The findings of the re-licensure survey conducted 04/04/22 through 04/06/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 04/06/22, conducted 08/30/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 04/06/22, conducted 12/15/22, are documented in this report.  It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

The kitchen was toured on 04/04/22 and 04/05/22 with Staff 5 (Dietary Supervisor). The following was observed to be in need of cleaning or repair:

* The stove and oven were in need of cleaning due to blackened and dried food debris;

* All observed cutting boards had deep gouges which deemed them to be uncleanable;

* Brown matter was observed on the ceiling in the food preparation area;

* The wall located on the other side of the walk in freezer had holes and chipped paint throughout;

* In the walk in refrigerator, the linoleum flooring had approximately one half of an inch gouges that were around a foot in length which deemed it to be uncleanable;

* The door going into the walk in refrigerator had built up debris and chipped paint on it;

* The wall behind and to the right of the three sink area was in need of cleaning and repair;

* There was dark orange debris located around the grease trap located on the floor at the right of the three sink area; and

* The black paint on the walls in the warewashing area was chipped throughout which deemed the walls to be uncleanable.

The memory care kitchenettes were toured on 04/04/22. The following was observed to be in need of cleaning or repair:

* The cabinets in both kitchenettes were gouged and scratched;

* The interior of the cabinets were missing laminate and were not cleanable surfaces;

* The cabinet interiors were dirty with food debris, spills and splatters; and

* Each hood range was scratched and missing paint.

The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (MCC Administrator) on 04/05/22. She acknowledged the findings.

1.On 4/5/22 deep cleaning was started in the kitchen.  The following items outlined in the SOD have been resolved or will be by 6/5/2022

oStove and oven cleaned

oCutting boards replaced

oCeiling in kitchen cleaned

oWall located on side of walk-in freezer was repaired

oLinoleum in walk in refrigerator repaired

oDoor to walk-in refrigerator repaired

oWall behind and to the right of 3 sink area cleaned and repaired

oOutside of grease trap cleaned

oWare-washing area painted

2.Dining Services Director and all dietary staff will be retrained on Powell Valley's kitchen cleanliness schedule.

3.Dining Services Director, Administrator and Executive Director will review kitchen overview weekly in their one-on-one meeting. TELS work orders will be submitted as needed.

4.Administrator, Executive Director and Dining Services Director are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the RN when necessary, for 1 of 3 sampled residents (#2), who experienced a change of condition. Resident 2 experienced a fall which resulted in a dislocation of the left hip. The resident continued to experience uncontrolled pain for several days before being sent to the emergency room. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 01/2011 with diagnoses including dementia.

The resident's progress notes, incident reports, temporary service plans (TSPs) and 02/2022 and 03/2022 MARs were reviewed and revealed the following:

* A 02/28/22 Fall Incident and Investigation form indicated the resident experienced an unwitnessed fall on the same date;

* A 02/28/22 a TSP instructed staff to monitor the resident for pain and discomfort;

* Between 02/28/22 and 03/04/22, the resident was noted to call out for help several times daily and to express pain with facial grimacing;

*Between 02/16/22 and 02/27/22 one dose of PRN pain medication was administered to the resident. The residents usage of PRN pain medication increased after the fall on 02/28/22 and for the four following days;

* 03/04/22 "... PT came to visit resident and noticed a significant length difference between legs ...[technician] said it looked like [s/he] dislocated it."; and

* 03/04/22 The resident was seen at the emergency department where the left hip dislocation was confirmed.

The facility failed to evaluate and refer the resident's condition to the RN for assessment. As a result, the resident continued to experience uncontrolled pain.

The need to ensure Resident 2's change of condition was evaluated and referred to the RN was discussed with Staff 1 (MCC Administrator) and Staff 2 (RN) on 04/06/22. They acknowledged the findings.

1.Resident #2 record was reviewed and will be updated to include recent change of condition that is now resolved.

Administrator, Licensed Nurse, or designee to review all remaining records to identify any changes of conditions and record updates as needed.

2.Health Services staff will be retrained on change of condition policy and CBC change of condition information training.

All staff will be in-serviced on change of condition, shift to shift communication guidelines and reporting guidelines.

3.Administrator, Health Services staff, or designee will review 24-hour report and incident reports daily at stand up to identify change of condition.  Weekly review of temporary service plans, wounds and chart notes will occur at weekly health services meetings to identify any residents with change of condition.  RN then follow up on these changes.

4.Administrator, RN, or designee are responsible to see that the corrections are completed and monitored.

Based on interview and record review, It was determined the facility failed to ensure an RN assessment was completed for 1 of  2 sampled residents (# 2), who experienced a significant change of condition. Findings include but are not limited to:

Resident 2 was admitted to the MCC in 02/2022. The resident experienced a partial left hip replacement in 01/2022 and was hospitalized on 03/04/22 after a dislocation  of the left hip. Progress notes, and interim service plans were reviewed and revealed the following:

Upon re-admission to the facility the resident continued to express pain and showed difficulty in motility.

The hip dislocation, pain and changes in motility constituted a significant change in condition for which an RN assessment was required.

There was no documented evidence the facility RN completed a significant change of condition assessment for the conditions which included documented findings and resident status.

The requirement to ensure an RN assessment was completed for residents who experienced significant changes of condition was discussed with Staff 1 (MCC Administrator) and Staff 2 (RN) on 04/06/22. They acknowledged the findings.

1. Resident #2 RN assessment was completed on 2/1/2022. Assessment was updated on 3/6/2022 to ensure changes of condition were documented.

2. Administrator, RCC and LN will complete audit of resident files to go over any change of condition that RN will need to complete. RN reviewed and signed Nile Living Health services change of condition and monitoring training form. All staff have reviewed and signed off on Nile Living Health services changed of condition and monitoring training form.

3. Administrator, RCC, LN and RN will review shift report, temporary service plans incident reports, skin reports at stand-up meeting daily, and will attend clinical meeting weekly to identify any residents with change of condition and monitoring as needed.

4.Administrator, RN or Designee are responsible to see that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 04/06/22 and identified the following:

Staff 8 (CG) hired on 12/8/20, and Staff 9 (CG) hired 02/02/22 lacked documentation of demonstrated competency in First Aid/abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (MCC Administrator) and Staff 14 (Staffing Development Coordinator) on 04/06/22. They acknowledged the findings.

1.During survey it was discovered that staff #8 and #9 lacked competency training, abdominal thrust and first aid training.  

These staff will receive training on above topics.

All training records will be reviewed to ensure these trainings are completed.

2.Staffing Coordinator or designee will implement a training checklist/report to ensure all trainings are complete per regulations.

3.Monthly audits to be conducted by Staffing Coordinator or designee to ensure trainings are in compliance.  

4.Administrator, Staffing Coordinator or designee are responsible to see that the corrections are completed and monitored

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:

Fire drill records from 11/2021 through 04/2022 were reviewed on 04/05/22. The facility lacked documented evidence fire drills were conducted every other month and included the following required components:

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

On 04/06/22, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (MCC Administrator). She acknowledged the findings.

1.Past fire drill documentation lacked necessary documentation required per CBC state rule.

Fire drill will be conducted and recorded per guidelines.

2.Staff conducting fire drills will be retrained on Powell Valley fire drill and safety policies, and CBC fire and life safety preparedness. Administrator will work with new Maintenance Director to ensure he is trained on life and safety polices and documentation.

3.Fire Drill form will be updated to include the following:

oEscape route used

oEvacuation time period

oResident evacuation problems encountered

oNumbers of occupants evacuated

Maintenance Director and Administrator will review fire safety overview weekly in their community updates meeting.

4.Administrator, Maintenance Director or designee are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to document all required components of fire drills. This is a repeat citation. Findings include, but are not limited to:

On 8/30/22, fire drill records were reviewed for 07/15/22 through 08/18/22. The facility lacked documented evidence fire drills included the following required components:

* The escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

On 08/30/22, the need to ensure all required components of fire drills were documented was discussed with Staff 1 (MCC Administrator) and Staff 14 (Plant Operations Director). They acknowledged the findings.

1.Past fire drill forms lacked necessary documentation required per CBC state rules. All future drills will include necessary documentation.

2.Maintenance Director was retrained on CBC guidelines.  Form will be updated to include the following missing information:

* Escape route used

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills

* Evacuation time period needed

* Number of occupants evacuated

* Evidence alternate routes were used during fire drills

3. Administrator and Maintenance Director will review fire drills monthly to ensure we are in compliance with CBC guidelines.

4. Administrator, Maintenance Director or designee are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Fire and life safety records from 11/2021 through 04/2022 were reviewed on 04/05/22. The facility lacked documentation of the following required elements:

* Evidence alternate routes were used during fire drills;

* Staff interviewed knew the designated point of safety; and

* Evidence residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (MCC Administrator) on 04/06/22. She acknowledged the findings.

1.During the survey it was discovered that documentation for annual and new resident fire safety training was not present.

All residents will be trained on fire safety per CBC guidelines.

2.Administrator will work with new Maintenance Director to ensure he is trained on life and safety polices and documentation.

3.Administrator and Maintenance Director will review fire safety overview weekly in their community update meetings.

4.Administrator, Maintenance Director or designee are responsible to see that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:

Refer to C240, C372, C420 and C422.

Refer to C240, C372, C420 and C422 for plan of correction details.

Based on interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C420.

Refer to tag C420 for plan of correction details.  

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (# 9) completed pre-service dementia care training, 3 of 3 newly hired staff failed to completed all required training and demonstration of competency (#s 8, 9 and 12) and 3 of 3 sampled long term direct care staff (#s 5, 7 and 13) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records were reviewed with Staff 14 (Staffing Development Coordinator) and Staff 1 (MCC Administrator) on 04/06/22. The following deficiencies were identified:

a. Staff 9 Care Partner (CP), was hired 02/02/22. There was no documented evidence Staff 9, had completed the 6 hour pre-service dementia care training.

There was no documented evidence that Staff 8, Staff 9 and Staff 13 had completed the required training in:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Changes of condition and changes that require reporting; and

* General food safety, serving and sanitation;

b. Staff 7 (CG) was hired 04/30/2013, Staff 5 (MT) was hired 03/14/2016 and Staff 13 was hired 02/15/2015. For the annual period of their respected hire dates, there were no documented hours of the required 16 hours of in-service training on topics related to dementia and provision of care.

The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties and pre-service training prior to working independently, that newly hired staff demonstrated and documented required 30 day competencies and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1 on 04/06/22. She acknowledged the findings.

Refer to C372 for plan of correction details.  

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are limited to:

Refer to C270 and C280.   

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 1 of 3 sampled residents (# 2), whose activity plans were reviewed. Findings include, but are not limited to:

Residents 2 was transferred to the MCC from the assisted living community in 01/2022. The resident's activity evaluation and service plan was reviewed on 04/06/22 and revealed the following:

There was no evidence an updated activity evaluation had been completed and the service plan individualized to reflect the following required components:

*Residents' current preferences;

*Current abilities and skills;

*Emotional/social needs and patterns;

*Physical abilities and limitations;

*Adaptations necessary for the resident to participate; and

*Identification of activities for behavioral  interventions.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with individualized activities.

On 04/06/22 the need to evaluate and develop individualized activity plans including all required components for Resident 2 was discussed with Staff 1 (MCC Administrator) who acknowledged the findings.