Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 03/16/2023. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
cc:cubic centimeter
CG:caregiver
cm:centimeter
F:Fahrenheit
HH:Home Health
HS or hs:hour of sleep
LPN:Licensed Practical Nurse
MA:Medication Aide
MAR:Medication Administration
Record
MCCMemory Care Community
mg:milligram
ml:milliliter
O2 sats:oxygen saturation in the
blood
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
RN:Registered Nurse
SP:service plan
TAR:Treatment Administration
Record
tid:three times a day
Based on interview, observation, and record review it was confirmed the facility failed to provide three daily nutritious palatable meals with snacks available seven days a week Findings include:
During separate interviews on 03/16/2023, Staff #1 (S1) stated that the residents complain about the food every day. Staff #3 (S3) stated that the food is provided by the independent living and transferred over to both assisted livings buildings in warmers. S3 stated that a caregiver takes the temperature of the food when it is delivered but that is the only time the temperature is recorded. S3 stated that the food is delivered 15 minutes before the meal is serviced. S1 and S3 stated that the steam table needs to be turned up higher.
During an unannounced site visit on 03/16/2023, Compliance Specialist (CS) observed S3 taking the temperature of the meal before being serviced which temped out at 121 degrees, which is within the danger zone. CS observed staff dishing out the meals and leaving it uncovered while assisting with another resident then picking up the food that had been sitting out to serve.
A review of the resident council meeting on 01/17/2023, facility menus, and the food temperature logs dated February and March 2023. The food temperature logs show the staff are not taking the temperatures of the food being served properly. The logs show multiple times where the food temperatures where not taken or documented. The resident council notes show multiple complaints regarding the food. Some of the complaints listed are, residents are not happy with dining services, eggs are cold, food is hard to cut, and rotten bananas are being served.
On 03/16/2023, these findings were reviewed with and acknowledged by S1.
Facility Plan of Correction: Have a meeting with staff to take temps for every day/ shift and will add a mid-meal temp. talk to servers to ensure food is not sitting out after being served and before given to resident. will turn the steam table up so the food stays above the danger zone.
Based on interview, observation, record review it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include:
During an interview on 03/16/2023 with Staff #1-2 (S1 and S2) both stated they will be using the Point Click Care (PCC) for their ABST, however, they do not have any tool in place currently and are about to launch PCC shortly. S1 stated they have a census of 44 residents with not all their information entered in their tool.
During an unannounced site visit on 03/16/2023, The Compliance Specialist (CS) observed no ABST in place.
In review of the ABST tool on 03/16/2023, there was no documented evidence the facility has fully implemented an ABST, this would determine a staffing plan that is reflective to meet the 24-hour scheduled and unscheduled needs of residents.
On 03/16/2023, these findings were reviewed with and acknowledged by S1.