The findings of the change of ownership survey, conducted 03/04/24 through 03/05/24, 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 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 first re-visit to the re-licensure survey of 03/05/24, conducted 05/14/24, 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 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure facility management or a licensed nurse was notified of services provided by outside providers, staff were informed of new interventions, and that the service plan was reviewed by the facility nurse and adjusted if necessary, and to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care for 1 of 2 sampled residents (#2) who were receiving outside services. Findings include, but are not limited to:

Resident 2 moved into the facility in 02/2024 with diagnoses including dementia.

Progress notes and outside provider notes dated 02/07/24 to 03/04/24, service plan dated 02/07/24, and temporary service plans were reviewed, and the following was identified:

a. There was no documented evidence the facility nurse reviewed health-related service plan changes, staff were informed of new interventions, and the service plan was updated for the following recommendations:

* 02/14/24 - HH RN noted, "tubi-grips applied to BLE [bilateral lower extremities] to assist with patient not scratching [at] legs. CG please ensure she [is] wearing daily";

* 02/19/24 - HH LPN noted, "[right] upper thigh with small scab[.] [S]ome bruising peri-wound possible[.] [Resident] self scratching small scab measures 0.9 cm x 0.6 cm";

* 02/23/24 - HH RN noted, "[resident] toileted today during visit and had small skin tear to [right] posterior thigh from seat"; and

* 02/23/24 - HH Physical Therapy Assistant noted, "Assist [resident] in frequent position changes, standing/ambulating every 2-3 hours, and skin integrity checks daily."

b. During an interview at 2:46 pm on 03/04/24, Witness 1 (HH Speech-Language Pathologist) stated she had conducted four therapy sessions with the resident on 02/13/24, 02/21/24, 02/26/24, and 03/04/24. There was no documentation in the facility of the first three visits made by Witness 1. During an interview at 9:30 am on 03/05/24, Staff 3 (LPN) stated she was not aware the resident was receiving speech therapy services. During an interview at 10:15 am on 03/05/24, Staff 2 (Memory Support Program Manager) stated she was not aware the resident was receiving speech therapy services.

The need to ensure facility management or a licensed nurse was notified of services provided by outside providers, staff were informed of new interventions, and that the service plan was reviewed by the facility nurse and adjusted if necessary, and to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care for residents with outside services was discussed with Staff 1 (Associate ED) and Staff 2 on 03/05/24. They acknowledged the findings, and no additional information was provided.

1. The Memory Support LPN Supervisor contacted all current outside providers to provide re-education about providing after visit documentation to the Med Tech or LPN on duty. In regards to resident #2, all Physical Therapy/Occupational Therapy and Speech Therapy notes since admission to Home Health were faxed to the LPN Supervisor on 3/7/2024. All Physical Therapy/Occupational Therapy and Speech Therapy notes were reviewed by the LPN Supervisor and recommendations were acknowledged/implemented in the progress notes and on the service plan as appropriate.

2. An outside provider tracking log has been created and implemented for all current residents living in Memory Support that receive outside provider services. This tracking log tracks the dates/frequency of visits/discipline and recommendations from provider visits. Provider after visit notes will be acknowledged by the LPN Supervisor or designee and recommendations will be added to the service plan as appropriate.

3. The LPN Supervisor or designee will review the outside provider tracking log weekly.

4. The LPN Supervisor or designee will be responsible for monitoring and tracking outside provider notes and recommendations.

2. Resident 1 moved into the facility in 05/2023 with diagnoses including Alzheimer's disease.

Progress notes indicated Resident 1 sustained a skin tear to the forearm on 02/23/24. Several notes between 02/23/24 and 02/28/24 indicated staff were administering wound care, including dressing the wound.

The facility failed to document the administration of the wound care on Resident 1's TAR.

The need to ensure the facility documented all treatments administered on the resident's TAR was discussed with Staff 1 (Associate ED) and Staff 2 (Memory Support Program Manager)  on 03/05/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a treatment record for each resident was kept of all treatments ordered by a legally recognized practitioner and administered by the facility for 2 of 2 sampled residents (#s 1 and 2) who were receiving treatments from facility staff. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2024. The resident's service plan dated 02/07/24, physician orders dated 02/16/24, and "Day Shift Shower" log for the week of 03/04/24 were reviewed, and the following was identified:

The resident had an order for the following: "[prescribed] dressings can be removed and regular band-aids applied to the wounds after shower." The treatment order was transcribed onto the facility "Day Shift Shower" log which included information for multiple residents. The log lacked the year and time the treatment was administered. During an interview at 12:57 pm on 03/05/24, Staff 3 (LPN) stated the shower log was not part of the resident's record.

The need to ensure a treatment record for each resident was kept of all treatments ordered by a legally recognized practitioner and administered by the facility that included all required components was discussed with Staff 1 (Associate ED) and Staff 2 (Memory Support Program Manager) on 03/05/24. They acknowledged the findings.

1. A standing order for basic first aid and treatments was requested for each resident living in Memory Support. These standing treatment orders were received by 3/12/2024. In regards to resident #2, standing treatment orders and resident specific treatment orders have been added to her MAR and service plan.

2. A standing treatment order request has been added to the new admission physican plan of care intake form. The LPN Supervisor has a skin management/treatment tracking binder.

3. The LPN Supervisor has a skin management/treatment tracking binder that is reviewed 3-5x weekly to verify current treatment orders.

4.The LPN Supervisor or designee will be responsible for updating treatment orders as prescribed.

Based on interview and record review, it was determined the facility failed to ensure soiled linens and soiled clothing were washed with a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant. Findings include, but are not limited to:

During an interview on 03/05/24, Staff 4 (Director of Buildings and Grounds) confirmed the facility water temperatures were set at 120 degrees Fahrenheit. This surveyor and Staff 4 confirmed together the detergent used in the facility lacked disinfectant.

The need to ensure a minimum rinse temperature of 140 degrees Fahrenheit or chemical disinfectant was used for soiled linen and clothing was discussed with Staff 1 (Associate ED) and Staff 2 (Memory Support Program Manager) on 03/05/24. They acknowledged the findings.

1. A chemical disinfectant was ordered on 3/5/2024 and arrived on 3/7/2024. A team member in-service was conducted on 3/18/2024 .

2. The chemical disinfectant "Clothesline Fresh Fabric Softner/Sanitizer" arrived on 3/7/2024 and will be used in the Memory Support laundry room effective 3/18/2024.

3. The Memory Support Administrator or designee will audit the use of the chemical disinfectant 1x a week for 4 weeks starting the week of 3/18/2024.

4. The Memory Support Administrator or designee will be responsible for monitoring the training process of using the chemical disinfectant in the washing machines.

Based on 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 530.

Refer to C 530.

Based on 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 290 and C 315.

Refer to C 290 and C 315.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations were completed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Review of Residents 1 and 2's evaluations revealed the facility had not evaluated the residents' activity needs in one or more of the following areas:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities which could be used as behavioral interventions, if necessary.

The need to ensure activity evaluations were completed for all residents was discussed with Staff 1 (Associate ED) and Staff 2 (Memory Support Program Manager) on 03/05/24. They acknowledged the findings.

1. The Memory Support Activity Coordinator completed new activity evaluations for resident #1 and resident #2 on 3/19/2024.

2. All current Memory Support residents will have an updated activity evaluation completed by 4/8/2024. New and current activity preferences and interventions will be added to current service plans by 4/12/2024.

3. The Memory Support Administrator or designee will get updated activity preferences and needs at each residents 90 day care meeting. These preferences and needs will be reflected on the residents service plans and activity evaluations.

4. The Memory Support Administrator, Memory Support Activity Coordinator or designee will be responsible for obtaining current and up to date activity evaluation information.