Print Inspection: UOMW

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 11/23/2022.  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 and observation it was confirmed that the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. Findings include:  

During separate interviews on 11/23/2022 with Staff #2, #5, #6 and #7 (S2, S5, S6, and S7) all stated that the lunch meal service should start delivering food at 12:00pm. S6 stated that breakfast service took 3 hours to deliver. Compliance Specialist (CS) walked into the kitchen and S7 stated the following,   

-That as of 12:20pm there hasn't been any food taken out due to staffing issues and that it would still be another 30 minutes before any food is sent out.  

-The last cart of deliveries was pushed out at 1:45pm.

-The kitchen has been hectic the whole week and normally the kitchen staff label and date the food but due to the time constraints they haven ' t been able to accomplish the task.  

-The food delivery had come in a couple days before, but the kitchen staff have not had the time to put any of the order away.   

Resident #5 (R5) stated portions of food are small and cold. R5 stated that one day for breakfast the kitchen served rice and toast.   

During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed:  

-Meal service to be 2 hours late with the last meal being delivered at 2:00pm.

-Multiple boxes stacked up on prep station.  

-Boxes of food in the refrigerator, freezer and dry storage on the floor blocking the pathway.

-Multiple food in the refrigerator to be not labeled or dated with expiration dates being unknown.

-Molded cheese uncovered in the refrigerator.  

-Food container bins uncovered.  

-A bag of raw chicken sitting out on the counter.   

On 11/29/2022, these findings were reviewed and acknowledged by Staff #1 (S1).  

Plan of Correction: S1 stated the order has been put away and the kitchen will audit the fridge and get all the food out that is out of date or not labeled. S1 said training to staff would occur once CS left for their understanding on how to properly label and date food. The facility is trying to fill the gap with other staff members (Dining manager and other cooks that do not work 40hrs to serve) for meal service to provide faster times for meals. S1 stated that the facility started this on 11/30/2022.

Based on interview and observation it was confirmed the facility failed to provide or arrange for transportation for medical and social purposes. Findings include:   

During separate interviews on 12/6/2022, Staff #1 (S1) and Resident #5 (R5) are quoted saying the following:  

-The facility is currently without a bus driver. One was hired but didn't pass their safety exam.

-The bus was in the shop due to vandalism.

-The facility closed all transportation and group activities due to a Gastrointestinal Infection (GI) outbreak for two weeks.

-The bus is not on a regular schedule and do not go out every week.  

-The bus rarely moves.   

During an unannounced site visit on 12/6/2022, Compliance Specialist (CS) observed the bus parked and not being used.   

On 12/6/2022, these findings were reviewed with and acknowledged by S1.  

Plan of Correction: S1 stated that the facility will work on keeping vandals from stealing gas, putting a policy in place to ban cutting bus gas lines from their bus, and work on keeping gastro virus issues out of the community.

Based on interview and observation it was confirmed that the facility failure to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents. Findings include:   

During an onsite interview on 11/23/2022, Staff #2-3 (S2 and S3) stated that they were sharing one Med Techs duties for the day. Staff #5-7 (S5, S6 and S7) stated that the meals are being delivered late due to shortage of staff. S7 stated that they were short in the kitchen and with servers. S6 stated that because of needing to deliver all meals to the residents ' rooms when they are short servers there are days when at least one Caregiver (CG) must help serve meals.   

During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed   

"The lunch meal service to take over 2 hours to deliver.  

"Resident #3 (R3) push their call light for assistance, it took staff 17 minutes to respond.  

"Garbage cans in common area laundry rooms overflowing.  

"Multiple boxes scattered the hallways.  

A review of the resident council notes dated 10/12/2022 states complaints about how the call light response times take too long when residents need help.   

On 11/29/2022, these findings were reviewed and acknowledged by S1.  

Plan of Correction: S1 stated the facility will increase training for call lights, they are currently hiring, and are trying to fill the gap with other staff members (Dining manager and other cooks that do not work 40hrs to serve) for meal service to provide faster times for meals. S1 stated that the facility started this on 11/30/2022.

Based on interview, observation, and 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 11/23/2022, Witness #1 (W1) stated   

-Resident #3 (R3) had not received their shower in 4 days.  

-No staff members follow through to ensure all services are completed.

-Staffing has been so bad.  

-Sometimes staff takes a long time to respond to call lights.

During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed 4 Caregivers (CG) and 2 Med Tech (MT) working during the day shift.  

A review of the facility posted staffing plan and the facility's Acuity Based Staffing Tool (ABST) indicated that the facility ABST tool does not have all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide care. The facility's ABST had multiple ADLs grouped together in subcategories. For example, there is a section for dressing and grooming that has personal hygiene, assistance with communication, hearing devices, vision and speech categorized together. The posted staffing plan and the ABST stated that on day shift the facility needs 1 MT and 3CG are required.  

On 11/29/2022, these findings were reviewed and acknowledged by S1.

Based on interview and observation it was confirmed that the facility failed to keep all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) 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 11/23/2022, Staff #1, #3, #5 and #6 (S1, S3, S5 and S6) all stated that the facility used to use pagers to inform staff of residents call lights. S3 stated that the pagers haven ' t been working for a while which is why S1 bought them walkie talkies to communicate with the receptionist for which residents need assistance. S6 stated that they cannot hear well on the walkie talkies and some Caregivers (CG) don ' t use their walkie talkies. S1 stated that it is company policy to have pagers for call lights. S6 stated that the garbage bins in the laundry rooms have been full all day.  

During an unannounced site visit on 11/23/2022, Compliance Specialist (CS) observed:  

-S6's walkie talkie was not on, making it unable for S6 to hear receptionist when residents called for assistance.

-The front desk call light panel to have all residents' pendants to state they were running low battery.

-Every laundry room of the facility to have the garbage's full and overflowing.

-In multiple hallways there to be boxes stacked up.    

On 11/29/2022, these findings were reviewed and acknowledged by S1.  

Plan of Correction: S1 will be ordering more walkie talkies and will have an in-service training for reminding staff to carry their pagers/ walkie talkies. S1 stated that they are starting to conduct this change on 11/30/2022. S1 stated on 11/29/2022 that the trash has been taken out and the facility will ensure that they stay empty. S1 stated that the boxes in the facility have been moved to their appropriate places and are out of the hallways.