The findings of the re-licensure survey conducted 03/14/22 through 03/16/22 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 03/16/22, conducted 06/01/22 through 06/02/22, 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 Division 57 for Memory Care Communities.  

Based on interview and record review, it was determined the facility failed to investigate incidents including falls and injuries of unknown cause in order to rule out suspected abuse or neglect for 1 of 1 sampled resident (#2), who experienced falls and injuries of unknown cause. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2021 and was identified in the acuity interview to be at risk for falls.

Interim service plans dated 12/23/21 through 03/08/22 noted the following fall interventions:

* Monitor resident and toilet every two hours to minimize continued falls or attempts to care for his/her self;

* Staff to do safety checks throughout [night shift] for toileting needs; and

* Stand by assist and cues needed for transfers and ambulation via four wheeled walker as tolerated.

The resident's 12/17/21 through 03/16/22 progress notes and incident reports noted the following incidents:

* 12/20/21 The resident was noted to have had a fall. The specifics of the fall were not identified;

* 12/31/21 The resident was found on the floor in his/her bedroom with an abrasion to the right knee. The resident reported s/he was trying to access the bathroom;

* 01/31/22 Staff noted an injury of unknown cause in the form of a large bruise on his/her right thigh;

* 03/03/22 The resident fell in the common area of the facility. The resident reported s/he was trying to access the bathroom; and

* 03/07/22 The resident was found on the floor in the doorway of his/her bathroom. The resident experienced pain and swelling to the right buttock and right heel.

The fall investigation for the 12/20/21 fall was dated 02/12/22. The fall investigation for the 12/23/21 fall was dated 03/09/22. None of the fall investigations included information on whether or not the any of the fall interventions were being followed at the time of the incidents.

In an interview with Staff 1 (Memory Care Administrator) on 03/16/22, she confirmed the incidents were not thoroughly investigated including determining if staff were following the fall interventions noted for Resident 2.

The facility lacked documented evidence the incidents were thoroughly investigated to rule out neglect of care as a contributor to the residents falls and injuries.  

The need to ensure injuries, including injuries of unknown cause were immediately and thoroughly investigated to rule out abuse and neglect or reported to the local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1, Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings. As requested, the falls and the injuries of unknown cause were reported to the local SPD office before the survey concluded.

Reports made and submitted to APS via fax, and confirmation given to surveyor 03/16/22 for all 4 falls noted for resident #2, before survey concluded. A thorough root cause analysis was done for resident #2 and her history of falls and interventions were updated on service plan.

Arbor Administrator, LN and Executive Director reviewed the abuse and neglect reporting guidelines and the need for thorough and timely investigations, including investigation as to whether previous interventions are being followed and proper documentation of such investigations.

Incidents reports will be reviewed to ensure proper response and investigation as a part of daily standup meeting. Incident report review will include a thorough investigation, including a review of previous interventions. If unable to rule out abuse and neglect, incidents will be reported to APS.

The Arbor Administrator and the LN will be responsible for maintaining this system.

3. Resident 3 was admitted to the facility in 2016.

Resident 3's evaluation was last reviewed in 10/2021, not quarterly as required.

In an interview on 03/15/22, Staff 1 (Memory Care Administrator) verified the resident's evaluation had not been completed quarterly.  

The need to ensure resident evaluations were performed at least quarterly was discussed with Staff 1, Staff 2 (Director of Health Services), and Staff 3 (ED). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed all required elements and resident evaluations were performed quarterly, for 3 of 3 sampled residents (#s 1, 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia with behavioral disturbance.

Review of Resident 1's initial move-in evaluation revealed the following required elements were not addressed:

* Customary routines including eating and bathing;

* Spiritual and cultural preferences and traditions;

* Cognition including memory and confusion;

* Personality including how the person copes with change or challenging situations;

* Pharmacological and non-pharmacological interventions for pain and how the resident expresses pain or discomfort;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

The move-in evaluation was reviewed with Staff 2 (Director of Health Services) on 03/15/22 and with Staff 1 (Memory Care Administrator) and Staff 3 (ED) on 03/16/22. They acknowledged the information that was lacking from the evaluation.

2. Resident 4 was admitted to the facility in 03/2021 with diagnoses including dementia and abnormalities of gait and mobility.

Review of the record indicated the last evaluation for Resident 4 was completed 11/24/21, not quarterly as required.

The need to ensure resident evaluations were completed quarterly was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

Evaluation and service plan for resident #1 updated to reflect and address all of the required components. All quarterly evaluations and service plans have been updated for resident #3 and resident #4

To prevent reccurence, the Arbor Administrator will complete an audit of all evaluation schedules and utilize reports in EMR program to schedule evaluations in a timely manner. Facility will complete preadmission and admission evaluations per regualtion and company policy on all new residents. Facility to utilize admission checklist to ensure preadmission and admission evaluations are completed. Evaluations will then be completed within 30 days, quarterly and with significant change of condition.

This system to be audited utilizing the clinical admission checklist which includes components to be audited prior to admission, upon admission, 72 hours from admission and at 30 days. This system will be evaluated semi-annually as part of the RNC focused audits.

The Arbor Administrator is responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident needs, included a description of services to be provided and were followed, for 3 of 4 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 03/2021 with diagnoses including dementia and abnormalities of gait and mobility.

Review of the current service plan, dated 02/11/22, observations of the resident and interviews with the resident and caregiving staff indicated the service plan lacked the following information:

* The resident's use of weighted utensils, cups with lids or a straw and the need to provide food items in a large, deep bowl so the resident could eat independently; and

* Use of a foam mattress topper in bed and a foam seat cushion in his/her wheelchair.

Information that was lacking from the current service plan was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

2.  Resident 2 was admitted to the facility in 12/2021 and was identified as a high fall risk.

Resident 2's service plan dated 02/11/22 was not reflective of the resident's needs and lacked clear direction to staff in the area of fall interventions, including:

* Signs to remind the resident to call for assistance before standing;

* Toileting schedule;

* Transfers and ambulation including the resident's need for stand by assist with verbal cues; and

* Assistive devices including scoop mattress and floor mat.

The need to ensure service plans were reflective of resident's needs and provided clear instruction to staff was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services), and Staff 3 (RN) on 03/16/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in 2016.

Resident 3's 02/11/22 service plan was not reflective of the resident's needs, not followed or lacked clear direction to staff in the following areas:

* Diet texture order change to puree;

* Food preferences including dislike of eggs;

* Aspiration interventions;

* Daily routine including assistance to geriatric chair and transportation to the dining room three times daily for meals and to the common areas; and

* Repositioning every two to three hours.

The need to ensure service plans were reflective of resident's needs, provided clear instruction to staff and were followed was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services), and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

Service plans for residents #2, #3 and #4 have been reviewed and have been updated as needed to include all required components and to reflect residents current status and care needs.

To prevent recurrence, all current resident service plans will be audited for accuracy. Direct care staff will be reeducated regarding the importance of reporting any questions or concerns related to resident service plans. A form was implemented for care staff to document any discrepancies between resident service plans and actual care needs. Form is to be turned into Arbor Administrator so that service plans can be updated and reflective.

Interim Service Plans (ISPs) will be reviewed at standup as part of the 24hr/72hr summary review (includes all progress notes written in past 24/72 hours), and service plans will be updated as needed. Service plans will be evaluated and reviewed by all departments upon admission, at 30 days, quarterly and with significant change of condition.

The Arbor Administrator will be responsible for maintaining this system.

3. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia with behavioral disturbance.

The previous 90 days of Progress Notes, the resident's service plan, Interim Service Plans (ISPs) and Incident Reports were reviewed. The following deficiencies relating to how the facility responded to Resident 1's changes of condition were identified:

a. On 01/31/22, the resident had a witnessed fall. The facility wrote an ISP instructing staff to "monitor resident for pain and bruising that was not noted during fall." There was no documented evidence the facility monitored the resident for pain and bruising as instructed.

b. On 02/15/22, staff documented the resident was not feeling well and was experiencing a runny nose and fatigue. An ISP was written informing staff of the runny nose and fatigue. However, the facility failed to determine and document what action or intervention was needed for the resident.

c. On 03/05/22, the resident stood up, took a few steps and fell down. Staff documented the resident stated s/he had not been feeling well at the time. There was no evidence the facility determined and documented what action or intervention was needed for the resident, or monitored and documented on the status of the resident until the condition resolved.

d. On 02/01/22, the facility RN evaluated the resident's weight and documented in an ISP new interventions: give supplement shakes twice daily and weigh weekly. Interviews with staff indicated they were unaware they should be providing shakes and weekly weights were not begun until 03/01/22 - 30 days after the new intervention was developed. The facility failed to monitor that new interventions were communicated to staff and implemented.

e. On 03/01/22, staff obtained Resident 1's weight for the month. At this time, the resident had lost 7.63% body weight over the past 90 days. This represented a significant change of condition. There was no documented evidence the facility referred the change to the facility nurse, documented the change, and updated the service plan as needed.

The need to develop, document and communicate new interventions to staff and to monitor the resident's condition until resolved was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

4.  Resident 4 was admitted to the facility in 03/2021 with diagnoses including dementia and abnormalities of gait and mobility.

The previous 90 days of Progress Notes, the resident's service plan, Interim Service Plans (ISPs), outside provider notes and physician orders were reviewed. The following deficiencies relating to how the facility responded to Resident 4's changes of condition were identified:

a. On 01/05/22, the physician ordered Resident 4's divalproex (a psychotropic medication to treat bipolar and other psychiatric conditions) to be decreased from 2 tablets to 1 tablet at bedtime. There was no evidence the facility determined and documented what actions or interventions were needed for the resident or documented at least weekly on the status of the resident until the condition was determined to be resolved.

b. On 02/02/22, the physician ordered Resident 4's bedtime divalproex to be discontinued altogether. There was no evidence the facility determined and documented what actions or interventions were needed for the resident or documented at least weekly on the status of the resident until the condition was determined to be resolved.

The need to determine and document what actions or interventions were needed for a resident and monitor the status of the condition following a change of condition was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

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, interventions determined, documented, communicated to staff on all shifts and monitored for effectiveness, and conditions monitored with weekly progress noted until resolved for 4 of 4 sampled residents (#s 1, 2, 3 and 4), who experienced short-term and significant changes of condition. Resident 2 continued to have falls with injury. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility on 12/17/21 with diagnoses including dementia and was noted as a high fall risk.

A progress note written by hospice services on the day of admission indicated the resident had fallen a week prior, injured his/her knee and directed the facility to monitor the resident for fall risk.

The resident's progress notes, incident reports, 02/11/22 service plan, and interim service plans (ISP's) were reviewed and revealed the following:

* On 12/20/21 staff documented on a Community Based Care Fall form, the resident experienced a fall on the same date. A visit note from the hospice provider on 12/20/21 directed the facility to walk/assist during ambulation via 4-wheeled walker as the resident was unsteady and high fall risk due to knee injury. There was no evidence these instructions were added to the resident's service plan and communicated to staff. The facility did not conduct an investigation of the fall until 03/09/22 and the investigation failed to evaluate whether fall interventions had been added to the service plan, were being followed at the time of the fall, were effective or if additional interventions needed to be developed.

* On 12/23/21 staff documented the resident experienced a fall around 11:00 am on the same date. "...resident complained of pain in lower back ...also has small scratch on right inner right wrist ...scratch that bled on the bridge of [his/her] nose ...and a bump (goose egg) on forehead." An ISP written 12/23/21 directed staff to monitor the resident and "toilet every two hours to minimize continued falls." There was no documented evidence the facility monitored that the resident was being assisted with toileting every two hours as instructed in the ISP.

The facility did not conduct an investigation of the fall until 02/12/22 and failed to evaluate if previous interventions were being followed at the time of the fall, were effective or if additional interventions needed to be developed.

* On 12/31/21 staff documented the resident experienced a fall at 5:40 am on the same day, resulting in a scratch to the right knee. Staff documented "[Resident] fell while trying to get to bathroom." There was no documented evidence the facility monitored that the resident was being assisted with toileting every two hours as instructed in the previous ISP. The facility did not conduct an investigation of the fall until 02/12/22 and failed to evaluate whether previous fall interventions were being followed at the time of the fall and were effective. The facility documented a new intervention on the Community Based Care Fall form: "Staff to do safety checks throughout [night shift] for toileting needs" but this intervention was not added to the resident's service plan or communicated to staff.

* On 1/27/22 an ISP noted the resident was a stand by assist with cues needed for transfers and ambulation via four wheeled walker as tolerated.

* On 03/03/22 staff documented the resident experienced a fall at 12:00 pm while attempting to get to the bathroom. An ISP instructed staff to monitor the resident and note any bruises on [his/her] lower back. The facility did not conduct an investigation of the fall until 03/14/22 and failed to evaluate whether previous fall interventions including monitoring and toileting every two hours and stand by assistance and cues with transfers and ambulation were being followed at the time of the fall and were effective. The facility documented a new intervention on the Community Based Care Fall form: "[Resident] will be provided with safety checks every two to three hours in an attempt to anticipate care needs" but this intervention was not added to the resident's service plan or communicated to staff.

* On 03/07/22 staff documented the resident experienced a fall at 11:01 pm while attempting to go to the bathroom. "...we found the resident in the doorway to the bathroom facing the bathroom on the floor...resident had a swollen right [buttock] as well as heel." The facility investigation, completed 03/07/22, failed to evaluate whether the resident was being assisted with toileting or provided safety checks every 2 -3 hours as specified in the previous ISPs, whether the interventions were effective or whether additional interventions needed to be developed.

Resident 2 experienced five falls between 12/20/21 and 03/07/22, and continued to experience falls with injuries. The facility failed to timely and thoroughly review each incident in order to determine if the resident specific service-planned interventions were being followed at the time of the fall and were effective. That placed the resident at risk for repeated injury.

The need to ensure changes of condition were evaluated, interventions determined, documented, communicated to staff on all shifts and monitored for effectiveness, and conditions monitored with weekly progress noted until resolution was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 2016 with diagnoses including

dementia.

The resident's 12/15/21 through 03/15/22 clinical records were reviewed and revealed the resident experienced the following short term changes of condition:

* 12/22/21 COVID vaccination booster;

* 01/18/22 Order to increase oxygen liters to three liters per minute; and

* 02/25/22 Diet texture order downgraded to puree.

The facility lacked documented evidence interventions were determined, documented, communicated to staff and the conditions monitored and noted at least weekly through resolution.

The need to ensure all changes of condition were evaluated with interventions determined, documented, communicated to staff on all shifts and monitored for effectiveness with conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

Med Aides will be re-educated on when to notify the LN immediately for change of condition vs notification via alert charting procedure. Education will also include a review of how and when to put a resident on alert, and utilizing the alert charting audit tool.

Arbor Administrator and LN have reviewed proper procedure for using the alert charting audit tool as well as cross referencing with incident reports to ensure that any incident with injury includes monitoring the injury until resolution.

To prevent recurrence, alert charting audit tool will be utilized by medications aides to document when a resident is put on alert to ensure that all required components are being completed. 24 hr summary will be reviewed as part of daily standup meeting. On Mondays, the 72 hr summary will be reviewed to include review of documentation from the weekend. This system will further be evaluated monthly as part of the continuous quality improvement (CQI) process to include a review of any area needing action that may have been missed by other systems.

The Arbor Administrator and LN will be responsible for maintaining this system.  

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers and failed to ensure the facility nurse reviewed health-related service plan changes, updated the resident's service plan as necessary and informed staff of new interventions, for 2 of 2 sampled residents (#s 2 and 4) who received outside services. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 03/2021 with diagnoses including dementia and abnormalities of gait and mobility.

The resident had been receiving home health services from an outside provider for skin breakdown on the heels and coccyx.

Review of the outside provider visit notes between 12/14/21 and 03/14/22 indicated the following deficiencies:

a. On 03/03/22, a home health nurse documented "Swelling on [genital area] - apply warm compress daily."

There was no documented evidence the treatment was reviewed by the facility nurse and the treatment implemented.

b. On 03/03/22, a home health nurse updated the current treatment orders for wound care to the resident's coccyx from the facility providing treatment every other day to home health providing treatment on Tuesdays and Fridays and the facility RN to provide treatment once per week and as needed if the dressing became soiled.

There was no documented evidence the new order was reviewed by the facility nurse and the TAR updated with the new treatment schedule.

c. On 03/09/22, a home health nurse updated the previous wound care order to allow facility staff to replace the wound dressing as needed if it became dislodged or saturated.

There was no documented evidence the new order was reviewed by the facility nurse and the TAR updated with the new treatment instructions.

The need to ensure the facility nurse was reviewing outside provider visit notes timely and implementing new orders and recommendations was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

Resident 2 was admitted to the facility in 12/2021.  

The resident's 12/17/21 through 03/16/22, "CBC[Community Based Care] Outside Provider" notes, progress notes, Interim Service Plans (ISP's) and 02/11/22 service plan were reviewed. The records indicated Resident 2 received hospice services from an outside provider for concerns including falls and edema.

Review of the Community Based Care Outside Provider forms indicated hospice providers left the following instructions for the facility:

*12/23/22 " ...Placing signs to remind patient to call for help and to use wheelchair and leave bathroom light on at night";

* 02/03/22 "Elevate both feet while sleeping and in Geri chair as tolerated to reduce swelling"; and

* 02/07/22 "Continue elevating both legs as tolerated when sleeping in Geri chair to reduce swelling. Apply ice pack PRN for discomfort as tolerated."

There was no documented evidence the facility updated the resident's service plan with those instructions or communicated the new instructions to staff.

The failure to update the service plan and communicate instructions to staff was discussed with Staff 1 (Memory Care Administrator) on 03/15/22. She acknowledged the findings.

All outside provider summary notes for the past 90 days have been reviewed for resident #2 and resident #4 and service plans have been updated with all recommendations and appropriate interventions. A care conference has been scheduled for each of these residents and care conference team has been invited to attend to ensure service plans are reflective and to ensure proper coordination of care. LN will complete a comprehensive assessment for resident #4, update service plan with current status and interventions and coordinate ongoing care with care team. Resident will continue to be assessed weekly until resolution.

To prevent recurrence all outside provider notes to be reviewed through facility triple check process, which includes review by LN. All information provided by outside providers will be followed up on by LN and steps will be taken as needed to update service plans and treatment plans accordingly.  

This system will be evaluated semi-annually as part of the facility's CQI program.

The Arbor Administrator and LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed and written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer, for 2 of 3 sampled residents (#s 1 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia with behavioral disturbance.

The resident's current signed physician orders and 03/01/22 through 03/13/22 MAR were reviewed.

The resident was prescribed two psychotropic medications to treat mental or mood conditions: olanzapine and quetiapine fumarate. Each medication was to be administered as needed for agitation as evidenced by threats of violence or screaming obscenities. The MAR indicated the resident was administered one or the other medication on seven occasions between 03/01/22 and 03/13/21.

On all seven occasions, documentation in the "eMAR - Order Notes" by the staff administering the medications did not indicate the resident was exhibiting threats of violence or screaming obscenities at the time the medication was given. Rather, on two occasions the staff documented only "agitation" and on the other five occasions staff documented things like "occasionally asking anxiety-based questions," "anxious and not sleeping," "walking around aimlessly," "asking when [his/her spouse] is getting here," or "calmed down but still can't sleep."

The need to ensure physician orders were followed was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2021 with diagnoses including dementia and abnormalities of gait and mobility. The resident's current signed physician orders and 02/01/22 through 03/13/22 MAR were reviewed. The following deficiencies were identified:

a. The MARs indicated the facility has been administering the resident 650 mg acetaminophen TID between 02/01/22 and 03/13/22. There was no signed physician order in Resident 4's record to administer the medication TID; the most recent signed order, dated 01/03/22, was for 650 mg acetaminophen to be administered as needed.

b. A home health note dated 03/04/22 directed the facility to apply a warm compress to Resident 4's genital area once daily. There was no documented evidence the facility was administering the compress as ordered.

The need to ensure physician orders were followed was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

Physician orders for residents #1 and #4 have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature. Orders will be updated to clearly reflect reason for use. Medication aides will be re-educated on proper PRN usage and documentation.

To prevent recurrence, all new orders will go through a triple check process, which includes LN review for accuracy of order transcription as well as LN review for clear instructions for use. EMAR administration progress notes will be reviewed as part of the 24 hour daily audit (72 hour audid on Mondays) to ensure appropriate documentation. Ongoing education will be provided to medication aides as needed based on findings of audits.

Clear instructions for PRN use will be evaluate monthly as part of our CQI audits. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature.

Arbor Administrator and LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician and administered by the facility, for 3 of 3 sampled residents (#s 1, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia with behavioral disturbance.

The resident's current signed physician orders and 03/01/22 through 03/13/22 MAR were reviewed. The following inaccuracies were identified:

a. The resident had an order for quetiapine fumarate (a psychotropic medication) to be administered BID at 12:00 pm and 9:00 pm. The 03/01/2022 through 3/13/2022 MAR instructions incorrectly directed staff to administer the medication at 12:00 pm and 6:30 pm.

b. The resident had an order to administer acetaminophen (for pain) every 8 hours as needed. The 03/01/2022 through 3/13/2022 MAR instructions incorrectly directed staff to administer the medication every 4 hours as needed.

The need to ensure physician orders were transcribed correctly to the MAR was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2021 with diagnoses including dementia and abnormalities of gait and mobility.

The resident's current signed physician orders and 02/01/22 through 03/13/22 MAR were reviewed. The following inaccuracies were identified:

a. The resident had an order to administer 8.6 mg Senna (for constipation) - 1 tablet daily as needed. The 02/2022 and 03/01/2022 through 3/13/2022 MAR instructions incorrectly directed staff to administer 2 tablets daily as needed.

The need to ensure physician orders were transcribed correctly to the MAR was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 2016 with diagnoses including dementia.

The resident's 03/01/22 through 03/14/22 MAR and TAR were reviewed. The following deficiencies were identified:

* The order for PRN oxygen lacked dosage information and lacked resident-specific parameters and instruction for staff regarding when to administer;

* Staff failed to document they had followed the treatment order to check bilateral arms and hands for non-blanching redness and placement of egg-crate cushion under left arm on 03/06/22;

* Staff failed to document they had followed the treatment order to place rolled washcloths in between fingers and palm each morning on 03/06/22 and remove each evening on 03/06/22 and 03/13/22;

* Order for mirtazapine 7.5 mg lacked all ordered reasons for use; and

* Order for Senna 8.6 lacked the correct reason for use.

The need to ensure MARs and TARs provided clear instruction and parameters for administration of PRN medications, included the initials of the person administering the medication or treatment and included correct reasons for use was discussed with Staff 1 (Memory Care Administrator) Staff 2 (Director of Health Services), and Staff 3 (RN). They acknowledged the findings.

Residents #1, #3 and #4's physician orders have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature.

To prevent recurrence, all new orders will go through a triple check process, which includes LN review for accuracy of order transcription. A weekly audit of missing documentation will be completed and ongoing education will be provided to medication aides as needed based on findings of audits.

Weekly audits will be reviewed monthly as part of the CQI process and any identified areas of concern will be addressed. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature.

Arbor Administrator and LN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering a PRN psychotropic medication, for 1 of 2 sampled residents (#1) who were prescribed PRN psychotropic medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2021 with diagnoses including dementia with behavioral disturbance.

The resident was prescribed two PRN psychotropic medications to treat mental or mood conditions: olanzapine and quetiapine fumarate. Each medication could be administered after staff attempted the following non-pharmacological interventions and documented they were ineffective: offer snack, redirect with an activity, talk about old cars.

The MAR indicated the resident was administered one or the other medication on seven occasions between 03/01/22 and 03/13/21. There was no documented evidence in the MAR or in progress notes that staff attempted non-pharmacological interventions, and that they were ineffective, prior to administering the PRN medications.

The need to ensure the facility had an effective system for documenting that non-pharmacological interventions were attempted with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

A complete MAR audit for all residents will be done by Arbor Administrator and LN to ensure all PRN psychoactive medications have clear instructions for administration, including how the resident indicates a need for the medication. Audit will also ensure resident specific non-pharmacological interventions are in place to attempt prior to the use of the medication unless an order from the provider negates the need for non-pharmacological interventions. All medication aides will be re-educated regarding the process of documenting non-pharmacological interventions prior to administering PRN psychoactive medications.

To prevent recurrence all provider orders to be reviewed through facility triple check process, which includes review by LN to ensure all necessary components are in place. EMAR administration progress notes will be audited as part of the 24 hour daily audit (72 hour audit on Mondays) to ensure appropriate documentation. Ongoing education will be provided to medication aides as needed based on findings of audits. Physician orders will also be reviewed quarterly by licensed nurse and sent to provider for signature to provide coordination of care.

This system will be evaluated monthly as part of the facility CQI program which will include an audit of all PRN psychoactive medications.

The Arbor Administrator and LN will be responsible for maintaining this system.

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 10/2021 through 03/2022 were reviewed on 03/16/22. The facility failed to document the following required components:

* Escape route used; and

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

There was no documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

On 03/16/22, 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 3 (ED) and Staff 5 (Director of Environmental Services). They acknowledged the findings.

A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at staff meeting in April on the fire drill procedure.

To prevent recurrence, company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

The Maintenance Director and Arbor Administrator will be responsible for maintaining this system.

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 drill records from 10/2021 through 03/2022 were reviewed on 03/16/22. The records lacked documentation the following required elements were reviewed with staff:

* Staff knowledge of the designated point of safety; and

* Documentation of interventions and/or resolution for resident evacuation concerns identified during fire drills.

The need to have all components of fire and life safety training documented was discussed with Staff 3 (ED) and Staff 5 (Director of Environmental Services) on 03/16/22. They acknowledged the findings.

A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at staff meeting in April on the fire drill procedure.

To prevent recurrence company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

The Maintenance Director and Arbor Administrator will be responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to keep all exterior materials and equipment needed for the health, safety and comfort of the residents clean and in good repair. Findings include, but are not limited to:

The exterior courtyard was toured on 03/14/22 at 11:15 am. The following issues were identified:

* Sections of the top of the perimeter fence were damaged; and

* A wooden bench was rough to the touch with peeling paint.

The surveyor toured the courtyard with Staff 5 (Director of Environmental Services) on 03/16/22 at 10:05 am. He acknowledged the bench needed refinishing and stated the facility intended to replace the entire fence.

The items in the courtyard needing repair were reviewed with Staff 1 (Memory Care Administrator) and Staff 3 (ED) on 03/16/22 at 3:00 pm. They acknowledged the items needing repair or replacement.

The fence has been temporarily repaired and will be schedule for permanent repair by 05/15/2022.

The bench has been removed and will be replaced.

To prevent recurrence, the Maintenance Director will walk the property weekly to identify any areas needing repair and will implement a plan to repair those areas by the end of the same day.  Weekly walkthrough will be discussed as part of daily standup.

The memory care unit and courtyard will be walked weekly, and all areas needing repairs scheduled will be reviewed monthly as part of the community CQI audit.  

The Maintenance Director and Arbor Administrator will be responsible for maintaining this system.  

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 C231, C420, C422 and C513.

Refer to POC for C231, C420, C422 and C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 6, 7 and 10) completed all required pre-service orientation, pre-service dementia training and demonstrated competency in all job duties within 30 days of hire. Findings include, but are not limited to:

On 03/16/22, training records for Staff 6 (MT) hired 10/20/21, Staff 7 (CG) hired on 11/12/21, and Staff 10 (MT) hired 12/15/21, were reviewed.

1. There was no documented evidence Staff 6, 7 and 10 had completed all pre-service orientation topics or the required pre-service dementia training in one or more of the the following areas:

* Standard precautions for infection control;

* Fire safety and emergency procedures;

* Had a written job description in their employee file;

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia and ensuring safety of residents with dementia including, but not limited to, addressing pain, providing food/fluids, preventing wandering, use of person centered approach;

* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in a change in the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

2. There was no documented evidence Staff 6, 7 and 10 had demonstrated competency in:

* 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.

The need to ensure newly-hired direct care staff completed all required pre-service orientation, pre-service dementia training and demonstrated competency in all job duties within 30 days of hire was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services), Staff 3 (ED) and Staff 4 (Business Office Manager) on 03/16/22. They acknowledged the findings.

A complete audit will be done of all training and competency records. All trainings and competencies will be complete and up to date for current employees no later than 5/15/22.

To prevent recurrence, newly hired staff will be required to complete the required pre-service training prior to working on the floor, and completing other required training and job specific competencies within 30 days of hire. Incomplete trainings and competencies will be reviewed as part of daily standup meeting to identify missing components and to review the status of new hires and where they are at with their trainings to ensure all training is completed within the required timeframe.

This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings.

The Arbor Administrator and Business Office Manager  will be responsible for maintaining this system.

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 C252, C260, C270, C290, C303, C310 and C330.

Refer to POC for C252, C260, C270, C290, C303, C310 and C330.

Based on observation, interview and record review, it was determined the facility failed to develop an individualized activity plan for residents based on their activity evaluation, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

During the survey many residents were observed needing assistance and encouragement from staff to initiate, attend and participate in activities. The facility offered group activities, but some residents did not attend the activities and, instead, preferred to remain in their individual rooms during much of the day.

Though the residents had been evaluated regarding past and current interests, current abilities and skills, social needs and patterns, physical abilities and limitations, adaptations necessary for the resident to participate in activities and activities for behavioral interventions, the facility had not used that information to develop an individualized activity plan for each resident which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The need to develop individualized activity plans, especially for residents who were not able to engage in group activities, was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Director of Health Services) and Staff 3 (ED) on 03/16/22. They acknowledged the findings.

Individualized activity plans have been developed and service plans have been updated for all 4 sampled residents.

Facility recently hired a new Life Enrichment Director for the Arbor, who will complete training on regulations related to activity programming for residents, including individualized activity plans. All resident activity profiles will be updated to include Individualized activity plans for all residents based on their activity preferences and needs no later than 5/15/22.

Monthly, as part of our CQI program, changes in activity levels will be reviewed and individualized activity plans will be adjusted as needed.

Individualized activity plans will be evaluated with each evaluation/service plan review quarterly, or with significant change of condition.

The Arbor Administrator and Arbor Life Enrichment Director will be responsible for maintaining this system.