The findings of the kitchen inspection, conducted on 09/14/22, 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 first revisit to the kitchen inspection of 09/14/22, conducted 11/17/22, 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.

The findings of the second revisit to the kitchen inspection of 09/14/22, conducted 02/28/23, 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 facility was found to be in substantial compliance.

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

Observation of the kitchen on 09/14/22 revealed the following:

* Staff were not wearing aprons when serving food;

* Plates and bowls had chips around the edges creating sharp edges;

* Drawers beneath food prep and food service areas would not stay closed;

* Drawers beneath food prep and food service areas had dried food in the drawer;

* Shelves throughout the kitchen were damaged and in need of repair; and

* Cupboard finish throughout the kitchen was damaged creating an uncleanable surface.

The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 09/14/22. They acknowledged the findings.

The ICS and Admin will purchase aprons for the dietary staff to wear. Facility ICS and Admin will conduct staff training on the appropriate use of aprons while serving in the kitchen and dining room.

Plates and bowls have been replaced as of 9/19.  Extra bowls and plates have been purchased and in the event of future damage they will be removed from service and new dinnerware added

Drawers will be repaired to ensure proper closure. In the event the drawers are unable to be repaired they will be replaced

Dried food cleaned from drawers.  Drawers to be repaired/replaced to ensure drawers do not open allowing food inside.

Shelves throughout the kitchen that are damaged and in need of repair will be repaired or replaced depending on the condition and recommendation of the contractor.

The cupboard finish throughout the kitchen will either be sanded down and refinished, or replaced on the recommendation of the contractor.

All items are to be reevaluated monthly for compliance, and Admin and Maintenance Director will see corrections are completed.

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

During the revisit survey conducted on 11/17/22, the facility was in the process of kitchen repairs. The allegation of compliance was dated 11/13/22, and the facility had not filed for an extension. The following areas were in need of repair:

* Kitchen cabinet doors had been removed and were needing to be replaced;

* Shelves throughout the kitchen were damaged and in need of repair; and

* Drawers were chipped, dinged, and gouged rendering the surfaces uncleanable.

The areas that required repair were observed and discussed with Staff 1 (Administrator) on 11/17/22. He acknowledged the findings.

Drawers to be repaired/replaced to ensure drawers do not open, allowing food inside.

Cabinet doors are currently being refinished; the install date is planned for 12/6.

Shelves throughout the kitchen that are damaged and in need of repair will be repaired or replaced depending on the condition and recommendation of the contractor.

The cupboard finish throughout the kitchen will be sanded down and refinished or replaced on the recommendation of the contractor.

All items will be reevaluated monthly for compliance, and Admin and Maintenance Director will see that corrections are completed.

Based on observation and interview, it was determined the facility failed to ensure it had a trained Infection Control Specialist and it consistently complied with masking requirements as prescribed in OAR 333-019-1011. 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 (including a Memory Care Community) are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.

Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose and mouth.

The need to ensure staff consistently wore a face mask, was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 09/14/22. They acknowledged staff needed to wear masks properly at all times.

1. The facility has designated the community RN as the ICS.

2. The facility ICS will conduct mandatory staff training on the regulations regarding infection control and proper use of PPE including donning and doffing.

3. The facility administrator will ensure staff is compliant with masking requirements daily by completing a walkthrough of the facility.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C 240 and Z 142.

Refer to C240.

Based on observation, interview and record review, 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 citations C240 and C295.

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

Refer to C 240.   

Refer to C240.