Print Inspection: B2TR

The findings of the kitchen inspection, conducted 04/25/23, 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 re-visit to the re-licensure survey of 04/25/23, conducted 07/06/23, are documented in this report. It was determined the facility was in compliance with the the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and appropriate measures were in place to prevent cross contamination in accordance with the Food Sanitation Rules OARs 333-150-0000. Finding include, but are not limited to:

On 04/25/23 at 11:10 am, the facility kitchen was observed to need cleaning in the following areas:

* The ceiling throughout the entire kitchen, including the dish washing room and the dry storage had vents and fire alarms with significant accumulation of dust/debris; and  

* The areas of the ceiling surrounding the vents and alarms also had significant build up of dust.  

The following observations conducted on 04/25/23 during the kitchen tour revealed improper cross contamination measures:

* Dishwashing staff failed to wash hands between dirty and clean activities in the dish room, and was observed to towel dry some dishes rather than allow to air dry;

* During the noon meal service one staff serving lunch left the steam table with gloves on and went to the walk in refrigerator/freezer to obtain frozen meat patty which was then placed in the microwave to be cooked. The staff returned to the steam table to continue serving food without washing hands and changing gloves; and

* The same staff was observed to return to the walk in refrigerator/freezer with gloves on and retrieve additional food to be prepared on the grill without washing hands and changing gloves.

The concerns were discussed with Staff 1 (Cook), Staff 2 (Executive Director) and Staff 3 (Assistant Executive Director) on 04/25/23. The findings were acknowledged.

Kitchen Cleanliness:

1. All ceiling vents and alarms to be cleaned to remove dust/debris by 5/12/2023.  

2. The Dining Services Manager will create a monthly cleaning schedule for all ceiling vents and alarms in collaboration with the maintenance director.

3. All ceiling vents and alarms will be on a monthly cleaning schedule in addition to our twice annual professional cleaning (of the vents above the line).

4. The Dining Services manager or designee will inspect cleanliness of ceiling vents on a weekly basis by adding to the weekly One-on-One agenda with ED.

Cross Contamination:

1. Immediate re-training was done for 2 employees observed using improperly.  All staff in-service completed on April 26th for glove usage (dirty to clean), cross contamination and proper glove usage.  

2. Ongoing kitchen staff training on cross contamination to be done as needed based on new staff. Dining Services Manager to audit monthly as part of Dining Services Quality Assurance Audit.

3. Dining Services Manager or designee will observe for proper glove usage/cross contamination violations on a daily basis in addition to Monthly Quality Assurance audits.  Will inspect weekly for the next 6 weeks as part of Weekly one on One.

4. Dining Services Manager or designee will be responsible for ensuring corrections are completed/monitored.