Print Inspection: T2R4

The findings of the re-licensure survey conducted 01/23/23 through 01/25/23 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 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 re-visit to the re-licensure survey of 01/25/23, conducted 05/04/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

2. In a group interview conducted with residents on 01/24/23, all eight of the residents in attendance voiced complaints about the food. The quality, variety, and temperature of the meals was brought into question.

On 01/25/23 at 12:45 pm, a test tray was obtained from the lunch meal, which consisted of a regular plate delivered with the hall cart, to ensure hot foods were maintained at 135 degrees F or above, and that the meal was palatable. The plate was taken and temperatures obtained after the last resident was served. Findings included the following:

*Glazed pork was 106 degrees, rice was 101 degrees, beets were 105 degrees, and a roll was 123 degrees;

*The pork was tough, chewy, and difficult to cut; and

*The rice was mushy, soft and bland.

On 01/25/23 the need to ensure meals were maintained at proper temperatures and items served were palatable was discussed with Staff 1 (ED) and Staff 2 (RCC). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

1. Observation of the kitchen on 1/23/23 at 10:20 am through 2:00 pm revealed the following deficiencies:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Pipes, walls, gauges, disposal, drain, walls and flooring behind/underneath the dish machine;

* Spice shelves;

* Juice dispenser;

* Coffee machine, juice machine, and beverage area;

* Sink next to juice machine;

* Kitchen drains;

* Trash cans;

* Pipes and flooring underneath the three compartment sink;

* Interior and exterior of drawers;

* Ceiling fire sprinklers and vents;

* Walls and floors throughout kitchen;

* Open shelving under the steamtable;

* Interior and exterior of microwave;

* Stove/grill/oven knobs, doors, interior, exterior;

* Area around grill/stove;

* Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers and around the hood;

* Open shelving throughout kitchen;

* Industrial mixer;

* Large can opener and housing;

* Floors throughout the kitchen had black matter build-up, food and trash debris and grease in corners, under equipment, shelving and around perimeter edges;

* Exterior of walk in refrigerator;

* Floors in walk in refrigerator and freezer;

* Rack shelving in dry good storage;

* Rack shelving storing equipment and dishes;

* Under and behind shelving in dry good storage;

* Door thresholds;

* Fan by hand washing sink;

* Window seal;

* Ceiling with food splatters/stains;

* Dish/Utility carts in kitchen and dish washing area;

* Bulk dry good bins, handles and lids;

* Mop sink area;

* Exterior and interior of ice machine;

* Toaster, ninja blender;

* Baking rack and can good storage rack;

* Mounted knife storage container; and

* Plate warmer and steam table.

b. The following areas were found in need of repair:

* Kitchen entrance and exit door with damage and missing paint in threshold and door;

* Caulking around dish machine area with black substance buildup;

* Window seal area with need of repairs;

* Vents in kitchen with dust/dirt build up;

* Threshold doors to Staff 2 office and dry storage with damaged/missing paint;

* Multiple light fixtures with cracks, light fixture in Staff 2 office broken and hole in ceiling;

* Walk in cooler with large ice/frost buildup;

* Refrigeration fans in walk in fridge/freezer with dust build up;

* Light not working in dry storage; and

* Fire sprinkler in walk in refrigerator with build up and damage.

c. Food items found in dry good storage that were not covered/sealed to prevent potential contamination.

d. Multiple wire racks for dish/equipment or food storage were found with build up of dirt/dust and or rust areas rendering them not a smooth cleanable surface.

e. Cutting boards/surfaces found to be heavily scored and/or stained.

f. Clean linens not stored in a method to ensure they were kept clean until used.

g. Plastic container for storage of ice scoop with water build up and mold like substance and hair observed in the bottom where scoop rests. Staff 2 removed scoop and container and immediately cleaned and sanitized both items.

h. During lunch tray service, kitchen staff was observed touching RTE foods (bread slices) with bare hands. Staff 2 was observed touching ready to eat food items with gloves that were potentially contaminated from prior tasks.

i. Kitchen staff not utilizing hair restraints as required.

At approximately 1:30 pm surveyor reviewed above areas with staff 2 (RCC). Staff 2 acknowledged the areas and assured surveyor they would be addressed. At approximately 1:45 pm the areas of concern were reviewed with Staff 1 (ED) who acknowledged the identified concerns.

1.Kitchen will follow a daily, weekly and monthly cleaning schedule

Dietary assignments to ensure complete sanitation after meals for the dining room and the kitchen

Sprinkler system to be checked to ensure fire sprinklers are replaced as needed

Kitchen door to be fixed and repaired per Vortex

Walk in cooler to be looked at by third party vendor to ensure functional and fixed to state standard

Caulking and window to be repaired in house

New equipment: cutting board and storage racks ordered.

Kitchen associates to be trained on hygiene and cross contamination which includes hair nets to worn at all times

Temperatures to be taken at serve out to ensure that the plated food is at correct temperature especially if food is plated and under heat lamp

2.System will monitor by the daily, weekly and monthly cleaning and deep cleaning schedule. DSM to monitor. New equipment to come in and third-party services scheduled to come in to ensure all equipment is safe and clean

3.System will be monitored daily, weekly and monthly

4.Sean Simmons the DSM will have oversight over the kitchen and systems

Based on interview and record review, it was determined the facility failed to ensure RN delegation was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules Division 47, for 1 of 1 sampled resident (#3) reviewed for the delegation of insulin injections by unlicensed staff.  Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 01/23/23, Resident 3 was identified to be administered insulin injections by non-licensed staff.

Resident 3's MAR dated 01/01/23 through 01/23/23 was reviewed and revealed insulin had been given by Staff 11, Staff 13, and Staff 23 (MTs) on multiple occasions.

Delegation records for Staff 11, 13 and 23 reviewed on 01/24/23, indicated Staff 24 ( Delegating RN ) failed to document all required components of delegation in accordance with the OSBN Administrative Rules, including:

* The rationale the task can be safely delegated to an unlicensed CG;

* The skills, ability, and willingness of the unlicensed CG;

* Written instructions that include risks, side effects, risk factors and whom to report the same; and

* The rationale for how frequently the CG should be supervised and re-evaluated.

The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 2 (RCC), Staff 3 (RN) and Staff 22 (Consultant) on 01/25/23. They acknowledged the findings.  

1. ANDs has been taken off of delegations for the community affective immediately. Community RN to take over delegations

2. Community will not use ANDs

3. Initial delegations taught the Prestige way to community RN by the District RN. Initial delegations completed, then reviewed at 60 days and then 90-180 days there after

4. Melanie Schrieder RN HSD to over see

2. Resident 4 was admitted to the facility in 08/2019. Review of the resident's MAR, dated 01/01/23 through 01/23/23, and physician orders identified the following:

The MAR lacked parameters for use of three PRN pain medications. These were acetaminophen 500 mg, hydrocodone-acetaminophen 5-325 mg, and lidocaine 5% patch. There were no instructions for the sequential order of administration of these medications.

On 01/25/23 the need to keep an accurate MAR of all medications prescribed by a legally recognized practitioner and administered by the facility was discussed with Staff 1 (ED) and Staff 2 (RCC). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 4 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2022. The resident's 01/01/23 through 01/23/23 MARs and physician orders were reviewed.

The following medications lacked physician's orders but were transcribed on the MAR:

* Acetaminophen PRN for pain;

* Tramadol PRN for pain; and

* Senna PRN for bowel care.

A review of the physician orders with Staff 2 (RCC), confirmed the above medications were discontinued on 04/02/22 and 06/07/22, respectively, however the facility failed to ensure the discontinued medications were removed from the MAR.

The need to ensure accurate MARs were kept by the facility was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 22 (Consultant) on 01/24/23. They acknowledged the findings.  

1. All resident current physician orders to be audited with the most current 90 days order to ensure accuracy of the MAR and all medications on hand to be audited to ensure what is on the MAR is what is in the medication cart. All PRNs to be reviewed by clinical team to ensure that accuracy of MAR and parameters are as prescribed

2. System will have an audit done immediately, then 90 day orders to be reviewed by LN/RN to ensure accuracy

3. Immediately and then every 90 days

4. Melanie Schrieder RN and Shawneen Santana LPN to oversee

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 15 and 16) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities or providing care to residents. Findings include, but are not limited to:

Staff training records reviewed on 01/24/23 at 11:22 am, with Staff 4 (RCC), identified the following:

There was no documented evidence Staff 15 (MT), hired on 10/27/22 and Staff 16 (MT), hired 12/20/22 had completed one or more of the following required training topics prior to beginning their job responsibilities and/or provided care to residents:

* Fire safety and emergency procedures; and

* There was no documented evidence Staff 15 and Staff 16 completed pre-service dementia training prior to providing care to residents.

The need for staff to complete all required pre-service orientation and dementia training prior to starting their job duties and providing care to residents was discussed with Staff 1 (ED), Staff 3 (RN), and Staff 22 (Consultant) on 01/24/23. They acknowledged the findings.

1. Preservice training to be audited to ensure all records are accurate and completed. Infectious disease training to be audited on all staff and assigned as needed. MT to have completed the PCA training checkoff along with the MT training.

2. RCC will audit all staff training to ensure that training is completed and assign to the associate if not completed

3. Training records will be audited by RCC and ED to ensure all documents are completed.

4. ED and RCC to oversee

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 direct care staff (#s 15, 16 and 17) demonstrated satisfactory performance in all job duties within 30 days of hire and completed First Aid and abdominal thrust training. Findings include, but are not limited to:

Training records were reviewed with Staff 4 (RCC) on 01/24/23.

There was no documented evidence Staff 15 (MT), hired 10/27/22, Staff 16 (MT), hired 12/20/22 and Staff 17 (MT), hired on 12/07/22, had demonstrated competency within 30 days of hire in the following training areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment and observation and reporting;

* General food safety, serving and sanitation; and

* First Aid and abdominal thrust.

The need to ensure staff had demonstrated competency in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (ED), Staff 3 (RN) and Staff 22 (Consultant) on 01/24/23. They acknowledged the findings.

1. All staff records to be audited to ensure that they have dementia training completed in the first 30 days of new hire along with CPR and abdominal thrust is completed by community RN

2. 30 days after new hire files to be audited before going into permanent record files to ensure a double check system to ensure accuracy and training completion

3. Employee file to be checked at 30 days by RCC and then ED to ensure all records are completed

4. ED, Racheal Catt and RCC, Taylor Lewis