The findings of the kitchen inspection and infection control, conducted on 07/20/22, 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, OARs 411 Division 57 for Memory Care Communities, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the kitchen inspection of 07/20/22, conducted on 09/08/2022, are documented in this report.  The facility was found 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, the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Upon entering the facility on 07/20/22, four direct care staff were observed not wearing face masks.

In an interview with Staff 1 (Owner/Administrator) on 07/20/22, she indicated all staff should be wearing face masks.

The need to ensure staff fully and consistently complied with masking requirements was discussed with Staff 1 during the exit meeting on 07/20/22. She acknowledged the findings.

Every staff member, visitor including outside service providers are required to wear a mask.  Signs were posted at each exterior entrance immediately the day of this violation.

Staff have all been re-trained and employee acknowledgements will be in place.  Daily supervision and checks will be made.  Every person entering our community are required to be screened for compliance and safety.  In addition, mandatory classes will be conducted routinely outlining the importance of personal protective equipment for safety of our Residents, staff and visitors.

Daily and at each shift.

All staff will be responsible.  The Medication Aide/Supervisor will oversee each shift and the Aministrator and Owner will conduct routine and random surveillance to confirm that requirements are strictly adhered to.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The annual kitchen inspection was conducted on 07/20/22 and revealed the following:

* No floor molding in the kitchen;

* The half door surface was damaged creating an uncleanable surface;

* The door frames of both doors in the kitchen were gouged;

* The garbage can did not have a lid and had dried food on the sides of the can;

* The exhaust fan in kitchen was broken;

* Cabinet shelves throughout the kitchen had dirt, dust and debris on them;

* The coffee machine had dried white crust around the edges; and

* The wall cabinet doors had dried on food.

The Surveyor and Staff 2 (Administrator in Training) toured the areas needing cleaning and repair. She acknowledged the findings.

Our community has recently undergone a very large and costly renovation.  The Kitchen molding was ordered but on back order from Lowes but is scheduled to be installed.  The half door is being removed and replaced with a full door.  The doorframes will be repaired/replaced.  The garbage can was replaced immediately at the time of the inspection.  The exhaust fan was replaced that day.  All cabinets, shelves and coffee maker were immediately cleaned.

The system will be corrected with a daily checklist for each shift with initials of staff.  Retraining on the importance of this Administrative Rule is scheduled for all staff.

This area of correction will be monitored daily with evaluations completed by our Administrator.

The Administrator and the Owner will be responsible to make sure that the corrections are completed and monitored.

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 C 160 and C 240.

Every staff member, visitor including outside service providers are required to wear a mask.  Signs were posted at each exterior entrance immediately following this violation. All persons entering our community will continue to be screened to adhere to compliance of this Administrative Rule.  As mentioned with C240 Violation (Kitchen), our community has recently undergone a very large and costly renovation.  The Kitchen molding was ordered but on back order from Lowes but is scheduled to be installed.  The half door is being removed and replaced with a full door.  The doorframes will be repaired/replaced.  The garbage can was replaced immediately at the time of the inspection.  The exhaust fan was replaced that day.  All cabinets, shelves and coffee maker were immediately cleaned

Staff have all been re-trained and employee acknowledgements will be in place.  Daily supervision and checks will be made.  In addition, mandatory classes will be conducted routinely outlining the importance of personal protective equipment for safety of our Residents, staff and visitors.  For the Kitchen, a daily checklist has been implemented.

Daily and at each shift by our Administrator.

All staff will be responsible.  The Medication Aide/Supervisor will oversee each shift and the Aministrator and Owner will conduct routine and random surveillance to confirm that mask and Kitchen safety and cleanliness requirements are strictly adhered to.