The findings of the change of ownership 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 and Home and Community Based Services Regulations OARs 411 Division 004.

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 re-visit to the re-licensure survey of 04/06/22, conducted 08/24/22, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

MCC:Memory 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 re-visit to the re-licensure survey on 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

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 need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (ED) and Staff 5 on 04/05/22. They 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

oWarewashing area painted

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

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

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

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

On 08/24/22 at 9:20 am, the facility kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:

* Multiple ceiling vents;

* Floor tile grout lines, perimeter, underneath appliances, open shelving and storage racks;

* Door and jamb leading to private dining room;

* Rolling serving carts;

* Pipes underneath the two-compartment sink;

* Ceiling surrounding a vent in food prep area;

* Wall behind the three-compartment sink;

* Rust colored water surrounding the metal grease trap;

* Ceiling and gas pipes in the three-compartment sink area; and

* Floor in walk-in freezer.

b. The following areas needed repair:

* An approximate 5X5 inch hole in wall near the thermostat;

* Gouged and scraped door leading to private dining room;

* An approximate 12X12 inch hole in the wall behind a green storage rack (near the walk-in refrigerator);

* Grout missing from between floor tiles in dish machine area;

* Peeling paint and caulking behind dish machine; and

* Discolored caulking coming apart from grease trap (located underneath three-compartment sink).

The areas that required cleaning and repair were observed and discussed with Staff 1 (Executive Director) and Staff 5 (Dietary Supervisor) on 08/24/22. The findings were acknowledged.

1.The following items outlined in the SOD have been resolved, or will be by 10/8/22:

Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:

* Multiple ceiling vents

* Floor tile grout lines, perimeter, underneath appliances, open shelving and storage    racks

* Door and jamb leading to private dining room

* Rolling serving carts

* Pipes underneath the two-compartment sink

* Ceiling surrounding a vent in food prep area

* Wall behind the three-compartment sink

* Rust colored water surrounding the metal grease trap

* Ceiling and gas pipes in the three-compartment sink area

* Floor in walk-in freezer.

The following areas needed repair:

* An approximate 5X5 inch hole in wall near the thermostat

* Gouged and scraped door leading to private dining room

* An approximate 12X12 inch hole in the wall behind a green storage rack (near the walk-in refrigerator)

* Grout missing from between floor tiles in dish machine area

* Peeling paint and caulking behind dish machine

* Discolored caulking coming apart from grease trap (located underneath three-compartment sink)

2.Dining Services Director and dietary staff will be retrained on kitchen sanitation.

3.Dining Services Director and Executive Director will do weekly walkthroughs of the kitchen.  Dining Services Director or Executive Director will keep Maintenance Director informed of any items in need of repair and submit work orders through TELS as needed.

4. Executive Director and Dining Services Director 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 ensure service plans were reflective of residents' current needs and status and failed to provide clear direction to staff for 2 of 6 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2021 with diagnoses including mild cognitive impairment.

Observations of the resident, interviews with the resident and staff, review of the service plan updated 02/02/22, Temporary service plans and 01/05/22 thru 04/04/22 progress notes, showed the plan was not reflective and did not provide clear direction to staff in the following areas:

* Mobility including use of a walker and wheelchair;

* Use of compression stocking status;

* Behaviors including refusal of care;

* Skin including edema and open wound status on legs; and

* Use of side rails.

The need to ensure resident service plans were reflective and provided clear directions to staff was discussed with Staff  1 (ED) and Staff 2 (RN) on 04/05/22. Staff acknowledged the findings.

2. Resident 1 was admitted in 06/2018 with diagnoses including dementia.

The 01/26/22 service plan was reviewed, the 03/2022 and 04/01/22 through 04/04/22 MARs and TARs were reviewed and staff were interviewed. The service plan was not reflective of the resident's current status or lacked clear caregiving instruction in the following areas:

* Weight loss status;

* Behavior interventions;

* Positive ways to approach the resident to negate potential behaviors; and

* Preference of the apartment door to be left open.

The need to ensure resident's service plans were reflective of their current status and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They acknowledged the findings.

1.Resident #4 service plan will be updated to ensure the following items are included:

oMobility including use of walker and wheelchair

oBehaviors including refusal of care

oSkin issues including edema and open would status on legs

oUse of side rails

Resident #1 service pan will be updated to ensure the following items are included:

oWeight loss status

oBehavior interventions

oPositive ways to approach resident to negate potential behaviors

oPreference of apartment door to be left open

These plans will also be updated to include clear directions for staff.

2.Executive Director, Licensed Nurse, Resident Service Coordinator or designee will review all remaining service plans to ensure that all service plans are personalized and include each resident specific care needs.

Health Services staff will be retrained on service planning and temporary service plan protocols.  

3.Resident Care Coordinator or designee will update service plan quarterly and at change of condition.  Service plans will be reviewed and updated as needed at weekly Health Services meeting.

4.Executive Director, Resident Care Coordinator 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 ensure service plans were reflective of the residents status for 1 of 4 sampled residents (# 1) whose service plans were reviewed.  This is a repeat citation. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2018 with diagnoses including dementia and a history of alcohol dependence.  

The current service plan dated 07/25/22 noted the resident had "behavioral and mood problems...exhibited by refusing care...becoming verbally aggressive if re-approached..."

During interviews on 08/24/22 with Staff 4 (Health Services Care Coordinator), Staff 10 (CG), Staff 18 (CG) and Staff 19 (MT) the following was stated:

* The resident refused to let staff in his/her room at times;

* Had started to refuse housekeeping services;

* The resident would hit, grab and throw items towards staff and the television at times;

* Was physically aggressive towards staff during care;

* Yelled at staff and was resistant to care, combative at times; and

* Required two staff people to assist with care related to behaviors.

On 08/24/22 at 11:40 am, Resident 1 was observed to slam the apartment door and refuse care from staff during meal delivery. At 11:56 am, Resident 1 accepted meal delivery from a different staff member.

Resident 1's service plan was not reflective of his/her behaviors including physical aggression.

Resident 1's service plan was reviewed and discussed with Staff 1 (Executive Director) and Staff 4 (Health Services Coordinator) on 08/24/22 at 4:06 pm. Staff acknowledged the findings.  

1.Resident #1's service plan will be updated to accurately reflect his behaviors including physical aggression towards others.

2.Executive Director, RN, Resident Care Coordinator will review remaining service plans to ensure all plans are person centered and include behavioral care needs.

3.Resident Care Coordinator or designee will update service plan quarterly and at change of condition.  Service plans will be reviewed and updated as needed at weekly Health Services meeting.

4.Executive Director, Resident Care 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 ensure short term changes were monitored until resolution for 1 of 4 sampled residents (#3) who experienced short term changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 1996 with diagnoses including cerebral palsy.

Interview with staff during the survey indicated the resident required staff assistance with transfers and bowel and bladder management.

Progress notes dated 01/10/22 through 03/22/22 indicated the following:

* On 01/27/22 - on alert charting due to "returned from procedure ...upper endoscopy and ...a bravo 48 hr [hours] ...";

* 02/25/22 - "Resident is on alert for increase in medications.";

* 03/03/22 - staff documents " ...Phenobarbital [a medication to treat seizures] being tapered ..." the dose of the medication was decreased; and

* 03/16/22 - staff documented " ...resident is having pain in [his/her] right eye ..."

There was no documented evidence the changes of conditions were monitored through resolution.

On 04/05/22, Resident 3's progress notes were reviewed with Staff 1 (ED) and Staff 2 (RN). Staff acknowledged the findings.

1.Resident #3 record was reviewed and will be updated to include recent change of condition that is now resolved.

Executive Director, 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.Executive Director, 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.  Health Services Director then follow up on these changes.

4.Executive Director, Health Services 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 ensure short term changes of condition were monitored weekly until resolved for 1 of 4 sampled residents (# 1) who experienced changes of condition. This is a repeat citation.  Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2018 with diagnoses including dementia and a history of alcohol dependence.

Progress notes dated 07/01/22 identified that the resident was placed on alert charting for an increase in behaviors. "...[resident] was very agitated [during] incontinent care...scratched and bit..." the staff member. Resident 1 was noted with an increase in agitation and was aggressive and combative towards the staff when offering to provide care. On 07/05/22, the resident continued to be on alert charting for behaviors. On 08/16/22 progress noted continued behaviors including hitting, kicking and throwing objects toward staff.

On 08/24/22 at 11:40 am, Resident 1 was observed to slam the apartment door and refuse care from staff during meal delivery. At 11:56 am, Resident 1 accepted meal delivery from a different staff member.

During interviews with Staff 3 (LPN), Staff 4 (Health Services Care Coordinator) and Staff 1 (Executive Director) they stated the resident had become increasingly resistant to care including refusing housekeeping services. Staff stated the resident was physically and verbally aggressive towards staff during attempts to provide care. Staff 1 explained she was working with the physician, family and case manager to consider alternate placement for Resident 1.

Resident 1 experienced a change of condition that was identified on 07/01/22 related to an increase in behaviors. There was no documented evidence the short term change was monitored weekly through resolution.

Short term changes of condition with weekly progress noted through resolution was discussed with Staff 1 and Staff 4 on 08/24/22 at 4:06 pm. Staff acknowledged the findings.

1.Resident #1's record will be updated to include latest change of condition.  Resident's care team is still working together to find the best living situation for resident to ensure all his behavioral needs are met.

Executive Director, 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.

      3.Executive Director, Health Services staff or designee will review 24 hour report and incident   reports daily at stand up to identify change of condition.  RN will follow up on these changes as needed.

4.Executive Director, 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 delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 04/04/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Resident 4's MARs, reviewed from 03/01/22 through 04/04/22, revealed insulin had been given by Staff 4 (Resident Care Coordinator), Staff 8 (MA) and 12 (Staffing Development Coordinator) on multiple occasions.

Delegation records for Resident 4, were reviewed during the survey and revealed the following:

* There was no documented evidence Staff 8 was delegated for the insulin administration to Resident 4;

* Delegations for Staff 4 completed 12/15/21 and Staff 12 completed 11/29/21, lacked documentation of how frequently the unlicensed person should be supervised and re-evaluated,  including rationale for the frequency based on the competency of the caregiver; and

* Additionally, there was no documentation that Staff 2 (RN) re-evaluated Staff 4 and Staff 12 within 60 days of the initial delegation.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They acknowledged the findings. No further information was provided.

1.During survey it was discovered that there were unlicensed staff administering insulin without proper delegations including:

oNot delegated

oLack of documentation outlining frequency of redelegation and competency of staff

Delegation binder will be reviewed to ensure that all staff responsible for administering insulin are properly delegated.

2.Health Services team will be retrained on CBC delegation rules and Powell Valley delegation policy and procedures.

Calendar system will be put in place to capture all med techs and due dates of delegations.  Delegation form will be updated to include necessary documentation.

3.Delegation binder will be reviewed at weekly health services meeting to make sure all delegations are kept up to date.

4.Executive Director, Health Services 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 physician orders were carried out as prescribed for 2 of 5 sampled residents (#s 4 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted in 2/2021 with diagnoses which included edema.

Resident 5's physician orders, MARs and TARs were reviewed from 03/01/22 through 04/04/22, revealed the following orders were not followed:

a. Resident 5 had an order for compression stockings for edema. The stockings were to be put on every morning and taken off every evening. On all but three days the compression stockings were initialed as being off all day. In interview with Staff 13 (CG) on 04/05/22, Staff 13 stated the resident no longer used the compression stockings.

b. The resident had an order for weekly weights. There were no weights documented on the MAR between 03/01/22 and 04/04/22.

In interview with Staff 1 (ED) on 04/05/22, she stated weekly weights had not been documented by staff.

The need to ensure orders were followed was reviewed with Staff 1 and Staff 2 (RN) on 04/05/22. The findings were acknowledged.

2. Resident 4 had a physician's order, dated 03/18/22, to administer Docusate sodium 100 mg [laxative with softening activity] two times daily.

Resident 4's 03/01/22 through 04/04/22 MAR revealed the medication was not administered on multiple occasions.

On 04/05/22 at 9:09 am, Staff 7 (MA) stated the resident self-administered the medication.  

On 04/05/22 at 2:04 pm, Staff 2 (RN) stated the medication should be administered by staff.  

On 04/05/22, the physician orders and the MARs were reviewed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

1.Residents #4 and #5 MARs will be updated to reflect accuracy of physician orders.  Any orders that need to be discontinued will be done so.

Physician orders for all residents will be reviewed to ensure accuracy.

2.Health Services staff will be retrained on medication orders and accurate documentation.

3.Health Services Director or designee will review all new physician orders as they come in to the community to ensure they are clear orders and that all med techs understand and can follow orders as prescribed.

4.Executive Director, Health Services 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 signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 3 sampled residents (#8) whose clinical records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the facility in 08/2021 with diagnoses including frequent falls and cerebral palsy.

On 08/24/22 at 2:00 pm signed physician's orders were requested for medications and treatments listed on the 08/01/22-08/24/22 MAR. Staff 1 (Executive Director) provided a copy of a fax to the physician dated 08/04/22 requesting signed physician's orders for a 90-day medication review. She reported that they had not received a reply. She was unable to provide further documentation.

The need to ensure there was a signed physician order for all medications and treatments the facility was responsible to administer located in the resident's facility record was discussed with Staff 1 on 08/25/22. She acknowledged the findings.

1.Resident #8's records revelaed that there was not recent signed physician orders.  Health Services staff to obtain these orders.  

Executive Director, RN or designee to review all physician orders to ensure all are current with signatures.

2.Health Services staff will be retrained on the importance of having current signed physican orders on file.

3.RN or designee will review all new physician orders quarterly to ensure all documentation is complete.

4.Executive Director, RN or designee are responsible to monitor physician orders

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#1) with multiple treatment refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2018 with diagnoses including dementia. The resident's 03/01/22 through 04/04/22 MARs and TARs, and physician's orders were reviewed.

On 03/24/22, the physician signed the order to "Notify PCP every time resident refuses medications/treatments." The order also directed staff to "Apply ace wrap bandages to bilateral lower extremities daily for treatment of edema. To be applied in the am and removed at night." The resident refused to consent to staff donning the wraps on the following dates:

* 03/01/22;

* 03/13/22;

* 03/19/22;

* 03/25/22;

* 03/26/22;

* 03/27/22; and

* 03/28/22.

An interview with Staff 7 (MA) on 04/05/22 at 12:27 pm indicated the MAs used to contact the physician when Resident 1 refused the treatments but due to the resident refusing "all the time," she didn't think they contacted the physician any more.

The need to ensure the facility notifies the physician each time a resident refused to consent to an order was reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They acknowledged the findings.

1.Resident #1 PCP was not notified of medication refusals as directed on MAR.  PCP will be notified of all future medication refusals.  

All medication refusals will be audited and PCPs will be notified if required.

2.Health Services staff will be retrained on PCP notification for medication refusals.

Med Techs will notify PCP during their shift when a resident refuses a medication.

3.Executive Director, Health Services staff or designee will review EMAR for missed medications  daily at stand up.  Health Services staff will notify PCP of refusals.

4.Executive Director, Health Services 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 MARs were accurate for 3 of 5 sampled residents (#s 1, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 02/2021 with diagnoses including edema.

The resident's 04/01/22 through 04/04/22 MARs were reviewed during the survey and lacked resident specific instructions for the following:

* PRN morphine versus PRN Norco for pain.

On 04/05/22, the need for the facility to ensure MARs provided clear instruction to unlicensed staff was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

3. Resident 4's 03/01/22 through 04/04/22 MAR was reviewed during the survey and revealed the following PRN bowel care medications and PRN pain medications:

* Polyethylene 1 packet daily as needed for constipation;

* Acetaminophen 650 mg every 6 hours as needed for pain and fever;

* Tramadol 50 mg every 6 hours as needed for moderate pain.

The MAR did not provide the resident specific parameters including when to administer the bowel care medication and two as needed pain medications.

Resident specific parameters were discussed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. Staff acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2018 with diagnoses including dementia. The resident's 03/01/22 through 04/04/22 MARs and TARs were reviewed and the following was identified:

a. There were blanks on the MAR for the resident's 5:00 pm nutritional supplement and the meal intake monitoring at 6:00 pm on 03/06/22.

b. Resident 1 had an order to apply "ace wrap bandages" each morning at 7:00 am and to take them off each evening at 7:00 pm. The following dates had documentation at 7:00 pm that the resident did not have the wraps on:

* 03/02/22;

* 03/03/22;

* 03/08/22;

* 03/09/22;

* 03/14/22 through 03/16/22;

* 03/23/22;

* 03/24/22;

* 03/29/22 and

* 03/30/22.

The corresponding documentation for the above listed dates each morning at 7:00 am reported staff had put the wraps on the resident.

The following dates had documentation the resident refused the wraps at 7:00 am:

* 03/13/22; and

* 03/19/22.

The corresponding documentation for the above listed dates each evening at 7:00 pm reported staff had taken the wraps off.

An interview with Staff 1 (ED) and Staff 2 (RN) on 04/05/22 at approximately 4:00 pm, confirmed the resident was not able to don or doff the bilateral wraps independently and needed staff assistance.

The need to ensure resident's MARs and TARs were accurate relating to initialing all entries and having correct documentation of what occurred was discussed with Staff 1 and 2 on 04/05/22. They acknowledged the findings.

1.Residents #1, #4 and #5 will be reviewed for parameters and clear directions.  Clarifications will be added.

Health Services staff or designee to review all remaining resident MARs and add parameters and clarification to medications orders as appropriate.

2.Health Services staff will be retrained on MARs and CBC accurate MAR documentation. Med techs will notify licensed nurse if medication orders do not have parameters or clear directions.

3.Health Services Director or designee will review all new medication orders and will add parameters and clarifications as part of a three check system when new medications are delivered.

4.Executive Director, Health Services 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 ensure a supportive device with potentially restraining qualities was assessed including a thorough review by an RN, PT or OT prior to use and documentation of less restrictive alternatives prior to use for 2 of 2 sampled residents (#s 3 and 4) who used bilateral half-length side rails and seatbelt while in a wheelchair. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 1996.

During the acuity interview on 04/05/22, the resident was identified to use the seatbelt by choice and s/he was not able to release the seatbelt without staff assistance.

On 04/05/22 at 9:04 am, Staff 7 (MA) stated the resident chose to use the seatbelt.

On 04/05/22 at 3:37 pm, Resident 3 was observed to use seatbelt while in the power wheelchair.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use.

The lack of assessment for use of the seatbelt was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 2021.

On 04/05/22 at 9:33 am, Resident 4's bed was observed to have bilateral half-length side rails.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use.

The lack of assessment for use of the bilateral half-length side rails was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They acknowledged the findings.

1.Resident #3 and #4 records will be reviewed and accurate supportive device assessments will be completed.

2.Health Services Director or designee will review remaining residents to ensure all assistive devices being used have proper assessments and documentation.

Med Techs and Care Partners will notify supervisor if they notice a resident with a new supportive device.  

Health Services staff will be retrained on supportive devices.

3.Health Services Director or designee will assess residents anytime a supportive device is ordered prior to resident use.

4.Executive Director, Health Services 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 2 of 2 newly hired caregiving staff (#s 9 and 11) demonstrated satisfactory performance in all job duties within 30 days of hire and had documented evidence of abdominal thrust and First Aid training. Findings include, but are not limited to:

Training records were reviewed on 04/05/22.

There was no documented evidence Staff 9 (CG), hired 02/08/22 and Staff 11 (CG), hired 02/25/22 had demonstrated competence in the following areas:

* Roles of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation and reporting of change of condition;

* Conditions that require assessment, treatment, observing and reporting; and

* General food safety, serving and sanitation.

Staff 11 lacked documented evidence of abdominal thrust and First Aid training.

The need to ensure staff had documentation of demonstrated competence in all job duties and had abdominal thrust and First Aid training within 30 days was reviewed with Staff 1 (ED) and Staff 12 (Staffing Development Coordinator) on 04/05/22. They acknowledged the findings.

1.During survey it was discovered that staff #9 and #11 lacked competency training, abdominal thrust and first aid training.  

These staff will receive training on above topics.

All staff 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.Executive Director, 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 ensure 2 of 2 sampled newly-hired direct care staff (#s 15 and 16) had demonstrated competency in all assigned job duties within 30 days of hire or prior to working independently. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 08/24/22.

1.  Staff 15 (CG), hired 08/04/22 lacked demonstrated competency in all assigned job duties prior to working independently in the following areas:

* Role of service plans in providing individualized care:

* Providing assistance with ADLS;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

During an interview with Staff 17 (Staffing Development Coordinator) on 08/24/22 at 3:20 pm, she verified Staff 15 was on the schedule working independently without documented evidence of competency in the above areas.

2.  Staff 16 (CG), hired 07/18/22, lacked documented evidence of competency demonstration in the following areas within 30 days of hire:

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* First Aid/Abdominal Thrust.

During an interview with Staff 17 on 08/24/22 at 3:20 pm, she verified the lack of documented competency demonstration within Staff 16's 30 days of hire.

1.During survey it was discovered that the core competency packets reviewed for staff #16 and 17 lacked all the required training areas including:

* Role of service plans in providing individualized care:

* Providing assistance with ADLS;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

* First Aid/Abdominal Thrust.

It was also discovered that the timelines outlined on our form did not align with the timeline of when topics are to be trained on.

Staff #16 and 17 will be trained on above topics. In addition, all staff will be trained on the missing topics as well.

2.Scheduling Coordinator or designee will update form to include missing topics and ensure that going forward new staff will be trained on all required topics and within the correct timelines.

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

4.Executive Director, 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 ensure long-term staff completed the required minimum 12 hours of in-service training annually for 2 of 2 long-term staff (#s 8 and 10) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 04/05/22.

There was no documented evidence Staff 8 (MA), hired 08/31/20, had completed a minimum of 12 hours of annual in-service training related to the provision of care, which included six hours related to dementia care.

Staff 10 (CG), hired on 03/27/17, lacked three hours of annual in-service training related to the provision of care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (ED) and Staff 12 (Staffing Development Coordinator). They acknowledged the findings.

1.During survey it was discovered that staff #8 and #10 lacked annual in-service training.  

These staff will complete annual in-service training.

All staff 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.Executive Director, 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 ensure fire and life safety instruction was provided to staff on alternating months and failed to ensure fire drills included documentation of all required components. Findings include, but are not limited to:

Fire and life safety records for 11/2021 through 03/2022 were reviewed on 04/05/22 and revealed the following:

* The lack of fire and life safety training provided to staff on alternating months on different topics;

* The facility was not consistently relocating or evacuating residents during fire drills; and

* Fire drill documentation lacked the following required information;

- Escape route used;

- Evacuation time-period needed;

- Resident evacuation problems encountered; and

- Number of occupants evacuated.

The need to ensure staff received required fire and life safety training and fire drills included required components according to the Oregon Fire Code was reviewed with with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They 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.

Executive Director with 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 Executive director will review fire safety overview weekly in their one on one meetings.

4.Executive Director, 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 include all required components on fire drill records. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records from 07/15/22 through 08/18/22 were reviewed and revealed the following fire drill components were not documented:

* 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; and

* Evidence alternate routes were used during fire drills.

The need to ensure fire drills included required components according to the Oregon Fire Code was reviewed with Staff 1 (Executive Director) and Staff 14 (Plant Operations) on 08/24/22. 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.Executive Director and Maintenance Director will review fire drills monthly to ensure we are in compliance with CBC guidelines.

4.Executive Director, 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 being met. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* Documentation that annual fire and life safety training was provided to residents, including evacuation methods, responsibilities during fire drills and designated meeting place outside of the building; and

* Alternate exit routes were used during fire drills.

The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, and alternate exit routes were used during fire drills was discussed with Staff 1 (ED) and Staff 2 (RN) on 04/05/22. They acknowledged the findings. No further information was provided.

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 and training will be documented.

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

3.Maintenance Director and Executive director will review fire safety overview weekly in their one on one meetings.

4.Executive Director, 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 ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 240, C 260, C 270, C 303, C 372 and C 420.

1.Powell Valley Assisted Living failed to pass resurvey on 8/24/2022 in the areas of C240, C260, C270, C303, C372 and C420.  The community will review these tags and the Plan of Corrections, the OARS in these areas, as well as community processes and procedures.

2.Executive Director will work with department leaders to ensure that the citations in this document are being addressed and followed up on in order to be in compliance.

3.Executive Director and department leaders will review at a minimum monthly of these citations.

4.Executive Director, Maintenance Director, RN, Staffing Coordinator, Resident Care Coordinator and other designees are responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:

Observations of the facility on 04/04/22 through 04/05/22 revealed the following areas were in need of cleaning and/or repair:

First Floor

* Resident Room doors including 103, 104, 107, 114, 118, 119, 122, 123, 124, 125, hand wash station door, near dining room and activity room doors were gouged and splintered;

* Accumulated dust on an air vent, near Resident room 111

* Handrails in the hall along with Resident Room 101, 102 and the beauty shop had several scrapes and gouges; and

* Baseboards throughout the dining room and below the menu board were gouged and splintered.

Second Floor

* Laundry room hand wash sink was stained;

* Wall and baseboard across from hand wash sink in the laundry room were stained;

* Accumulated dust on air vents, between elevators and stairs;

* Multiple rusted spots and water damage on air vents near Resident Rooms 207, 201 and 218

* Multiple rusted spots and water damage on an air vents between Resident Room 212 and 227; and

* Resident Room doors including 204, 205, 210, 212, 213, 219, 220, 223, 226, 230, 234 and 235 were gouged and splintered.

Third Floor

* Resident Room doors including 305, 307, 308, 312, 316, 319, 323, 326, 327, 332, 335, 336 and 338 were gouged and splintered;

* Laundry room hand wash sink was stained; and

* Accumulated dust on air vents, near Resident Room 314 and near Resident Room 325.

The need to ensure the environment was clean and in good repair was discussed with Staff 1 (ED) and Staff 6 (Maintenance Tech) on 04/05/22. They acknowledged the findings.

1.The following items outlined in the SOD will be resolved:

oResident apartment doors, handwash station door and activity room doors will be free of splinters and gouges.

oAir vents will be dusted and free of rust and water damage

oHandrails by resident apartments 101 and 102 and beauty shop will be free of scrapes and gouges

oDining room baseboards will be free of gouges and splinters

oLaundry room sinks will be free of stains

2.Executive Director will work with new Maintenance Director when he starts regarding these items.  

All Maintenance staff will be retrained on environmental safety.

3.Maintenance Director and Executive Director will review environmental safety weekly in their one on one meeting and TELS work orders will be submitted as needed.

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