The findings of the re-licensure survey, conducted 08/16/22 through 08/18/22, 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
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 re-visit to the re-licensure survey of 08/18/2022, conducted on 1/03/2022, 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 interview and observation, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:
On 08/16/22 between 10:51 am and 11:58 am, the kitchen was toured and observed to need cleaning and repairs in the following areas:
a. Kitchen
* The cutting board connected to the steam table was missing wood along the corners and had knife scoring gouges;
* The can opener had food debris where the sharp part would enter the can;
* The stove, third from the left, both the top and the right side were in need of cleaning and repair;
* There were broken tiles on the right side and front right corner of the stove;
* The ice machine vent had a build up of dust;
* There was a scoop left in the panko bin;
* One of the bins in the dry storage room had no cover, leaving dry food exposed;
* There were spatters throughout the ceilings and light covers of the kitchen;
* There was uncovered food observed on a rack behind the back food preparation area;
* The reach-in refrigerator had food debris on the lowest shelf;
* There was brown matter on the wall by the fans in the walk-in cooler;
* There was a package of hot dogs thawing on top of a cardboard box in the walk-in cooler;
* The walk-in cooler had food items that were either not covered or not dated;
* The freezer fan had debris on it;
* The freezer floor had built-up ice with frozen vegetables imbedded in the ice;
* There were floor tiles to the left of the three compartment sink that were coming off of the wall;
* There were no testing strips available to staff for the three compartment sink or sanitation buckets; and
* The back splash where the warewashing and three compartment sink were located was in need of cleaning.
b. Dining room
* There was spillage observed inside the cabinet doors;
* There was a blackish build-up on the floor to the right of the "Out" door; and
* The black garbage receptacle located to the left of the "In" door had spillage and debris on it.
The kitchen was toured with Staff 1 (Administrator) and Staff 5 (Executive Chef) on 08/16/22 at 2:25 pm.
The need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-0000 was discussed Staff 1 and Staff 5 on 08/16/22. They acknowledged the findings.
C240 -
1.
The following items listed on the survey have been resolved:
- The new polytylene plastic cutting board arrived Friday, August 19, 2022 and replaced the damaged board.
- The broken tiles have been replaced. Those coming off the wall have been affixed to the wall.
- The wear and tear to the side of the stove has been repaired.
- Testing strips are now available to the staff.-
The following cleaning has been completed:
- The can opener has been cleaned and sanitized.
- The stove has been cleaned.
- The ice maching vent has been cleaned.
- Kitchen ceiling and light covers have been cleaned.
- All shelves in the reach in refrigerator have been cleaned and debris removed.
- The wall by the walk-in cooler fans has been cleaned.
- The freezer fan has been cleaned.
- Ice build up on the freezer floor has been removed and the debris removed.
- Back splash walls by washing stations has been cleaned.
- Dining Room: Spillage inside the cabinet doors has been cleaned.
- Dining Room: Buildup on the floor has been removed, floors cleaned.
- Dining Room: The black garbage can by the door has been .
Education for Culinary team has been completed in the following areas:
- Sccops are not to be left in the bins. The scoop has been removed from the panko bin.
- Bins in dry storage must be covered immediately following their use. The bin cover has been replaced.
- Food safety standards related to covering, labeling and dating food stored either on a rack or in the walk-in cooler.
- Proper thawing of food standards, focus on meat.
2.
Ongoing Compliance: Kitchen staff will follow the Hawthorn guidelines, utilizing the daily cleaning schedule. Admistrator and Executive Chef will walk the kitchen utilizing the CPA quality assurance tool. Staff will continue to be educated on safe food handling practices and sanitation requirements. Administrator will initiate Thursday walks in the kitchen with a focus on specific areas of compliance.
3.
Education of staff is monthly. QA audits of the kitchen will be daily for 30 days, weekly (Thursday Walk Through) and monthly with the CPA Quality Assurance tool.
4.
The Administrator and the Executive Chef will be responsible for compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff completed their Pre-Service Infectious Disease Prevention training prior to 07/01/22. Findings include, but are not limited to:
There was no documented evidence Staff 6 (Sous Chef), hired 02/12/09, and Staff 7 (Activities Director), hired 02/02/15, completed the Infectious Disease Prevention training prior to 07/01/22.
The need to ensure all staff completed the required Infectious Disease Prevention training by 07/01/22 was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 08/17/22. They acknowledged the findings.
C370
1.
The Sous Chef (staff number 6) completed the approved Infectious Disease Prevention training 8/15/2022.
The Activity Coordinator (staff number 7) completed the Infectious Disease Prevention training 7/29/2022.
2.
- An audit will be completed to assure all other employees hired before 7/1/2022 have completed the approved Infectious Disease Prevention training.
- The Assistant Administrator will use a QA checklist when putting the new staff files together to assure all required elements are present.
- The Infectious Disease Prevention training has been added to the new hire orientation checklist.
- All new hire staff will complete Infectious Disease Prevention training through Oregon Care Partners.
3.
- Quality Assurance audits will be completed monthly for all new hire staff to assure all required elements are present.
4. Administrator and Assistant Administrator.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff completed abdominal thrust and First Aid training within 30 days of hire. Findings include, but are not limited to:
Facility training records reviewed on 08/17/22 revealed there was no documented evidence Staff 15 (Resident Assistant), hired on 06/25/22, completed abdominal thrust and First Aid training within 30 days of hire.
The need to ensure staff completed abdominal thrust and First Aid training in the required time frame was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 08/17/22. They acknowledged the findings.
C372
1.
- Resident Assistant (staff 15) received abdominal thrust training, provided by the community RN 8/18/2022. Training included a return demonstration of the task.
- Resident Assistant (staff 15) obtained first aid training (6/26/2022, DOH - 6/26/2022).
- Resident Assistant (staff 15) has both trainings documented in the personnel record.
2.
- An audit will be completed on direct care staff personnel records to assure all staff have completed the required training.
- The Assistant Administrator will use a QA Checklist when putting new hire personnel files together to assure all required elements are present.
- First Aid/Abdominal Thrust have been added to the New Hire Orientation form.
3.
- Quality Assurance audits will be completed monthly for all new hire staff to assure all required elements are present.
4.
Administrator and Assistant Administrator.
There are no detail notes for this visit.