The findings of the Change of Ownership survey, conducted 01/08/24 through 01/10/24, 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

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 first revisit to the Change of Ownership survey of 01/10/24, conducted 03/28/24, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear instructions to staff for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2023 with diagnoses including dementia.

Observations, interviews, and review of the current service plan, dated 12/18/23, revealed the service plan was not reflective of the resident care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas:

* Two person transfer assistance; and

* Wandering behaviors.

On 01/10/24, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (Administrator). She acknowledged the findings.

Resident #1's Service Plan was updated to reflect current transfer status and interventions for wandering behavior.

All residents service plans were reviewed for accuracy, with specific attention to transfer status and behaviorial concerns.

Service Plan Updates will be completed with input from IDT no less than quarterly and with each Change of Condition to ensure accuracy. Changes to Service Plans will be communicated to all staff through the ISP Process.

Resident Care Coordinator and/or designee will be responsible to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure the Acuity Based Staffing Tool (ABST) entries were reflective of the resident's current care needs for 1 of 2 sampled residents (#1) whose ABST was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2023 with diagnoses including dementia.

Observations of Resident 1, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs and had inaccurate minutes assigned in the following areas:

* Dressing and undressing; and

* Transferring in or out of bed or chairs.

On 01/10/24, the need to ensure the facility ABST entries were reflective of the resident's care needs was discussed with Staff 1 (Administrator). She acknowledged the findings.

ABST for Resident #1 has been updated to include additional time for dressing and transfering.

All residents ABST data will be reviewed to ensure needed time is captured in staffing tool to accurately reflect current care needs.

With each service plan update, ABST data will be reviewed, no less than quarterly or each change of condition, with results brought to QAPI for 6 months.

Administrator/RCC or designee will be responsible for compliance.

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 not limited to:

Refer to C 361.

Refer to C361

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 not limited to:

Refer to C 260.

Refer to C260