Print Inspection: RQ2K

The findings of the kitchen inspection, conducted 08/06/24, 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 revisit to the kitchen inspection of 08/06/24, conducted 10/10/24, 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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the facility kitchen was reviewed on 08/06/24 from 10:55 am through 1:45 pm and the following was identified:

a. An accumulation of food spills, splatters, dirt, dust, and/or black matter was visible on or underneath the following:

* Cart holding clean plates;  

* Industrial can opener and housing;

* Top of range;   

* Front and sides of Alto-shaam warmer/steamer;

* Vents over the tray-line and between tray-line and dishwashing area;

* Wall behind warewasher and near rinse sink;

* Top of warewasher; and

* Drains in dishwashing area.

b. The following areas were in need of repair or replacement:

* Toaster on tray-line with worn and peeling front panel and knobs;

* Cutting boards on make-line heavily scored and stained;

* Muffin pan with significant visible damage and wear;

* Plastic carafes which were scored and cloudy; and

* Sections of caulking by sink near warewasher cracked/missing or with black debris.

c. Multiple cooking items found on the floor including tongs and muffin pan.

d. Multiple food items in the fridge and/or freezer were found to be open or not sealed appropriately to protect from potential contamination.

e. Kitchen staff were observed to not wash cantaloupe prior to slicing as a ready to eat item to serve to residents.

f. One kitchen staff was observed to not have hair restrained as required.

g. Thawing protein under running water without the protein fully submerged.

The surveyor toured the kitchen areas described above at 1:50 pm with Staff 4 (Dietary Services Manager), and at 2:00 pm with Staff 2 (Assisted Living Director) and Staff 3 (Memory Care Director). The need to ensure food sanitation rules were followed as above was reviewed with Staff 1 (Assistant Executive Director), Staff 2, Staff 3, Staff 4 and Staff 5 (Regional Director of Operations) on 08/06/24 at 2:20 pm. They acknowledged the findings.

1. Cleaning was completed to address food spills/splatters, dirt, dust and/or black matter on: carts, industrial can opener and counter, top of range, front and sides of alto-shaam warmer and steamer, venters over the tray-line, dishwashing area, wall behind warewasger and near rinse sink, top of warewasher, and drains in dishwshing area.

The following items were repaired or replaced:

Toaster on tray line, cutting boards, muffin pan, pastic carages, and caulking by sink near warewasher.

DSM/AED/ED have re-educated kitchen staff on proper food storage in fridge/freezer/dry storage. Kitchen staff were re-educated on proper food washing prior to cutting/using along with thawing procedures. Kitchen staff were re-educated on proper hair restraints while in the kitchen. This training was completed 9/4/2024.

2-4. Ongoing training and cleaning will occur weekly to ensure that kitchen remains in compliance. DSM/ED/Designee will continue to oversee this process on a weekly basis.

Based on interview and record review, it was determined the facility failed to have policy and procedures in place for exclusion of food service workers when sick or ill with potential or actual contagious food related illness. Findings include, but are not limited by:

On 08/06/24, Staff 1 (Assistant Executive Director) was asked to provide policy and procedure for when employee's who prepared food were sick and had illnesses or symptoms that may be related to a potentially contagious pathogen. Staff 1 stated she had spoken with Staff 5 (Regional Director of Operations) who was in the process of attempting to find the information. During the exit interview at 2:20 pm, Staff 5 reported she had not been able to locate the policy yet but would have it shortly. She agreed to email the information to the surveyor by 2:00 pm on 08/07/24. No policy and procedure was conveyed to the surveyor by 2:00 pm on 08/07/24.

The need to have infection prevention policy and procedure was reviewed via phone with Staff 1 at 2:11 pm on 08/07/24. She acknowledged the findings.  

1. The policy was revised by Bonaventure Senior Living coporate office to ensure we are hitting all required components per regulation. AED/ED/Designee has in-serviced all community staff on this updated policy in August 2024.

2. Policy is in place for the community.

3. As needed- AED/ED/Designee will cover ongoing during orientation. All staff have been in-serviced on the revised policy.

4. AED/ED/DSM/Designee.