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 9/27/2022.  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 that the facility failed to provide three daily, nutritious, palatable meals to the residents, including fresh fruits and vegetables. Findings include:  

Review of Uniform Disclosure Statement (UDS), Food menu for 9/25/22-10/01/22, Chef ' s Chat meeting minutes for 09/27/22, and always available menu. The meeting minutes included multiple complaints regarding cold food, lack of fresh fruits and vegetable, and being served food they didn ' t order. The menu does not include vegetarian options and does not always include fresh fruits and vegetables in each meal. CS requested food temp logs for 09/09/22-09/15/22, however, the facility did not have any completed logs to provide. They are not documenting food temps, or documenting follow up from menu chat meeting. The UDS states that vegetarian diets are included, however, the facility is not providing it.

On 09/27/22, CS observed lunch service. The food being served was what was listed on the menu. The portion sizes were normal and filled the plate. No concerns from residents that they were still hungry or didn't get enough food. In separate interviews with Staff #1 and #4 on 09/27/22, they stated that staff should be temping the food and documenting it. They have not heard of any frozen fish being served. They have their monthly chef chat meeting today. They currently do not provide a vegetarian diet. They haven't heard of residents going hungry. Staff #4 stated that sometimes staff don't use the temp log and will write it on a sticky note and throw it away.  

Interviews with residents #1-2 and #4 stated that the food is served late, served cold, they do not always serve what they request or ordered off the menu/anytime menu, they do not provide vegetarian diets, and the food is carb heavy without fruit and vegetable options.

CS shared the above information with Staff #1 on 09/27/22.

Plan of correction: Facility will provide vegetarian meals per their UDS, training for kitchen staff on documenting and keeping food temperature logs, hiring additional dietary staff, keep minutes at menu chat meetings, talk about modification in the meeting to make sure staff are paying attention to what residents are ordering.

Based on interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include:

In review of staffing schedules for September 2022, posted staffing plan, Acuity Based Staffing Tool (ABST), service plans for Residents #1-3, and call light response times for 09/10/22. There were multiple response times between 20 and 50 minutes. The facility is not responding to call lights timely.

In an interview on 09/27/22, Staff #1 stated that they are not aware of any needs being missed. Meals are being served timely with the exception of the weekend before last. They just hired 2 new cooks. Staff #4 stated they have heard that dinner has been served late most nights. Staff #3 stated that they are responding to call lights within 2-4 minutes, but there have been some complaints about long wait times.

In separate interviews with Residents #1-2 and #4, they stated that there is not enough staff. Weekends and nights are the worst.  Call lights can take more than 20 minutes, sometimes 45 minutes.

Plan of Correction:

Hiring kitchen and care staff, re-training staff, auditing call light response times when complaints received, using agency staff, ISP for call light response times, and discuss in shift to shift.

Based on interview and record review, it was confirmed that the facility failed to directly supervise staff until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable. Findings include:

In review of the facility's policy and procedures for transfers and an incident report from 09/11/22, it was determined that the staff was not following policy and had not completed training. The staff member transferred a 2-person transfer alone. On 09/27/22, Compliance Specialist (CS) requested the staff member's training records however, this information was not provided.

In separate interviews with Staff #1-2 on 09/27/22, they stated that the incident did occur. A new staff member was told not to do a transfer alone as it was their 1st and 2nd day of training, and they did not follow the policy and procedures, which resulted in the resident and staff member falling. This staff member is no longer working at the facility.

Plan of correction:   Staff member quit and is no longer working at the facility. Reminders to staff regarding safe transfers. ISP to remind staff about transfers and supervised training for new staff.