Print Inspection: 7GHY

The findings of the kitchen inspection and facility site visit, conducted 12/12/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054 for Residential Care and Assisted Living Facilities for Resident Services, Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 12/12/23, conducted 02/29/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff treated residents with dignity and respect during dining for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 moved to facility on 11/3/2022 with diagnoses that included severe dementia with behavioral disturbance.

On 12/12/23 at 11:45 pm, lunch service was observed in Cedarwood unit. Staff 4 (CG), Staff 5 (CG), and Staff 6 (MA) were observed assisting with meal service. Resident 1 was observed to be served their tray of food. The resident then set their plate of food down and returned to the counter and reached across the counter and grabbed a plate that was dished up for another resident. Staff 4 quickly reached for the plate and tried to retrieve it from the resident's hands. Staff 4 and Resident 1 struggled with the plate of food. Staff 5 was telling Resident 1 that was not his/her plate. After a few moments of the resident and staff member tugging at the plate back and forth, the staff member let the resident have the plate. Resident 1 walked away from the service area with the additional plate of food. A few moments later Resident 1 returned to the dining room/meal service area and quickly reached for another resident's dished up plate of food. Staff 4 and Staff 5 both with raised voices tried to deter the resident from taking the additional plate of food stating, "That's not yours, you already have yours." Staff 4 lunged for the plate, trying to reach it before the resident grabbed it but was not able to.  Resident 1 left the dining area and went to his/her room with the additional plate of food. A few moments later the resident came out of his/her room to the dining space where residents were seated and having their meal. Resident 1 again grabbed a pre-plated plate of food from the counter and walked away from the area where s/he sat down with the plate.

Staff 4 and Staff 5 were verbalizing frustration about the resident taking off with another resident's food. They had a conversation about how another resident now didn't have a tray for lunch. Resident 1 again came back to the dining area and made his/her way to where residents were seated at their tables. The resident was about to reach for another resident's plate when the seated resident stated, "Go," and Resident 1 turned around. Staff 6 had made his/her way to the table and encountered the resident where s/he tried to redirect the resident to their room. Resident 1 was visibly agitated and frustrated, pushed Staff 6, and attempted to bat/strike at his/her arms. Staff 6 guided the resident away from the dining tables. Staff 4 and 5 were visibly frustrated.

This encounter was not a dignified dining experience for Resident 1 and other residents in the dining room.

At 1:45 pm Staff 3 (RCC) and Staff 1 (ED) were interviewed. They acknowledged Resident 1 was not treated with dignity or respect during dining.

1.Staff involved were coached on proper serving with dignity and resident rights.

2.All staff training will be provided on resident rights and dining with dignity. Managers will do regular walk throughs during meal times.

3.Daily walk throughs and monitoring during meals.

The management team including the Executive Chef, RCC, and Executive Director

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observation of the main kitchen and unit kitchenettes on 12/12/22 from 10:30am to 3:30pm revealed the following:

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following:

* Ice machine with visible black substance on the inside;

* Ceiling fire sprinklers;

* Hood vent above stove/grill;

* Metal piping hanging from ceiling above steam table;

* Metal rack shelving with dust accumulation;

* Reach in refrigerators in care units;

* Kitchenettes in units behind, between and under cabinets;

* Toasters in all unit kitchenettes with heavy crumb buildup; and

* Oven in kitchenettes.

b. The following areas were in need of repair:

* Multiple areas of kitchen floor with damage, cracks, gaps and other integrity issues rendering the floor not a smooth cleanable surface;

* Large area in ceiling over the reach in freezers was open with visible water damage from a broken pipe. Parts of the ceiling had visible black matter;

* Area in the ceiling in dry storage room had visible prior water damage that had not been repaired leaving bubbles and cracks in ceiling;

* Temperature gauge dials of dish machine were cracked and condensation accumulation made reading of the dials difficult;

*Vent in ceiling was not completely flush with ceiling, leaving a large crack where potential pests could enter the kitchen;

* Metal wire racks with visible corrosion and/or rust build up;

* Microwave in kitchen with visible rust colored areas where protective, smooth wipeable surface of internal oven was gone;

* Screen door to back with areas where screen was ripped and torn near bottom of door allowing possible pest entry access when door was open. Surveyor observed door left open during survey process;

* Reach in freezer in units with heaving frost/ice build up; and

* Two reach in refrigerators were not holding correct temperature.

c. Dining room tableware was preset, and utensils were not covered to prevent potential contamination.

d. Caregiving staff did not have an aprons during meal service to protect from potential contamination of clothes during care provisions.

e. Multiple bulk bins of food had scoops stored inside the food product posing potential contamination of food product.

f. Handwashing sink did not contain sign for staff to wash hands as directed in rule.  

g. Two reach-in refrigerators located on units had temperatures above the required 41 degrees Fahrenheit. Cedarwood fridge thermometer was at 60 degrees. Milk from that fridge was found at 52 degrees. Temperature logs were reviewed and documented several times the temperature was above the required 41 degrees. There were also several missing temperatures not recorded. The reach in refrigerator in Birchwood unit was found at 50 degrees. Milk from that fridge temperature was at 52 degrees. Facility staff were notified to remove/discard items in those fridges as it was unclear how long those items were above 41 degrees and could be unsafe.

Staff 2 (Dietary Manager) toured kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor and Staff 1 (Executive Director) reviewed areas of concern with kitchen and unit kitchenettes. Staff 1 acknowledged the above areas needed to be cleaned and repaired and practices that needed addressed.

1.The noted issues with the ice machine, ceiling fire sprinklers, hood vent, metal piping, metal rack, reach in refrigerators, kitchenettes, cabinettes, toasters and ovens will all be deep cleaned. The cracked and uncleanable floor surfaces will be fixed (in process of getting bids for repair), The hole in the ceiling has been fixed, the ceiling in the dry storage is in process of being repaired, The temperature gage on the dishwasher has been repaired, vent in the kitchen is being fixed, the frost build up in the freezers in the pods have been fixed, aprons were ordered, and the seals replaced in the pod refrigerators to hold temp. Microwave will be replaced, silverware will not be pre-set for meals, food scoops removed from bulk bi.ns, sign posted above sink for handwashing procedure

2.Cleaning schedule created for Pod Kitchenettes, Main kitchen has an updated cleaning schedule, Regular monitoring and auditing monthly on all kitchen processes, including: temp logs, cleanliness, areas needing repair.

3.Executive Chef will monitor main kitchen cleanliness and address issues 5 days per week. The pod kitchenettes will be monitored daily. Kitchen books with logs/etc. will be reviewed weekly.

Executive Chef, RCC, and ED.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs, provided clear direction for staff, and were consistently implemented by staff for 1 of 1 sampled resident (#1), whose service plan was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2022 with diagnoses including dementia with behavioral disturbances.

Observations of the resident, interviews with staff, and review of the resident's 12/04/23 service plan were completed.

On 12/12/23 at 11:45 am, Resident 1 was observed to exhibit behaviors of taking other residents' food/plates during mealtime. The staff were observed to attempt to grab away the plates the resident reached for. At one time, Staff 4 and the resident were noted to tug back and forth on a plate of food until the staff member eventually relinquished the plate to the resident. The interactions were observed to escalate and frustrate the resident and the staff. The resident was observed to continually pick up a plate of food that was not designated for him/her throughout the meal service. Visual frustration by the staff assisting and the resident was observed. During attempts of redirection, Resident 1 escalated to the point of shoving and attempting to strike Staff 6 while Staff 6 was trying to lead the resident back to his/her room to prevent the resident from grabbing at another resident's plate.

On 12/12/23 at approximately 12:45 pm, Staff 4 (CG) was interviewed and confirmed the observed behavior by Resident 1 at the recent meal was a common daily behavior exhibited by the resident. Staff 4 stated, "It happens every day at every meal." Staff 4 acknowledged being frustrated with having to try to manage Resident 1's behavior while serving other residents. S/he stated, "It just feels impossible. We just try and get the food out to the other resident's as fast as possible." Staff 4 acknowledged they did not feel the current interventions were effective and that the other residents' meal experience was negatively affected by Resident 1's mealtime behavior.

The resident's service plan was reviewed and was not reflective, lacked resident-specific direction for staff, and/or was not consistently implemented by staff relating to meals and behaviors. The service plan did not address behaviors around attempting to take food from other residents or from staff during dining service. There were no identified interventions to help guide staff on how to intervene or redirect the mealtime behavior. The service plan indicated the resident could become "grumpy" with staff, with verbal bossiness and physical behaviors around completing ADL care tasks. Some goals indicated the resident was "easily directed with communication asking if [s/he] needs to use the restroom or offering to color or offering snacks." It also suggested to "change the subject by asking about [his/her] family history book or asking about [his/her] son." The service plan also indicated s/he was easily redirected with ice cream. During the meal observation on 12/12/23 none of the interventions listed in the service plan were attempted with the resident.

At 1:45 pm the above observations were reviewed with Staff 1 (ED) and Staff 3 (RCC). Staff 3 indicated she was unaware of any issues the resident had around mealtimes and taking or attempting to take other residents' plates. Staff 3 acknowledged these items were not addressed in the service plan and that interventions were needed to prevent behavioral escalation by Resident 1.

The need to ensure Resident 1's service plan was reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) at 2:00 pm. They acknowledged the findings.

1.Resident's service plan has been updated to reflect a new set of interventions, staff trained to understand the interventions

and ensure that they are using them.

2.All staff training to ensure that staff understand dining with dignity. Caregiver Service Plan Review form will be used regularly (handed out prior to updating each residents service plan in order to ensure accuracy.

3.Daily walk throughs to monitor, service plan reviews initially, 30 days, quarterly and as needed.

The RCC and Executive Director will be responsible

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C200, C240 and C260.

Refer to C200, C240, and C260