cups or scoops stored in them.

h. Multiple items in freezer and refrigerator were not dated or labeled when opened or prepared.

i. A large pot of dirty/rancid oil was observed stored in kitchen area. There was no lid and staff were not able to clearly state approved method of disposal of fryer oil.

j. Kitchen staff were observed to handle ready to eat items with potentially contaminated gloves. The staff was observed to handle utensils, touch handles, and other potentially contaminated items with his/her gloves and then touch ready to eat items. The staff was observed to not change gloves or wash hands when appropriate.

k. Kitchen staff was observed to prepare a hamburger to order and serve to resident without checking temperature to ensure it reached the appropriate safe temperature prior to serving. Surveyor stopped the process and requested the food item be tested prior to service.

l. Multiple rags were observed lying about the kitchen prep areas and not in appropriate sanitizer buckets with sanitizer at appropriate concentrations.  Staff was observed to wipe gloved hands with these rags and then handle RTE food items.

m. multiple kitchen staff did not have facial hair or hair restrained as required.

n. Dining area was observed to have preset silverware and service ware that was not protected from potential contamination as required.

In an interview on 12/06/23 at 12:45 pm, Staff 1 (Executive Director) and Staff 2 (Dining Services Manager) were informed of concerns found. They acknowledged the concerns and presented a plan to address identified issues. The facility had recognized areas of concern prior to kitchen survey and were implementing measures to correct deficient practices. A new interim (Dining Services Manager) was brought in to assist facility in implementing corrective actions.

- Documented training provided to all kitchen staff on food temping requirements, hair/beard net/ hair up requirements, sanitation requirements, oil disposal protocol, and food storage requirements.

- Cleaning task lists implemented to ensure kitchen remains above sanitation requirements and turned into ED daily by DSM. Additional cleaning parties held as needed to retain excellent sanitation expectations.

- New DSM hired and trained on protocols.

- Additional support weekly from the company Dietician on all protocol matters.  

- ED or DSM to walk kitchen 3x daily to ensure sanitation, cleanliness, and all protocols are being followed and properly trained on.

- ED to audit trainings provided weekly

- ED/DSM daily.