Print Inspection: 8RA3

The findings of the kitchen inspection, conducted 05/16/23, 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 05/16/23, conducted 08/14/23, 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 food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen, food storage, prep, and service on 05/16/23 revealed:

Spills, splatters, and debris were noted:

* The sides and interior of the range, grease build up on hood;

* Interior and exterior of cabinets and drawers throughout the kitchen;

* The open shelving;

* The can opener blade and casing;

* Interior of reach in refrigerators and freezers;

* Floor throughout the kitchen; and

* Interior of the microwave.

* Staff 3 (Lead Cook) explained the facility used auto dispense Quaternary solution for the sanitizer bucket. There was no documented evidence it was monitored to ensure the correct solution. The sanitizer bucket was tested and found to be above the required part per million.

* The chlorine solution used for sanitizing dishes was not monitored to ensure correct ratios.

* Prepared food items in the refrigerator were not dated or labeled.

* A bowl of undated un-unlabeled food with a serving spoon lying with the handle in the food.

* Multiple packaged food items were not dated when opened.

* There was no evidence of the monitoring of food temperatures on the steam table.

* Staff observed washing dishes did not remove gloves or wash hands between handling dirty and clean dishes.

* The laminate on the facing of open shelving was damaged creating an un-cleanable surface.

The areas in need of cleaning and repair, food storage guidelines,and hand hygiene were reviewed with Staff 1 (Executive Director) and Staff 3 on 05/16/23. They acknowledged the findings.

C240-OAR 411-054-0030 (1) (a) Resident Services Meals, Food, Sanitation Rule-

The following actions have been taken to correct this violation, per each example listed.

1.Facility is actively working on correcting the following: Updating cupboards surfaces and shelves, cleaning all surfaces (ensuring that all spills, splatters, and debris from meal prep are cleaned in a timely manner). The facility has painted shelves and covered uncleanable surfaces with a cleanable surface. The clear vinyl sheeting cupboard covers has been removed from the lower cupboards. Weekly checks/walk-through of kitchen and Memory Care dining area by the administrative team after stand-up each working day has been implemented to ensure that all food opened is dated.

2.This system is being corrected to eliminate future violations, as follows:

a.Facility Administrator, Dietary Manager, and administrative team members will do a daily walk-through to ensure that the kitchen and Memory Care dining area are in good repair/ clean.

b.During each working day the Facility Administrator, Dietary Manager, and administrative team will spot check all open food items in the kitchen and Memory Care dining room to ensure all open food items have been dated and disposed of after expiration.

c.Facility Administrator will oversee daily, weekly, and monthly cleaning schedules to ensure cleanliness and good repair of the kitchen.

d.The Dietary Manager will bring all cleaning checklists to monthly QA meetings to review with the interdisciplinary team making sure all necessary items are brought to the team's attention.

3.These systems will be evaluated as follows:

a.Facility Administrator and Dietary Manager (or designee) will conduct at least once weekly walk-throughs of the kitchen and Memory Care dining area.

b.Facility and kitchen staff will complete scheduled cleanings as follows: daily, weekly, and monthly. All cleaning checklists will be turned into the Administrator of the facility once a week and monthly.

c.All interdisciplinary team members will review all kitchen cleaning and repairs daily, weekly, and monthly.

4.A new stove (should arrive in 30 days)  has been ordered. Hood cleanings will continue on the quarterly scheduled by an outside agency (the outside agency's business/contact sticker located on the stove is updated every time they clean it, as shown by date).  Removable parts will be cleaned daily and run through the dishwasher to ensure that there is no grease build-up on the hood.

5.A new can opener has been ordered and will be broken down, with all fixed and removable parts cleaned separately at the end of each day.

6.Daily monitoring and recording of Quaternary solution used for sanitizer bucket. The Dietary Manager will check each working- day to ensure that the solution is correct in its solution.  Juniper Paper and Supply of Bend will come out on a scheduled basis to ensure that the solution is where it needs to be. This will also hold true on the dishwashing solution as well.

7.The steam table temperatures will be logged daily by kitchen staff/ cooks. The Administrator and Dietary Manger will ensure this by conducting daily checks of this log during working-days.

8.All staff hand hygiene in-service/training to be done on 05/25/2023 by facility RN. "When and how to use gloves correctly" to be reviewed by all staff. Administrator, RN, and Dietary Manager will follow up with daily spot checks to ensure this is being done correctly after training is completed.

9.The facility Administrator and Dietary Manager will be responsible for corrections and overseeing ongoing compliance.