Print Inspection: NOHS

The findings of the re-licensure survey, conducted  06/20/23 through 06/23/23 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 re-licensure survey of 06/23/23, conducted 12/20/23 through 12/21/23 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 in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 06/20/23 and 06/21/23, the facility's kitchen was observed to need cleaning and/or repair in the following areas:

* Shelving throughout the kitchen and dry storage had food spills, white/gray accumulation, dust, and/or debris. An untreated wood shelf in the back of the kitchen had gouges and small chunks of missing wood;

* Shelves in the refrigerator and freezer had spills, white/brown accumulation, and debris. Food, dirt, and/or packaging debris was noted under shelves in the dry storage, refrigerators and freezer;

* Debris and spills were noted on storage shelves which held clean dishes, pots, and pans;

* Three large baking pans were noted with a thick black/brown accumulation in the corners of the pan;

* Two large bags of rice and corn starch were open in the dry storage area outside the kitchen;

* Debris was noted in the interior of the ovens and stove burners;

*  Numerous lidded pitchers, as well as pitchers with no lids had broken and cracked bottoms, edges and/or handles;

* Numerous areas of the curved floor baseboard were cracked and separating at wall corners and edges throughout the kitchen, black accumulation was noted along edges of baseboards;

* A large tear in the linoleum was noted near the dishwashing area, flooring throughout the kitchen had gouges and large areas of black/gray discoloration along wall and cupboard edges as well as under equipment.

* Vents in the ceiling had dust and web accumulation on the slats;

* Handles to the freezer had dried on food and debris, spills were also noted on the doors and sides of the refrigerators and freezer;

* Two pans of unknown liquid and a package of cheese located in the refrigerator were uncovered, undated and/or not labeled;

* Drains under the prep table and dishwashing area had debris, dark accumulation on edges of the drain and on the cover;

* Broken plastic was noted on the corner of the counter closest to coffee makers as well as a large piece of missing laminate along the edge of the counter;

* Walls and the ceiling had spills, splatters and dust/webs throughout the kitchen;

* A cracked plastic lid, on a dry storage bin had missing pieces of plastic;

* Food transportation carts were covered in spills, splatters and food debris for both days of observation. The smaller of the two carts had significant cracking on both shelves with the pieces lifting apart; and

* A broken light cover was noted nearest the dishwashing area.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (RCC/Administrator Designee) and Staff 5 (DM) on 06/20/23 and 06/21/23. Staff 3 (Regional Director of Operations) was shown the areas in need of cleaning and repair on 06/23/23. The staff acknowledged the findings.

1: All Areas noted on the Kitchen Inspection under C240 2567 (including cleaning & repairs) completed

2. Cleaning schedules were updated and staff training was done to ensure splatters, spills, drips, and debris are cleaned in a timely manner on shelving (around the kitchen and inside both fridges), kitchen equipment, floors and walls, vents, baseboards and drains.

Inservice conducted on cleaning expectations with Kitchen Staff.

Work Order Training occurred with Kitchen Staff for reporting of uncleanable surface or damages.

All Kitchen staff in-serviced on proper labeling and storage of food items that are placed in the fridges.

Kitchen Audits updated with the above items.

3. Kitchen Audits will be completed weekly for four weeks then monthly as a part of our ongoing QA program.

4: Dining Manager and Executive Director will be responsible for ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and care needs and provided clear instruction to staff for 1 of 3 sampled residents (#3) whose service plan was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in April 2022 with diagnoses including chronic obstructive pulmonary disorder, dementia, and anxiety disorder.

The resident's current service plan, dated 03/22/23, was reviewed, observations were made, and interviews were conducted between 06/21/23 and 06/23/23. Resident 3's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Verbal disruptive behaviors and interventions;

* Mobility status;

* Specific assistance needed with incontinence care provided in bed;

* Use of oxygen and settings; and

* Refusals to get out of bed.

The need to ensure resident service plans were reflective of current status and care needs, and provided clear direction to staff was reviewed with Staff 1 (RCC/Administrator Designee), Staff 3 (Regional Director of Operations) and Staff 4 (Regional RN) on 6/23/23. They acknowledged the findings.

1. Resident 3 service plan updated to reflect missing resident specific items from survey along with clear direction and instruction to staff.

2. Executive Director to conduct an in-service with the service planning team on the proper service planning process as well as review the service planning OAR.

3. Service planning team will audit 1 service plans per week to assure accuracy, reflectiveness and instruction/direction for staff.

4. Executive Director, facility RN, Resident Care Coordinator or designee are responsible.

Based on interview and record review, it was determined the facility failed to ensure resident entries were reflective of resident care needs for 3 of 3 sampled residents (#s 1, 2 and 3).  Findings include, but are not limited to:

Review of three sampled residents' records, interviews with staff, and observations of the residents noted ABST entries were not reflective of the current care needs. The ABST data showed multiple areas which reflected zero minutes when the resident required more than zero minutes of assistance in several of the marked areas.

Inaccuracies on resident entries for the ABST tool, were discussed with Staff 1 (RCC/Administrator Designee), Staff 3 and Staff 4 (Regional RN) on 06/23/23. They acknowledged the findings.

1: Sample resident # 1-3 ABST was updated to reflect her individual care needs.  

2: ABST will be reviewed and updated for asssited living residents to ensure it is reflective for their individual care needs.

3: ABST will be audited weekly for 4 weeks then monthly as a part of our ongoing QA

4: Executive Director or Designee will update the ABST every quarter or as a result of changes of condition.