Vancrest of Ada Assisted Living

Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was stored in a manner that protects it from contamination and spoilage. This had the potential to affect all 41 residents who receive food from the facility kitchen.

Findings include:

Observations on 11/06/25 at 8:08 A.M. of the kitchen revealed there were two, approximately two-quart, pitchers of milk in the fridge with no date or label in the free-standing refrigerator. The free-standing freezer had no internal thermometer.

Interview on 11/06/25 at 8:20 A.M. with Dietary Manager #200 verified there were two pitchers of milk in the fridge with no date or label in the refrigerator and no internal thermometer in the freezer.

Review of the facility policy titled Date Marking with a revision date of May 2011 revealed any ready-to-eat and potentially hazardous foods prepared and held in refrigeration for over 24 hours, shall be date marked utilizing an established procedure to ensure food safety. Commercially processed foods once opened and 41 degrees Fahrenheit (F) or less shall be held for seven day ands used before the manufacturer's use by date.

Review of the undated facility policy titled Refrigerated Storage revealed a thermometer shall be present inside the refrigerator.

This is an example of continued non-compliance from the survey dated 02/06/25.

Based on employee file review and interview, the facility failed to ensure Resident Assistant (RA) had first aid training within 60 days of hire. This affected one (RA) #69 of four employee files reviewed. This has the potential to affect all residents in the facility. The facility census was 37.

Findings include:

Review of employee file for RA #69 revealed a hire date of 10/22/24. No first aid was found in employee file.

Interview on 02/06/25 at approximately 2:00 P.M. with the Administrator verified RA #69 had not completed first aid training within 60 days of hire.

Based on record review, observation, and interview, the facility failed to ensure proper infection control practices during medication administration. This affected one (Resident #35) of two residents observed during medication administration. The facility census was 37.

Findings include:

Review of medical record for Resident #35 revealed an admission date of 06/01/23 with diagnoses including but not limited to bipolar disorder, major depressive disorder, post-traumatic stress disorder, arthritis, anxiety, hypertensive heart disease, weakness, and pain.

Review of current service plan for Resident #35 revealed the resident required assistance with medication administration.

Observation on 02/04/25 from 7:54 A.M. to 8:09 A.M. of medication administration revealed Resident Assistant (RA) #68 touched the keys to unlock the cupboards in the room when pulling out the basket which held the medications. RA #68 then touched the bottles and packs that contained the medications. RA #68 touched the cart and mouse for the computer. RA #68 then removed the medications from the bottles into her bare hands and placed into the med cup to hand to the resident. RA #68 accidentally poured out two capsules from one bottle into the med cup and dumped the medications from the cup into her hands, picked out the extra capsule and returned the capsule to the bottle and the remaining medications in her hands back into the med cup.

Interview on 02/04/25 at 8:11 A.M. with RA #68 verified she poured the medications from the bottles into her bare hands and placed them in the med cup to hand to the resident. RA #68 stated she did not know it was not allowed to touch the medications with her hands.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect all 37 residents residing in the facility. Findings include: Observation on 02/03/25 beginning at 8:40 A.M. of the kitchen area revealed the floor surrounding the deep fryer had a thick amount of grease as well as both left and right sides of the deep fryer; the handles of the oven had a large amount of dried food substances; the shelf above the range was covered in aluminum foil but black with foods and grease; the two shelves above the steam table had a moderate film of grease build-up; the top of the convection oven had a thick film of black grease; and the ice scoop was stored inside the machine on top of the ice. Interview on 02/03/25 at 9:00 A.M. with Cook #110 provided verification of the above findings. Review of the policy titled, SanitizationBased on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen environment. This had the potential to affect all 37 residents residing in the facility.

Findings include:

Observation on 02/03/25 beginning at 8:40 A.M. of the kitchen area revealed the floor surrounding the deep fryer had a thick amount of grease as well as both left and right sides of the deep fryer; the handles of the oven had a large amount of dried food substances; the shelf above the range was covered in aluminum foil but black with foods and grease; the two shelves above the steam table had a moderate film of grease build-up; the top of the convection oven had a thick film of black grease; and the ice scoop was stored inside the machine on top of the ice.

Interview on 02/03/25 at 9:00 A.M. with Cook #110 provided verification of the above findings.

Review of the policy titled, Sanitization