Hillside Memory Support.

“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 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. 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. 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.”

“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. 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:”

“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. 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.”

“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. 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. Refer to C 530. There are no detail notes for this visit.”

“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. 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. Refer to C 290 and C 315. There are no detail notes for this visit.”

“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. 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.”