Print Inspection: 2QS5

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 02/08/2023.  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 02/08/2023, Staff #1-2 (S1 and S2) stated that there have been concerns revolving the quality and palatability of the food. A cooperate food consultant is onsite and will be providing additional consulting to help elevate the kitchens performance. S2 stated that the kitchen has undergoing many in-service trainings, there will be one for the proper handwashing techniques. Resident #1-3 (R1, R2, R3) all state concerns around the meals being nutritious, palatable, or available. The following was stated:   

"The beef in the beef tips today was tuff and hard to chew.  

"The facility has gone days without butters, creamers, and sugars on the tables.  

"There was a period where there was no orange juice for weeks.  

"Many times, we do not get what we have ordered

"Multiple meals have been skipped during a covid lockdown there were many days and meals that were not provided unless I called staff and told them I did not receive a meal.  

"The kitchen runs out of food.

"Poached eggs/ breakfast has been a huge issue for months.   

During an unannounced site visit on 02/08/2023, Compliance Specialist (CS) observed,   

"The kitchen starting to run out of enough pie portions and cut the portions to slivers to ensure everyone got a piece.  

"Many residents taking the beef out of their dish and setting it to the side because they couldn't chew the meat.   

A review of resident council notes from January-February 2023, pictures provided by R2, and an in-service conducted on 2/7/2023 for the kitchens understanding of labeling products and first in, first out.  

On 02/08/2023, these findings were reviewed and acknowledged by S1.  

Plan of Correction: The facility promoted a new dining coordinator and has a cooperate consultant working with the kitchen to ensure better performance and quality of food.

Based on interview and record review it was confirmed that the facility ' s service plans are not getting updated quarterly. Findings include:  

During separate interviews on 02/08/2023, Staff #1 (S1) stated there are several residents service plans that have not been updated quarterly. There is a team of staff from a sister facility currently working on getting the service plans updated.  

A review of the Service Plan binders indicates they have multiple service plans not updated quarterly.   

On 02/08/2023, these findings were reviewed and acknowledged by S1.  

Plan of Correction: The facility is currently working on getting all residents service plans updated. S1 states they will ensure quarterly updates moving forward.

Based on interview and observation it was confirmed the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include:   

During separate interviews on 02/08/2023, Resident #1-3 (R1, R2 and R3) stated that the dining room has been dirty for some time, and no one cleans it. R2 stated that housekeeping has been short for weeks and their room had not been cleaned for weeks due to not having enough staff to provide services. R2 stated that they have had to vacuum their own room, wash their linens, and make their own bed. Staff #3 (S3) stated there the facility was short staffed because one caregiver went home. On shift that day was 2 Med Techs (MT) and 2 Caregivers (CG).   

During an unannounced site visit on 02/08/2023, Compliance Specialist (CS) observed 2 MT and 2 CG working.   

No documents were provided for site visit.   

On 02/08/2023, these findings were reviewed and acknowledged by S1.  

Plan of Correction: No plan was provided by S1.

Based on interview and record review it was confirmed the facility failed to provide records to the Department upon request. Findings include:

Compliance Specialist (CS) requested documentation from the facility for an investigation conducted on 2/8/2023 and did not receive them. Reviewed email request dated 2/10/2023 following up on the request for documentation still needed to Staff #1 (S1). The facility did not provide the documentation requested. On 02/16/2023 CS informed S1 about documentation not being provided upon request.

Plan Of Correction: Per S1 email on 02/17/2023 in the future, they will be responding to requests for documentation within 48 hours.

Based on interview and observation it was confirmed the facility failed to keep all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. Findings include:   

During separate interviews on 02/08/2023, Staff #1 (S1) stated no action has been taken to repair main fireplace other than putting the out of order sign up. S1 stated that the facility is only budgeted for 10 hours of housekeeping per day. Resident #2 (R2) stated that housekeeping has been short for weeks and their room had not been cleaned for weeks due to not having enough staff to provide services. R2 stated that they have had to vacuum their own room, wash their linens, and make their own bed.  

During an unannounced site visit on 02/08/2023, Compliance Specialist (CS) observed,   

"The main fireplace to be not working with an out of order sign on it.

"The dining room tables and chairs to be sticky and dusty.

"Buckets of rock salt around the facility exit doors.  

On 02/08/2023, these findings were reviewed and acknowledged by S1.  

Plan of Correction: On 2/9/2023 the facility's maintenance director placed a call out to Albany Stove to have the fireplace repaired.