Avamere at Sandy Assisted Living Facility

C240a. 1) Facility staff immediately did a deep clean of all kitchen and dining room areas including but not limited to all areas noted in the SOD. 2) Plan of correction includes a Dietary Audit Sheet to be completed daily by dietary staff. If an items needs to be referred to maintenance or housekeeping for deeper cleaning, a referral will be made through the maintenance workflow system, TELS with follow up by the Dietary Services Manager. Inservice with all relevant employees completed on cleaning and sanitation protocols. Protocols all posted in the kitchen area for reference.3) Dietary Service Manager will audit weekly and provide additional inservice and training as needed.4) Executive Director is responsible to see that the corrections are completed and monitored. b. 1) Non-functioning Montague Grizzly oven and grill were removed from the kitchen. Gasket for freezer is on order. Follow up email sent to vendor for estimated delivery date. Work order placed with maintenance for cabinet veneer door replacement. 2) Plan of correction includes weekly walkthrough between DSM, Maintenance Director and ED and any areas of improvement needed, will be placed on a workorder for repair and/or removal.3) Weekly walkthroughs will be completed.4) Executive Director is responsible to see that the corrections are completed and monitored.c. 1) Plan of correction includes salad bar food temperature readings on three different foods, during meal service. Documentation on temperature log kept in the kitchen by either the salad bar attendant or cook. Inservice on process completed and documented.2) Monitoring and documentation of temperatures completed daily by salad bar attendant or cook. 3) Dietary Services Manager will review logs weekly and spot check temperatures periodically.4) Executive Director is responsible to see that the corrections are completed and monitored.d. 1) DSM immediately reached out to all kitchen staff to get copies of all Food Handler cards, that were not found in the personel files. All are current and up to date.2) Plan of correction includes audits conducted of certifications for all new hires and renewals for exisiting employees, using the training grid.3) Review training grid and certifications at monthly CQI meeting.4) Executive Director is responsible to see that the corrections are completed and monitored.

The incident for resident #3 was reported to APS. An audit was done of the past 90 days of Incident Reports to ensure regulations were followed on self reporting any incident in which abuse and neglect could not be ruled out. The Abuse Reporting Guidelines for the State of Oregon were also reviewed with the clinical IDT teamTo prevent recurrance abuse and neglect reporting guidelines will be reviewed with all staff at community monthly July 2021 All Staff Meeting. Additionally, Incident reports will be reviewed 5 days a week as part of our daily standup process, and on weekends the staff will report any Incident Reports to the on-call LN. Any incidents in which abuse and neglect cannot be ruled out will be reported timely to APS This system will be evaluated 5 days a week at standup, and all Incident Reports will be reviewed by ED, RCC, DHS and other parties "as needed". This will also be evaluated as part of the montly RNC site visits. The Executive Director and RN will be responsible for maintaining this sytem

Resident #3 was assessed by RN and appropriate interventions have been implemented and service plan has been updated. A complete audit has been done of all resident weights to ensure any significant fluctuations have been assessed. To prevent reoccurrence all resident monthly weights will be documented by the 10th of each month and will be reviewed by clinical IDT team. This will include a review of all residents who experienced a significant gain or loss to ensure interventions are in place as needed. This also includes an audit to ensure service plans are reflective of current weight status for all residents. This system will be evaluated monthly as part of the facility CQI program and during RNC monthly site visits. The RN and Executive Director will be responsible for maintaining this sytem

A complete audit was done of all residents with a significant change of condition during the past 45 days to ensure that a RN Assessement was completed and appropriately documented. The facility policy on change of condition and RN Assessment was reviewed with the clinical IDT team, including the LPN, RN and RNC (Regional Nurse Consultant). To prevent recurrence, all residents with a significant change of condition will be assessed by the RN with weekly RN follow-up until resolution or a new baseline is established. 24 hour summary will be reviewed five days a week as part of our daily standup meeting. This summary report shows all progress notes written in the past 24 hours. On Mondays, the 72 hour summary will be reviewed to include review of all documentation from the weekend. Incident reports and alert charting will also be reviewed daily at standup to identify any new change of condition requiring assessment. This system will be evaluated monthly as part of the facility CQI program, which includes an audit of residents with significant change of condition as well as during RNC monthly site visits. The RN and Executive Director will be responsible for maintaining this sytem

A complete audit was done of all training records. All trainings will be complete and up to date for current employees no later than 8/23/2021.To prevent recurrance all staff will be required to complete the required pre-service training prior to working on the floor. Incomplete trainings will be reviewed five days a week as part of daily standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings to ensure all training is completed within 30 days of hire. Monthly in-service form has been updated to include documentation of topics covered at the in-service as well s the length of the training. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings. The Executive Director and Staffing Coordinator will be responsible for maintaining this sytem.

A complete audit was done of all training records. All trainings will be complete and up to date for current employees no later than 8/23/2021.To prevent recurrance all staff will be required to complete the required pre-service training prior to working on the floor. Incomplete trainings will be reviewed five days a week as part of daily standup meeting to identify missing training components and to review the status of new hires and where they are at with their trainings to ensure all training is completed within 30 days of hire. Monthly in-service form has been updated to include documentation of topics covered at the in-service as well as the length of the training. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings. The Executive Director and Staffing Coordinator will be responsible for maintaining this sytem

Facility completed fire drill in June with all required components covered and staff to be re-educated at the July 2021 staff meeting on the fire drill procedure. All residents will be re-edcuated on fire drill and evacuation procedures by 8/23/2021.To prevent recurrance company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts. Monthly In-service calendar updated to include fire and life safety trainings on alternating months from fire drills. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.Executive Director and Maintenance Director will be responsible for maintaining this system.

Facility completed fire drill in June with all required components covered and staff to be re-educated at the July 2021 staff meeting on the fire drill procedure. All residents will be re-educuated on fire drill and evacuation procedures by 8/23/2021.To prevent recurrance company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts. Monthly In-service calendar updated to include fire and life safety trainings on alternating months from fire drills. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.Executive Director and Maintenance Director will be responsible for maintaining this system.