Landings of Oregon

Based on review of the medical record, hospital document review, staff interview, and policy review, the facility failed to ensure resident medication orders were updated as required. This affected one (#16) of three residents reviewed for medications. The facility census was 42. Findings include: Review of the medical record for Resident #16 revealed an admission date of 07/03/24. Diagnoses included dementia, type two diabetes mellitus, and chronic kidney disease. Review of a hospital after visit summary dated 11/24/24 revealed Resident #16 had a change in medications. The resident had physician orders to stop taking the antiplatelet medication clopidogrel 75 milligrams (mg), the muscle relaxer Zanaflex four (4) mg, and the nonsteroidal anti-inflammatory medication ibuprofen 200 mg. Review of the current physician orders dated 11/24/24 through 01/22/24 revealed Resident #16 had orders for ibuprofen 200 mg with instructions to give one tablet every six hours as needed. The clopidogrel 75 mg and Zanaflex 4 mg medications were discontinued. Review of the medication administration records from 11/24/24 through 01/22/24 revealed Resident #16 did not receive any ibuprofen during that time frame. Interview on 01/23/25 at 8:03 A.M., with Licensed Practical Nurse (LPN) #300 verified the hospital discontinued Resident #16's ibuprofen in November 2024 and the facility should have discontinued the medication. LPN #300 verified Resident #16 had not received the ibuprofen. Review of the policy titled, Medication AdministrationBased on review of the medical record, hospital document review, staff interview, and policy review, the facility failed to ensure resident medication orders were updated as required. This affected one (#16) of three residents reviewed for medications. The facility census was 42.

Findings include:

Review of the medical record for Resident #16 revealed an admission date of 07/03/24. Diagnoses included dementia, type two diabetes mellitus, and chronic kidney disease.

Review of a hospital after visit summary dated 11/24/24 revealed Resident #16 had a change in medications. The resident had physician orders to stop taking the antiplatelet medication clopidogrel 75 milligrams (mg), the muscle relaxer Zanaflex four (4) mg, and the nonsteroidal anti-inflammatory medication ibuprofen 200 mg.

Review of the current physician orders dated 11/24/24 through 01/22/24 revealed Resident #16 had orders for ibuprofen 200 mg with instructions to give one tablet every six hours as needed. The clopidogrel 75 mg and Zanaflex 4 mg medications were discontinued.

Review of the medication administration records from 11/24/24 through 01/22/24 revealed Resident #16 did not receive any ibuprofen during that time frame.

Interview on 01/23/25 at 8:03 A.M., with Licensed Practical Nurse (LPN) #300 verified the hospital discontinued Resident #16's ibuprofen in November 2024 and the facility should have discontinued the medication. LPN #300 verified Resident #16 had not received the ibuprofen.

Review of the policy titled, Medication Administration

Based on observation, staff interview, and policy review, the facility failed to ensure the kitchen and food items were maintained in a safe and sanitary manner. This had the potential to all 42 residents residing in the facility. The facility census was 42. Findings include: Observation of the kitchen on 01/22/25 beginning at 10:07 A.M. revealed there was a build of grease and food debris on the side of cooking top griddle and underneath the stove. Observation of the reach-in freezer revealed a bag of chicken nuggets, a bag of fish fillets, and a bag of french fries had no use by date. There was no thermometer in the reach-in freezer or reach-in refrigerator. Observation of the bread rack revealed a package of flour tortilla shells were wrapped in clear plastic wrap with no open date or use by date. Located in the walk-in refrigerator was a bag of opened diced potatoes that were not sealed and not dated when it was opened. There was also a bag of meatballs with no use by date. Observation inside the walk-in freezer revealed bags of stewed beef, chicken quarters, and boneless rib meat with no use by dates. There was also a buildup of debris on the floor below the walk-in freezer shelves. Interview on 01/22/25 beginning at 10:07 A.M., with Dining Services Director (DSD) #100 verified the buildup of debris on the side of and underneath the stove. DSD #100 verified there were no thermometers in the reach-in freezer or refrigerator to determine the internal temperature. DSD #100 verified the chicken nuggets, fish fillets, and french fries had no use by date. DSD #100 stated the date would have been on the box but the dietary staff removed the food items from those boxes. DSD #100 verified the flour tortilla shells were not dated when opened and had no use by date. DSD #100 verified the meatballs, stewed beef, chicken quarters, and boneless rib meat were not labeled with use by dates after they were removed from the original food containers. DSD #100 stated the stove was cleaned every two weeks and the walk-in freezer was cleaned yearly. Review of the policy titled, Kitchen SanitationBased on observation, staff interview, and policy review, the facility failed to ensure the kitchen and food items were maintained in a safe and sanitary manner. This had the potential to all 42 residents residing in the facility. The facility census was 42.

Findings include:

Observation of the kitchen on 01/22/25 beginning at 10:07 A.M. revealed there was a build of grease and food debris on the side of cooking top griddle and underneath the stove. Observation of the reach-in freezer revealed a bag of chicken nuggets, a bag of fish fillets, and a bag of french fries had no use by date. There was no thermometer in the reach-in freezer or reach-in refrigerator. Observation of the bread rack revealed a package of flour tortilla shells were wrapped in clear plastic wrap with no open date or use by date. Located in the walk-in refrigerator was a bag of opened diced potatoes that were not sealed and not dated when it was opened. There was also a bag of meatballs with no use by date. Observation inside the walk-in freezer revealed bags of stewed beef, chicken quarters, and boneless rib meat with no use by dates. There was also a buildup of debris on the floor below the walk-in freezer shelves.

Interview on 01/22/25 beginning at 10:07 A.M., with Dining Services Director (DSD) #100 verified the buildup of debris on the side of and underneath the stove. DSD #100 verified there were no thermometers in the reach-in freezer or refrigerator to determine the internal temperature. DSD #100 verified the chicken nuggets, fish fillets, and french fries had no use by date. DSD #100 stated the date would have been on the box but the dietary staff removed the food items from those boxes. DSD #100 verified the flour tortilla shells were not dated when opened and had no use by date. DSD #100 verified the meatballs, stewed beef, chicken quarters, and boneless rib meat were not labeled with use by dates after they were removed from the original food containers. DSD #100 stated the stove was cleaned every two weeks and the walk-in freezer was cleaned yearly.

Review of the policy titled, Kitchen Sanitation

Based on review of personnel files and staff interview, the facility failed to ensure Care Partners (non-licensed staff who provide care to residents) received first aid training within 60 days of hire. This had the potential to affect all 43 residents in the facility.

Findings include:

Review of the personnel file for Care Partner (CP) #307 revealed a hire date of 06/13/24. Further review revealed no evidence CP #307 received first aid training.

Review of the personnel file for CP #308 revealed a hire date of 05/22/24. Further review revealed no evidence CP #308 received first aid training.

Interview on 10/07/24 at 5:58 P.M. with the Wellness Director confirmed CP #307 and CP #308 had not yet received first aid training.

Based on personnel file review and staff interview, the facility failed to ensure Care Partners (non-licensed staff who provide care to residents) received skills training. This had the potential to affect all 43 residents in the facility.

Findings include:

Review of the personnel file for Care Partner (CP) #307 revealed a hire date of 06/13/24. Further review revealed no evidence CP #307 received skills training with oversight by a Registered Nurse (RN).

Review of the personnel file for CP #308 revealed a hire date of 05/22/24. Further review revealed no evidence CP #308 received skills training with oversight by an RN.

Interview on 10/07/24 at 5:00 P.M. with the Wellness Director revealed newly hired CPs were trained by their peers (other CPs) and the facility maintained no documentation of the skills training for CP #307 and CP #308.

Based on review of the facility's incident log, resident record review, and staff interview, the facility failed to ensure the incident log included an incident of elopement. This affected one (#37) of one resident reviewed for elopement. The facility census was 43.

Findings include:

Review of the medical record for Resident #37 revealed an admission date of 06/01/23 with a diagnosis of Alzheimer's disease.

Review of the Annual Evaluation completed on 08/22/24 revealed Resident #37 could communicate and understand directions but could not use the call system to make her needs known. Additionally, Resident #37 was assessed to be cognitively impaired, and did not require assistance for mobility, ambulation, or transfers.

Review of a progress note dated 07/06/24 at 2:51 A.M. revealed staff heard the exit door alarm and observed Resident #37 outside the building at approximately 7:30 P.M. Resident #37 was observed walking down the short sidewalk toward the parking lot. Staff redirected Resident #37 back into the building.

Review of the facility's incident log dated November 2023 through October 2024 revealed no documentation of Resident #37 exiting the facility on 07/05/24.

Interview on 10/07/24 at 11:03 A.M. with the Wellness Director confirmed elopements should be included on the incident log. Further, the Wellness Director defined elopement as any time a resident was outside the building and confirmed Resident #37's exit from the building on 07/05/24 was considered an elopement although Resident #37 did not leave the property. The Wellness Director further confirmed the incident of elopement for Resident #37 was not documented on the incident log.

The facility was unable to provide a policy regarding the types of incidents that should be documented on the incident log.

Based on observation, staff interview, and review of the facility's policies, the facility failed to ensure staff wore hairnets and practiced appropriate hand hygiene during meal service. This had the potential to affect all 43 residents in the facility. Additionally, the facility failed to ensure food items were dated upon opening, failed to ensure food was stored in closed containers, and failed to ensure expired food items were removed from the refrigerator. This had the potential to affect all 43 residents in the facility.

Findings include:

1. Observation and interview on 10/07/24 at 10:04 A.M. with Cook #301 revealed she walked out of the kitchen without wearing a hairnet. Cook #301 stated she had already checked with her supervisor and confirmed the facility did not have hairnets.

Observation on 10/07/24 at 11:44 A.M., during noon meal service, revealed Cook #301 with ear-length straight hair, held back with a thin headband, preparing resident meals. Cook #301 wore disposable gloves and touched the steam table lid over the gravy before picking up the gravy ladle and pouring it over an open-faced sandwich. Cook #301 then touched the steam table lid over the corn and used a utensil to spoon corn onto the plate. Cook #301 then picked up the plates and moved them to the serving area, placed three new plates on the trayline, and picked up three pieces of bread from a bagged loaf of bread and put them on the plates before proceeding to touch the steam table lid over the roast beef, the mashed potatoes, the gravy, and the corn, and touching each utensil to service the resident's meals. Cook #301 then picked up two slices of bread, picked up a jar of peanut butter and proceeded to make a peanut butter and jelly sandwich.

Interview on 10/07/24 at 11:48 A.M. with Cook #301 confirmed she did not change her gloves or wash her hands between touching serving utensils, steam table lids, and ready-to-eat bread for the open faced sandwiches; additionally, she did not change her gloves after opening a reusable jar of peanut butter and proceeding to make a sandwich.

Observations on 10/07/24 beginning at 12:29 P.M. revealed Care Partner (CP) #302 donning disposable gloves before opening a food cart and removing bulk items for the noon meal, including pans of beef, mechanical soft beef, pureed beef, corn, pureed corn, and mashed potatoes. CP #302 removed the coverings for each food item, opened two drawers to retrieve serving utensils. Continued observation revealed CP #302 opened a bag of sliced bread and removed two pieces and placed them on two different plates. CP #302 then picked up slices of roast beef with her gloved hand and used scissors to cut the meat into bite-sized pieces.

Interview on 10/07/24 at 12:41 P.M. with CP #302 revealed the scissors were sent to the kitchen for washing after each meal. CP #302 further confirmed she did not change gloves or wash her hands after unloading the meal cart, uncovering all the food items, opening drawers for utensils, and touching residents ready-to-eat food with the same gloves.

Review of the policy, Kitchen Infection Control Procedures

Based on record review and staff interview, the facility failed to ensure fire drills were transmitted to the appropriate fire department or monitoring station. This had the potential to affect all 43 residents in the facility.

Findings include:

Review of the facility's fire drills revealed no evidence the alarms were transmitted to the local fire department or monitoring station.

Interview on 10/07/24 at 12:15 P.M. with Facilities Manager (FM) #309 confirmed he did not verify the local fire department or monitoring station received the alarms transmitted during the drills completed at the facility. FM #309 stated he placed the system in test mode before pulling the alarm during a drill. FM #309 stated a third party provided continuous monitoring of the fire alarm system and would notify the facility if the system was not functioning properly.

Based on record review and staff interview, the facility failed to ensure the central heating system was checked within two years. This had the potential to affect all 43 residents in the facility.

Findings include:

Review of the receipt for preventative maintenance on the facility's air conditioning and furnace units revealed a service date of 10/28/20.

Interview on 10/07/24 at 1:48 P.M. with the Executive Director confirmed the facility's central heating system was not checked since 2020.

Based on observations, staff interview, and review of the facility policy, the facility failed to ensure a resident's insulin pen was labeled and dated upon opening and failed to ensure two tuberculin vials were dated when opened. This affected one resident (#11) who received medication from the east medication cart and had the potential to affect all 45 residents residing in the facility. Findings include: 1. Observation of the east medication cart on 06/14/23 at 11:00 A.M. revealed one insulin pen in the top drawer, in a compartment to the upper right of drawer. The insulin pen was Lantus and did not contain a resident name or open date. Interview with Licensed Practical Nurse (LPN) #100 at the time of the observation revealed only one resident (Resident #11) received insulin from the east medication cart. LPN #100 verified the insulin pen did not contain a resident name and it should and the pen was also without an open date and should be dated when opened. 2. Observation on 06/14/23 at 11:15 A.M. of the medication refrigerator at the east nurse's station with LPN #100 revealed two half empty vials of tuberculin purified protein derivative opened and undated. Both of the tuberculin vials were labeled with a lot number of C5928AA with an expiration date of 03/01/24. One vial was delivered from the pharmacy on 02/08/23 and the second was delivered from the pharmacy on 03/08/23. Interview with LPN #100 verified the tuberculin vials were not dated and should be dated when opened. Review of the facility policy titled Medication ProgramBased on observations, staff interview, and review of the facility policy, the facility failed to ensure a resident's insulin pen was labeled and dated upon opening and failed to ensure two tuberculin vials were dated when opened. This affected one resident (#11) who received medication from the east medication cart and had the potential to affect all 45 residents residing in the facility.

Findings include:

1. Observation of the east medication cart on 06/14/23 at 11:00 A.M. revealed one insulin pen in the top drawer, in a compartment to the upper right of drawer. The insulin pen was Lantus and did not contain a resident name or open date.

Interview with Licensed Practical Nurse (LPN) #100 at the time of the observation revealed only one resident (Resident #11) received insulin from the east medication cart. LPN #100 verified the insulin pen did not contain a resident name and it should and the pen was also without an open date and should be dated when opened.

2. Observation on 06/14/23 at 11:15 A.M. of the medication refrigerator at the east nurse's station with LPN #100 revealed two half empty vials of tuberculin purified protein derivative opened and undated. Both of the tuberculin vials were labeled with a lot number of C5928AA with an expiration date of 03/01/24. One vial was delivered from the pharmacy on 02/08/23 and the second was delivered from the pharmacy on 03/08/23.

Interview with LPN #100 verified the tuberculin vials were not dated and should be dated when opened.

Review of the facility policy titled Medication Program

Based on review of the facility provided grievance committee information, policy review, and staff interview, the facility failed to have the required number of resident to staff ratio on the grievance committee as required. This had the potential to affect all 45 residents residing in the facility.

Findings include:

Review of the facility's Grievance Committee revealed there was no information to review and no evidence of a Grievance Committee existed.

Review of the facility's policy titled Complaint - Grievance, dated 02/15/20, revealed the facility had not established any requirement for resident to staff ratio.

Interview on 06/14/23 at 3:30 P.M. with the Administrator verified the facility did not have a formal grievance committee and no process in place to manage concerns and/or grievances.

This violation represents non-compliance investigated under Complaint Number OH00142473.

Based on observation, staff interview, and review of a facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 54 residents who reside in the facility that receive food from the kitchen. The census was 54.

Findings include:

Observation of the facility kitchen on 09/01/22 between 10:30 A.M. and 10:41 A.M. revealed a dried black substance along baseboards, around shelving units in the dishwashing area, food preparation and cooking area and in dry storage areas of the kitchen. Some of the areas with the dried black substance were speckled and some areas were streaked on the floor tile. Further observation of the floor revealed grease on the floor between the deep fryer and flat top stove and solidified grease on the front wheel of the flat top stove. Additionally, there was heavy dust buildup observed on vent in the ceiling above bread cart.

Interview on 09/01/22 at 10:43 A.M. with Dietary Manager #1 stated the floors in the kitchen had not been scrubbed for a couple of months and stated he did not keep records of the day to day cleaning in the kitchen. Dietary Manager #1 verified the dried black substances and grease on the floor and flat top stove wheel. Dietary Manager #1 verified the heavy dust build up on the vent above the bread cart and stated the kitchen staff did not clean the vents and it was the responsibility of the maintenance department.

Interview on 09/01/22 at 10:50 A.M. with Maintenance Director #1 stated he was not responsible for cleaning anything in the kitchen and verified he never cleaned any of the ceiling vents in the kitchen.

Review of a facility policy, titled, Kitchen Sanitation

Based on observation and staff interview, the facility failed to maintain the environment in a sanitary manner. This affected all residents in the facility with the exception of the 19 (#38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, and #56) residents residing on the memory care unit. The census was 54.

Findings include:

Observation on 09/01/22 at 11:15 A.M. revealed the wall between the back kitchen entrance and laundry room near the 100 and 300 Halls was covered with wall paper that appeared to have paper tape along the seams holding onto the wall. Further observation revealed a section approximately six inches long near the ceiling where the wall paper was peeling back and a back substance could be observed on the wall behind the wallpaper. The wall behind the wallpaper was made of sheet rock.

Interview on 09/01/22 at 11:18 A.M. with Maintenance Director #1 stated there was a leak about a month ago that caused moisture on the wall and the section of wallpaper came off. Maintenance Director #1 verified there was black mildew on the wall behind the wallpaper and he used a disinfectant spray on the black substance before he put the wallpaper back up on the wall. Maintenance Director #1 stated they were in the process of trying to find someone to fix it, but not many contractors had the desire to work on such a small project at that time.

Observation 09/01/22 at 11:20 A.M., with Maintenance Director #1, revealed an aerosol can of mold and mildew disinfectant Maintenance Director #1 verified he sprayed on the wall before placing the wallpaper back on the wall. Review of the label of the aerosol can mold and mildew disinfectant revealed the spray was to be used on nonporous surfaces only, meaning it was not designed to be used on porous surfaces such as sheet rock. The facility confirmed the identified concern had the potential to affect all residents residing in the facility except the 19 (#38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, and #56) residents residing on the memory care unit.

This violation substantiates Complaint Number OH00134807.

Based on medical record review, staff and resident interviews, review of a facility self-reported incident (SRI), review of a facility investigation, review of door alarm reports, and review of a facility policy, the facility failed to ensure a resident who was cognitively impaired and assessed at high risk for elopement did not elope from the facility. This affected one (#40) of three residents reviewed who were at risk for elopement. The census was 54.

Findings include:

Review of Resident #40's medical record revealed an admission date of 05/05/22. Diagnoses included late onset Alzheimer's without disturbance, hyperlipidemia, arthritis, and fibrocystic breast changes.

Review of an admission nursing assessment dated 05/05/22 revealed Resident #40 was not oriented to person, place, time, or situation, resided in the memory care unit, and was independent with bed mobility, transfers, and walking.

Review of an elopement risk assessment dated 05/05/22 revealed Resident #40 was assessed at high risk for elopement.

Review of a quarterly health assessment dated 08/12/22 revealed a service plan which indicated Resident #40 was at risk for wandering and elopement with interventions to attempt to engage resident in pleasant, meaningful activities during episodes of wandering, observe Resident #40's location in the community every shift, and Resident #40 must be supervised when leaving the community by either staff or responsible party.

Review of a nursing progress note dated 08/13/22 revealed Resident #40 was found outside in the parking lot by a staff member.

Review of a facility SRI dated 08/14/22 revealed Resident #40, from the memory care unit, was found in the parking lot on 08/13/22 at approximately 5:50 P.M. by staff reporting to work. Resident #40 was taken back into the facility with no injuries or distress. Review of written statements as part of the SRI investigation revealed Resident #40 was last seen by a staff member on 08/13/22 at 8:45 P.M. sitting with another resident in the dining room. Review of door alarm records revealed the last door alarm activated on the memory care unit on 08/13/22 was at 5:10 P.M. with no other doors alarming after that on that day. Visitor logs were checked and no visitors were in the memory care unit at the time Resident #40 was discovered in the parking lot. All the secured doors on the memory care unit were tested and functioned appropriately. Review of written statements from all staff members dated 08/13/22 and 08/14/22 revealed no staff member who provided care to Resident #40 on 08/13/22 had any knowledge of how she eloped from the facility on 08/13/22. The facility closed the investigation on 08/18/22 and substantiated the allegation of neglect and mistreatment.

An interview was attempted on 09/01/22 at 9:55 A.M. with Resident #40; however, Resident #40 could not appropriately answer screening questions and had no recollection of the incident from 08/13/22.

Interview on 09/01/22 at 12:44 P.M. with the Administrator and Wellness Director #1 both stated through review of the incident, interviews with staff members, review of door alarm reports and visitor logs, and after testing the functionality of all the doors on the memory care unit, they were not able to determine how Resident #40 eloped from the facility on 08/13/22. Both staff members verified Resident #40 was not to be outside the facility unsupervised and verified the facility had interventions in place to prevent Resident #40's elopement, but despite those interventions Resident #40 was able to elope from the facility.

Review of a facility policy titled, Abuse, Neglect, Exploitation