Print Inspection: B9IE

The findings of the kitchen inspection, conducted 03/27/24, 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 03/27/24, conducted on 05/28/24 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 and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:

On 03/27/24 at 11:00 am the kitchen was observed and the following areas of concern were identified:

* The interior of the microwave had food splatters;

* The sides of stove/grill had food spills/drips;

* Ceiling vents (above steam table, dishwashing room and beverage station) were dusty and the ceiling area surrounding the vents had accumulation of dust;

* Ceiling vent grate above toaster had a heavy layer of dust;

* Ceiling light in dishwashing area was not covered;

* Improper glove use: staff were not washing hands between glove changes; used the same gloved hands between dirty and clean tasks;

* Staff failed to wash hands when returning to the kitchen;

* Staff returned to the kitchen with gloved hands without washing hands and/or changing gloves before beginning another task; and

* Non-kitchen employees delivered carts/trays/soiled dishes to the dishwashing area within the kitchen.

The areas of concern were observed and discussed with Staff 1 (Culinary Director) and discussed with Staff 2 (Executive Director) on 03/27/24. The findings were acknowledged.

C 240 Resident Service Meals, Food Sanitation Rules

1. Spills/Splatters/Dust-

     a. The microwave was cleaned of any splatters.

         Completed- 3/27/24 by Culinary Service Director

     b. The side of the oven was cleaned of any spills/drips.

         Completed- 3/27/24 by Culinary Service Director

     c. Ceiling vents were cleaned of any dust.

         Completed- 3/27/24 by Maintenance Director

     d. Light fixture- will be replaced by a new fixture with  

         cover. On order ETA 4/8/24, by Maintenance Director

     e. Glove usage- staff in-service completed by CSD on  

         appropriate glove usage and handwashing.

         Completed-3/29/24

      f. Non-dietary staff in the kitchen- dietary and care staff

         in-serviced on leaving dirty dishes and carts outside

         the kitchen alleviating entering the kitchen by CSD.

         Completed- 4/1/24

2. Cleaning tasks 1a, 1b, and 1c will be included in kitchen staff weekly and monthly deep clean tasks by CSD/designee. Maintenance Director/designee will conduct monthly building walk-thru to identify broken or malfunctioned items and report results to the ED. Culinary Director/designee to do weekly spot checks on glove usage by dietary staff and non-dietary staff coming into the kitchen and report results to ED.

3. All areas of the kitchen will be examined weekly by the CSD/designee for basic cleaning and monthly for deep cleaning. CSD/designee to monitor completion of Daily, Weekly, Monthly cleaning task lists. Maintenance Director will perform monthly walk-thru inspection of kitchen. All staff will be provided with training on food sanitation and glove usage upon hire and at minimum annually through in-services completed by ED and HSD.

4. The Culinary Director, Maintenance Director and Executive Director are responsible for corrections.

Results of audit findings will be reviewed monthly at CQI meeting by ED and corrective measures taken as needed.

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

Refer to C 240.

Z 142- Administration Compliance

1. All corrections made under C240 POC.

2. All changes to systems made under C240 POC.

3. All evaluations indicated under C240 POC.

4. Culinary Director, Maintenance Director and Executive Director responsible for corrections and compliance.