Print Inspection: IRXH

The findings of the kitchen inspection, conducted 06/20/23, 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 333-150-0000.

The findings of the first re-visit of the annual kitchen inspection of 06/20/23, conducted 08/24/23, 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 and appropriate glove use were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

a. On 06/20/23 at 11:05 am, the facility kitchen was observed to need cleaning in the following areas:

* Floors throughout the kitchen including dry storage, walk in refrigerator, underneath the stove/grill/deep fat fryer;

* Lower shelves throughout the kitchen including under the food preparation sink, commercial mixer and steamer;

* Ceiling and walls throughout the kitchen had build up of dust including light fixture covers, area above the three compartment sink, kitchen door leading into the hallway, areas with dust build up were near or next to ceiling vents; and

* Equipment: including stove/grill/deep fat fryer, sandwich refrigerator (exterior with drips/splatter), microwave oven (interior and exterior), dishwasher booster and exterior of the dishwasher.

b. Improper glove use included:

- Not washing hands between glove changes;

- Not washing hands when changing gloves between dirty and clean dishwashing; and

- Not washing hands when entering kitchen or donning new gloves.  

c. Food was transported down the hall away from the dining area uncovered.

The concerns were observed and discussed with Staff 1 (Director of Food Services) and discussed with Staff 2 (Executive Director) on 06/20/23. The findings were acknowledged.  

Plan of Correction for 'The Food and Sanitation' Deficit:

The DSM constructed a detailed daily cleaning schedule that dietary staff must adhere to and sign off on. The DSM will delegate the cleaning tasks and ensure that each task is completed daily starting 7/3/23.

We also have implemented a designated employee who will be scheduled on Mondays and Thursdays to detail clean and organize the kitchen entirely as part of his role to assist with the upkeep and cleanliness of the kitchen.

In addition, the ED is currently seeking quotes from outside contractors for a professional cleaning of the kitchen floor in order to remove old stains.

To address the improper glove usage deficiency:

To emphasize the importance of proper glove usage among workers, the ED has purchased signage to be posted in several locations throughout the kitchen. Once it arrives, it will be posted immediately.

The DSM will provide mandatory monthly in-services to cover subjects relating to the responsibilities of the dining staff, including those covered in this deficiency. (10th of every month)

To address the handwashing deficiency:

To emphasize the importance of handwashing among workers, the ED has purchased signage to be posted in several locations throughout the kitchen. Once it arrives, it will be posted immediately by the DSM.

To prevent cross-contamination, the DSM will make sure that all of her employees are properly washing their hands throughout the day, for she will continue to remind and educate them of the importance of handwashing until we are deficiency-free.

With on-going training and guidance from the DSM, staff will be taught how to distribute food throughout the community and will always be reminded that no food should be un-convered while being delivered.

All direct care staff and dining staff are required to have their food handler certificates. The ED will be responsible for ensuring everyone has completed their certification.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

The ED has reviewed and acknowledged the rules and policy and will conduct bi-weekly kitchen audits to ensure that the dining department is in compliance and meeting standards.

The ED will have biweekly quality assurance manager one-on-one meetings to discuss the direction of the department, discuss audit findings with the DSM, and come up with a plan of correction on how to address ways to resolve any challenges or tasks within the dining department.

The ED will also perform walkthroughs to ensure detailed cleaning is being performed, communicate with the DSM if it is not meeting standards, and compliment it when it is.

To track progress, all dining audits and meeting notes will be filed in the ED office.

The ED will make sure the DSM has all the tools and resources she needs to be effective in her role and that she feels fully supported..