The findings of the re-licensure survey conducted 04/25/22 through 04/27/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

MCC:Memory 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 re-licensure survey of 04/27/22, conducted 08/01/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:

1. On 04/25/22 at 1:00 pm, Staff 11 was observed and the following was noted:  

*Staff 11 prepared salad with plastic gloved hands;

*During the preparation of the salad, Staff 11 walked away from the tray line and went to the refrigerator to retrieve two containers including sliced tomatoes and cucumbers.  Staff 11 grabbed the refrigerator handle with the gloved hands;

*Staff 11 went back to the tray line without changing gloves or washing his hands;

*Staff 11 was observed touching sliced tomatoes and cucumbers with the same gloved hands;

*Staff 11 walked away from the tray line again, went to the dry storage area to retrieve a large container of salad dressing and returned to the tray line without changing gloves or washing hands; and

*Staff 11 was observed touching sliced cucumbers with the same gloved hands.

During the observation, Staff 11 did not change his gloves or wash his hands.

On 04/25/22 at 1:35 pm, the observation was shared with Staff 1 (ED) and infection control practice including washing hands and changing gloves was discussed.

2. Observation of the kitchen on 04/25/22 from 12:42 pm to 1:12 pm, revealed the following areas needed cleaning and repair:

Beverage countertop and cabinet:

  * Side of the countertop, next to the trash can, had gouges and splinters;

  * Front and side towel dispenser was sticky to the touch;

  * Interior of several cabinets and drawers had brown matter and food debris;

  * The cabinet below the hand washing sink, had black and brown matter; and

  * The metal shelf behind the hand washing sink had brown matter and rusted metal.

Kitchen area:

  *The door and the door frame was chipped and gouged;

  *The wall behind of the kitchen door had food spills and debris;

  *The drain underneath the sink next to the ice maker had thick black and brown matter;

  *Ice maker lid was sticky to the touch;

  *Ice maker filter had layers of dust;

  *Microwave handle was sticky to the touch;

  *Drains underneath of 2-compartment sink had black and brown matter;

  *Sink back splash had brown matter;

  *Interior of a free-standing refrigerator had food spills and debris;

  *Soap dispenser near the hand washing sink had brown matter and food debris;

  *The wall around the 2-compartment sink had food debris and brown matter;

  *The ceiling, around the 2-compartment sink had food debris;

  * Walls throughout the kitchen had multiple spills, smears and splatters; and

  * A mixer surface was sticky to the touch.

Dry food storage area:

  *The ceiling had brown spots and food debris; and

  *Walls throughout the storage area had multiple scrapes.

Dish washing area:

  *The wall throughout the area had brown matter, food spills and debris;

  *The surface dishwasher was sticky to the touch; and

  *A metal ceiling vent had brown matter and rusted metal.

Floor:

  * Station II pathway floors and baseboards had thick black matter build-up and food debris in the corners.

On 04/25/22 at 1:35 pm, the kitchen was toured with Staff 1 (ED) and the above areas were reviewed.  Staff acknowledged the above areas needed cleaning and repair.

1) All areas of the kitchen including, but not limited to, areas specified in the statement of deficiencies were cleaned at time of survey and then will be deep cleaned through a third-party professional cleaning company that specializes in commercial cleaning services by complaince date and then maintained by community staff following a cleaning schedule.

Gouged and splintered areas have been identified and sanded.

Kitchen staff who are involved with food preparation and handling will be re-trained in infection control and food safety and will obtain a new food handlers card.

2) Daily Cleaning schedule has been placed in the kitchen, and will be reviewed weekly, which includes all areas noted in the findings.

Kitchen staff who are involved with food preparation and food handling will be retrained in food safety by obtaining a new food handlers card.

3) Kitchen cleanliness will be monitored on a weekly basis. Food preparation will be monitored on a weekly basis.

4) The Executive Director, or designee, and the Dining Services Manager will be responsible for monitoring continued compliance.