Print Inspection: 4X9S

The findings of the kitchen inspection, conducted 03/07/23, 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 Service - Meals and Oregon Health Service Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/07/23, conducted 06/07/23, 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 revisit to the kitchen inspection of 03/07/23, conducted 07/31/23, 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, food was stored and infection control measures were practiced in accordance with the Food Sanitation Rules OAR 333-150-0000.  Findings include, but are not limited to:

On 03/07/23 at 10:45 am, the kitchen was observed to need cleaning in the following areas:

* The shelf below the microwave and the top of the dishwasher had build-up of dried debris/food.

The following food items were observed on 03/07/23 at 10:45 am not stored appropriately:

* An uncovered  food bin contained open bags of granulated sugar and cornstarch which were open to possible contamination;

* A foil package of fried onions sitting in a closed container of dried onions;

* A plastic bag of wild rice was in a closed container of rice;

* Container of chocolate chips had a scoop in the product; and

* A cardboard box of parchment paper pan liners sitting on the storeroom floor.

A dietary staff was observed to be moving from dirty to clean dishes without washing hands and changing soiled gloves. The same staff was observed to use gloved hands directly from handling dirty dishes to obtaining a clean plate and placing a frozen meat product on it to cook in the microwave. Staff 1 (Acting Person In Charge)  immediately informed to intervene.

A dietary staff was observed without hair or beard restraints.

The areas described above were observed and discussed with Staff 1 on 03/07/23. The findings were acknowledged.

1)Action to correct:

Both areas have been cleaned. Implemented a regular cleaning schedule of these areas.

New food bins purchased to keep food items covered and trainig staff to keep bags inside these bins closed.

_______________________________

2)Avoid happening again:

Have a sign off sheet for staff to be accountable when areas have been cleaned.

Staff training to remove scoops from bags and bins when done using.

Removed pan liners from floor and further training on keeping items off floor. and further training on keeping item from being put directly on the floor.

Requiring all staff further training on cross contamination.  (Collins Learning)

Staff person not wearing a net over beard left employment 3-17-23 Posted sign regarding hair nets.

We posted signs saying hair restraints must be used while in the kitchen.

_____________________

3)On-going monitoring:

Daily and weekly cleaning schedules

_____________________________

4)Person responsible to see ongoing monitoring is done:

Rebecca Cross, Kitchen Manager

Based on observation, interviews 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 OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to:

The kitchen was toured on 06/07/23 at 11:15 am and found:

a. The following items were not stored appropriately:

* A bag of gluten free flour was not properly sealed, dated and was open to possible contamination;

* Industrial mixer and slicer lacked proper covers to protect from possible contamination; and

* Containers of coconut and hot cocoa powder each had a scoop in their respective bin.

b. The following areas were found to have dings, chips or rough surfaces causing an uncleanable surface:

* White shelving next to reach-in fridge; and

* Cabinets under serving counter.

c. Staff were observed to potentially contaminate hands while serving food and did not wash or sanitize hands when switching from dirty to clean tasks. Server was not observed to wash hands in between tasks of reaching into a sanitizer bucket, wiping service area, and then grabbing a biscuit for plating. Same server was not observed to wash his/her hands after removing their gloves and putting on new ones. Multiple times the server would don oven mitts for use, remove and then not remove gloves/hand wash prior to plating food.

d. Possible sources of contamination were observed when server removed a tomato and lettuce from walk-in without properly cleaning prior to making a sandwich. Server was asked by surveyor to toss this sandwich, properly clean the produce, and make another sandwich and staff complied. Same server also using the service area for cutting the vegetables.

Staff 2 (Person in Charge) toured kitchen with surveyors and acknowledged the above areas of concern. At approximately 12:00 pm, Staff 1 (Executive Director Assistant) and surveyors reviewed areas of needed attention and sanitation concerns. Staff 1 acknowledged the areas of non-compliance.

The Kitchen area has been repainted where needed and chipped counter tops repaired.

Maintenance department will be monitoring closely for all surfaces to be cleanable.

Maintenance department will monitor weekly needed repairs. - Ismael Ramirez will monitor (mait. dept)

Rebecca Cross - Kitchen Manager

Ismael Ramirez - Maintenance Department

Based on observation and interview, it was determined the facility failed to ensure kitchen staff were taking necessary precautions to protect residents health and safety. Findings include, but are not limited to:

On 03/07/23 observations of staff working in the kitchen and serving food to residents were not wearing face masks.

In an interview on 03/07/23, Staff 1 (Admin Assistant/ Kitchen Person in Charge) acknowledged the findings.

1 and 2)Corrective action taken:

Our Risk manager is Cathy Baker.  she is our approved infectious control person.  She does have the approved State required designation. We initiated additional training regarding food safety and sanitation.

Kitrchen staff began wearing masks untill the requirement was lifted.

_____________________________

3)Ongoing monitoring so does not happen again:

Cathy Baker created

_____________________________

4)Person Responsible:

Rebecca Cross, Kitchen manager

Cathy Baker, Risk Manager, Infestion Specialist  

Based on interview, observation and review of documentation, 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.

Retraining of staff to avoid cross contamination including washing hands between tasks and glove use.

Instruction, training, and sinage how to avoid cross contamination.

Rebecca Cross kitchen manager will train and monitor staff as they work.

Rebecca Cross , Kitchen Manager

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

Refer to C 240 and C 295.

Corrective action:

We have studied over the rules and department copies are now printed for quick referencing of the rules in each department.

___________________

Corrections so not happen again:

Make sure department leaders are aware of the rules that were lacking in practice and all rules. this includes ongoing trainig for cross contamination and infection control.  

_______________________

On-going monitoring:

Making department leaders more aware of the concerns and given instruction to monitor everyday kitchen staff action in potential staff. Required all kitchen staff to take cross contamination training through Collins Learning.  

___________________________

Person responsible:

Rebecca Cross, Kitchen manager

Katya Ciriano, Administrator

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

Refer to C 240.

1. Training on sealing bags after each use to reduce the possibility of cross contamination.

2. Mixers and slicer have covers on them.

3. Retrained staff and signs posted reminding staff not to leave scoops in bins.

4. Maint Dept painted and repaired formica counter tops for cleanable surfaces, including under counter.

5. Retraning and posting signs for proper food handling and handwashing / glove use.

Rebecca Cross is responsible to monitor and train staff on going.