The findings of the on-site investigation, conducted on 06/14/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

ADL:activities of daily living

CBG:capillary blood glucose or blood sugar

CG:caregiver

CS: Compliance Specialist

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MT:            Medication Tech

MAR:Medication Administration Record

MCC:Memory Care Community

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

RCC:Resident Care Coordinator

RN:Registered Nurse

Notes on Abbreviations:

"The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself.

"Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate.

"Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate.

"If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation and interview,conducted during a site visit on 06/14/23, it was confirmed the facility failed to provide three daily nutritious, palatable meals. Findings include, but not limited to:

In an interview on 06/14/23, Staff 2 (Caregiver) stated there were residents who complained about meals being late and often cold, however, the food was provided by the ALF and if the food was late it was because the ALF did not deliver the food on time, or the MCC dietary aide needed to rewarm the food prior to serving the meal. Meal service was from 12:00 pm-1:00 pm, and residents were usually served within 30 minutes.

In an interview on 06/14/23, Staff 3 (Dietary Aide) stated s/he turned on the steam table 30 minutes before the meal, however, today s/he was unable to. S/He turned the steam table on when the food was placed inside the serving line.  

On 06/14/23 CS observed the following:

·11:41 am- food delivered to MCC kitchen.

·Five staff assisted with meal service with 18 residents in attendance.

·11:47 am-Staff 3 was taking temperatures of food provided,

-BBQ beef tips: 168-degrees Fahrenheit

-Cod: 133-degrees Fahrenheit

-Vegetable mix. cauliflower, carrots, and broccoli: 169-degrees Fahrenheit

-Brussels sprouts: 169-degrees Fahrenheit

-Sweet potato fries: 155-degrees Fahrenheit

-Baked beans: 161- degrees Fahrenheit

·No steam was observed coming from the steam table or the food.

·12:03 pm-Residents were offered small bowls of cantaloupe.

·12:06 pm- First meals entered dining room and were served to residents.

·12:10 pm- A resident asked for salt and pepper for their meal, which staff provided within minutes of the request.

·No residents were overheard complaining about the temperature of the food or the service time.

·12:18 pm- All residents had been served in the dining room.

·At the same time, a sample plate was provided to CS. The plate consisted of BBQ beef, cod, baked beans, steamed vegetables such as cauliflower, carrots, broccoli, brussels sprouts, and sweet potato fries. All food except the baked beans were cold when sampled.

It was confirmed the facility failed to provide palatable meals.

On 06/14/23, the findings were reviewed with and acknowledged by Staff 1 (Administrator).

Verbal Plan of Correction: Staff 1, daily will have the dietary aide turn on the steam table before meal service by creating a log, in addition, s/he is looking into buying a warmer box to transfer food over from ALF to MCC. Will purchase the warmer box within the next month.  

Based on observation and interview, conducted during a site visit on 06/14/23, it was confirmed the facility failed to ensure the glass and area surrounding the fireplace did not exceed 120-degrees Fahrenheit. Findings include, but are not limited to:

On 06/14/23, CS took the temperature of the surrounding area of the fireplace. The temperature gage read 289-degrees Fahrenheit on one occurrence and 337-degrees Fahrenheit on the second.

On 06/14/23, an interview with Staff 1 (Administrator) and Staff 4 (Maintenance Director) explained the facility has a TELS system to record the temperature of the fireplace weekly but that it has not been completed recently due to the facility not having a consistent maintenance director. CS observed Staff 4 take the temperature of the fireplace with his/her own temperature gage and the temperature was 223-degrees Fahrenheit. Both Staff 1 and Staff 4 acknowledged the temperature of the fireplace was higher than 120-degrees Fahrenheit.

It was confirmed the facility failed to ensure the glass and area surrounding the fireplace must not exceed 120-degrees Fahrenheit.

On 06/14/23, the findings were reviewed with and acknowledged by Staff 1 and Staff 4.

Verbal plan of correction: Staff 4 called a vendor out before CS left the facility and stated they would be coming out on 05/22/23 to fix the temperature or the fireplace. Once the new maintenance personal is trained and working on their own, the ED and the maintenance person will do weekly checks for the temperature.