Print Inspection: 398S

The findings of the kitchen inspection, conducted 01/26/23, 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, Oregon Health Service Food Sanitation Rules.

The findings of the first revisit to the kitchen inspection survey of 01/26/23, conducted 04/24/23 through 04/26/23 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, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 01/26/23 the kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside or underneath the following:

* Floor throughout the kitchen including the dry storage area;

* Stainless steel upper and lower shelves throughout the kitchen;

* Entryway doors, door to dry storage area and walk-in refrigerator and freezer doors;

* Wall between walk-in refrigerator and walk-in freezer; and

* Pipe fittings and couplings next to the warewasher.

b. The following areas and equipment were in need of repair:

* Entryway doors had chipped paint and were un-cleanable;

* Left wall in the dry storage area had holes in it; and

* Seal to the walk-in refrigerator door was torn in several areas.

c. Observations made during the survey revealed the following:

Observations made of Staff 3 (Cook) prepping breakfast for the following day showed;

* Staff 3 prepared bacon on a baking sheet with gloved hands;

* While preparing the bacon, Staff 3 walked away from the prep area and carried a sheet of bacon to the walk-in refrigerator, grabbing the door handle with the gloved hands;

* Staff 3 went back to the prep area without changing gloves or washing her hands;

* Staff 3 was observed touching bacon with the same gloved hands.

During the observation, Staff 3 did not change her gloves or wash her hands.

On 01/26/23 at 2:26 pm, the surveyor shared the above observations with Staff 2 (Dining Services Director). She acknowledged the findings.

On 01/23/26 at 3:43 pm, the surveyor discussed infection control practices with Staff 1 (ED). She acknowledged the findings.

Review of the menu for the week of 01/22/23 revealed the facility offered over easy style eggs to residents daily. During an interview with Staff 2 at 2:37 pm, she confirmed the facility did not consistently use pasteurized eggs for egg dishes in which the eggs were not fully cooked.

On 01/26/23 at 3:43 pm, the concern regarding using non pasteurized eggs in dishes where the eggs were not fully cooked was discussed with Staff 1 and Staff 2. They acknowledged the findings.

The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1. Kitchen was deep cleaned including all areas identified during the survey. Doors to walk-in/freezer and main kitchen door has been painted. A new seal for the freezer door has been ordered and will be replaced as soon as it comes in.

2. All dietary staff have been re-trained on proper procedures for changing gloves and washing hands before and during food preparation, We have placed signage in the prep area to ensure proper food sanatation practices are being followed reguarding the use of gloves and handwashing. Cleaning schedules have been implemented including daily, weekly and monthly cleaning duties to ensure cleanliness is maintained. All cooks have been re-trained regarding the use of pasturized eggs in any dishes that the eggs will not be cooked thoroughly and the Dietary manager will ensure that pasturized eggs are available when those items are on the menu.

3. This system will be evaluated monthly as part of our Continuous Quality Improvement program which includes a kitchen audit.

4. The Dietary Manager and Executive Director are responsible for maintaining this system.