Print Inspection: SH3I

The findings of the initial licensure survey, conducted 5/11/22 through 5/12/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

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 05/12/22, conducted on 07/19/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.

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:

Observations of the kitchen, food storage, prep, and service on 5/11/22 revealed:

* The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million;

* Walls throughout the kitchen had splatters, spills, and drips;

* Spills and food debris were on both sides of the range;

* Storage shelves, cabinets, and drawers throughout the kitchen had debris, splatters, spills, and drips;

* The stand mixer had splatters, spills, and drips;

* Garbage can lids had splatters, spills, and drips;

* Multiple dented cans of food were noted in they dry storage area;

* Staff were observed to not change gloves between tasks or sanitize hand upon entering the kitchen; and

* Caregiving staff assisting with meal service and delivery were not using aprons.

The areas in need of cleaning and repair and infection control practices were reviewed with Staff 1 (Administrator) and Staff 5 (Dietary Manager/Cook) on 5/11/22 and 5/12/22. They acknowledged the findings.

*Obtain and train on use of testing strips for PPM. Routinely check PPM in solution. * Create task sheet for routine cleaning of all areas including those noted in survey.* Retrain staff on proper use of gloves during food prep. *Retrain staff on apron use.* Educate staff on identifying and return of damaged cans of food to supplier.   

PPM strip use monitored Weekly. Cleaning task sheets monitored for adherence weekly. Glove use training to be done and then monitored routinely. Include in new hire training. Apron use monitored daily,  

See above

Administrator Martin Stewart

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used when washing residents' soiled linens and clothing, and to provided a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

During a tour of the facility, washers utilized by staff to wash residents' linens and clothing were noted to have a cold water rinse setting only. Commercial grade laundry detergent was noted in the laundry room, but did not contain a disinfecting agent.

Observation of the hopper room, designed to be used for processing soiled laundry, identified there was not a one way flow of soiled items.

The lack of the use of a disinfectant and the need to ensure the one way flow of soiled laundry was discussed with Staff 1 (Administrator) on 5/12/22. He acknowledged the findings.

1. *Hopper room was reconfigured and locks were replaced to allow for one way route from Memory Care into laundry room. This was also done for AL.

*Insure laundry detergent contains 60-100% Calcium Carbonate, a known disinfectant as documented in EPA resource. SDS sheet and EPA doc scrutinized for facts.

2. *Training of staff re soiled laundry flow at monthly meetings. Include in new hire training. *Advise office manager of need for disinfectant in laundry detergent when purchasing supplies. No other allowed.

3. *Training of staff on laundry flow. Evaluate quarterly during safety audit. Include at monthly all staff mtgs. All new hires to be trained. *Disinfectant in detergent to be checked monthly.  

3. Administrator Martin Stewart   

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 C 240 and C 530.

See plans of correction above.