The findings of the kitchen inspection, conducted 10/06/23, 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 re-visit to the kitchen inspection of 10/06/23, conducted 12/12/23 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 second revisit to the kitchen inspection of 10/06/23, conducted 02/23/24, 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, interview, and record review, it was determined the facility failed to ensure proper food storage, proper preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The facility kitchen was toured on 10/06/23, observations of the facility kitchen, including food storage areas, food preparation, food service, and interviews with staff were conducted during the annual kitchen inspection.

a. Observations of food storage identified the following:

* Multiple food containers in the dry food storage, two door reach-in refrigerator and walk-in freezer were not properly covered, labeled and dated; and

* Sauce(s) that required refrigeration after opening were stored on racks in the kitchen.

b. Observations of food preparation and food service identified the following:

* Alcohol wipes were not being used to sanitize the food thermometer after each use;

* Staff 4 (Cook), had a sanitation cloth saturated with a chemical base sanitizer laying partially on a cutting board used to cut up food during meal service;

* Staff 4 used tongs to serve fries from the tray line and used the same tongs to stir ground beef throughout the meal service; and

* The facility failed to have enough dishware and utensils which resulted in some residents being served food on paper plates and plasticware.

c. Review of employee infection control practices identified the following:

* Staff 3 (Dietary Manager), failed to have a valid Oregon Food Handler card; and

* Staff 4 failed to use and store sanitation cloths properly.

c. Sanitation of equipment identified the following:

* The chlorine sanitation level in the warewash machine was over 110 parts per million (PPM);

* The quaternary sanitation levels for the sanitation buckets and 3 compartment sink were over 200 ppm;

* Dish racks in the warewashing area were stored on the floor;

* Garbage cans were not enclosed after use;

* Multiple floor drains were visibly dirty with food waste;

* Steam table, prep counters, plate warmer, and microwave were visibly dirty and were not sanitized prior to food preparation and food service;

* Janitorial closet door was open and cleaning equipment was not properly stored;

* Toasters, coffee machine, coffee counter, food service carts, handwashing sink and single compartment prep sink were visibly dirty and were not sanitized after use;

* Ice machine was visibly dirty on the exterior and interior;

* The walk-in refrigerator and freezer floors were visibly dirty with food debris and spillage; and

* Spice containers and spice cart was visibly dirty.

d. The following areas within the kitchen required repair:

* The plate warmer was not fully operational;

* The walk-in freezer had a buildup of ice that formed near the condenser, blower cage and freezer door frame;

* The exit door and screen were broken and had rips in the screen; and

* The floor drain below the three compartment sink had issues with flooding.

The kitchen was toured, and the above areas were discussed with Staff 1 (ED), Staff 2 (Assistant ED ) and Staff 3 (Dietary Manager) on 10/06/23 at 1:25 pm. They acknowledged the findings.

Food Storage

Staff were in-serviced on proper food storage on 11/01/2023

DM obtained Oregon food handlers card on 10/10/2023

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Food Preparation

Staff were in-serviced on food preparation standards 11/01/2023

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Infection Control

Staff were in-serviced on infection control practices 11/01/2023

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Sanitation of Equipment

Staff were in-serviced on proper sanitizing of equipment and storage of equipment on 11/01/2023

Ecolab serviced kitchen machines and sanitizers on 10/09/2023, new garbage can lids were purchased 10/30/2023. Janitorial closet was organized and staff in-serviced on proper storage and keeping door closed on 11/01/2023. Ice machined, walkin refrigerator and freezer were cleaned on 10/09/2023

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Kitchen repair required

Maintenance work order clip board hung in kitchen, Maintenance Director to do weekyl inspections; staff in-serviced to write repair items on board 11/01/2023

Walkin freezer de-iced of ice buildup 10/30/2023, plate warmer to be repaired on 11/30/2023, exit door fixed, exit door screen removed, floor drain below three compartment sink fixed on 10/30/2023

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Based on observation and interview, it was determined the facility failed to ensure proper food storage, proper preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The facility kitchen was toured on 12/12/23, observations of the facility kitchen, including food storage areas, food preparation, food service, and interviews with staff were conducted during the first revisit kitchen inspection.

a. Observations of food storage identified the following:

* Multiple dry good food containers were left open and undated, and cold food storage in the walk-in refrigerator were not properly covered, labeled and dated; and

* The floor of the dry food storage area had multiple single service food items that had fallen on the floor and underneath the food racks.

b. Observations of food preparation and food service identified the following:

* Staff 4 (Cook), placed a visibly soiled oven mitt on a cutting board used to prep food items during meal service. The oven mitt was observed to directly touch food just prior to being placed on the residents plate; and

* Food (tortilla shells) while inside the plastic manufacturers packaging was heated in the microwave and then served to multiple residents.

c. Review of employee infection control practices identified the following:

On multiple occasions, Staff 4 (Cook) failed to ensure gloves were single use and gloves were changed between dirty and clean tasks.

d. Sanitation of equipment identified the following areas had a build up of dust, debris, grease and food particles:

* The steam table and shelf below the steam table;

* Stainless steel cart used in the dishwasher area was visibly soiled with clean dishes on it;

* The rack next to the handwash sink had bins of clean dishes with a buildup of food particles that had fallen into the bins;

* Shelf below the microwave was visibly dirty and had clean dishes stored on it;

* The interior and exterior microwave was not sanitized prior to food preparation, reheating of food and food service; and

* Steel rack to the left of the oven had a build up of dust, grease and sticky residue. The rack had clean dishes and equipment stored on it.

e. The following areas within the kitchen required repair:

* The plate warmer was not fully operational; and

* The walk-in freezer had a buildup of ice that formed near the condenser and blower cages.

The kitchen was toured, and the above areas were discussed with Staff 1 (Executive Director), Staff 3 (Dietary Manager) and Staff 5 (Dietary Manager trainee) on 12/12/23. They acknowledged the findings.

Food Storage

All kitchen staff will be in-serviced on 01/10/2024 on proper food storage protocols

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Staff in-serviced on 01/10/2024 on proper cleaning standards

Kitchen cleaning audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Food Preparation

All kitchen staff in-serviced on proper food preparation and serving protocols on 01/10/2024

Admin and or designee will observe 5 meal preparations/food services weekly for four weeks then monthly after as part of our ongoing QA program

Infection Control

All kitchen staff in-serviced on infection control practices and correct sanitation protocols on 01/10/2024

Kitchen audits will be completed weekly for four weeks then monthly as part of our ongoing QA program

Sanitation of Equipment

Debris areas were sanitized on 12/12/2023

All kitchen staff will be in-serviced on 01/10/2024 on proper sanitation of equipment, racks and storage areas

Kitchen audits will be completed weekly for four weeks then monthyl as part of our ongoing QA program  

Kitchen Repair

HVAC repairs scheduled for 01/10/2024

01/02/2024 Appliance repair company assessed plate warmer, parts ordered scheduled repair for unit on 01/12/2024

Based on observation and interview it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C 240.

Refer to C240

Based on observation, interview and record review, 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 C 240.

Refer to C 240

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.

Refer to C240