22 clia 03/06/2018mr. mark bichler, administrator north star manor 410 south mckinley street warren,...

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL

PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00356

ID: K1PP

WARREN, MN

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

7

12/31

03/06/2018

NORTH STAR MANOR

1. MEDICARE/MEDICAID PROVIDER

NO.(L1) 245550

2. STATE VENDOR OR MEDICAID NO.

(L2) 304842000

02

410 SOUTH MCKINLEY STREET

56762

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

11. .LTC PERIOD OF CERTIFICATION 10.THE FACILITY IS CERTIFIED AS:

From (a) :

To (b) :

A. In Compliance With And/Or Approved Waivers Of The Following Requirements:

Program Requirements

Compliance Based On:

1. Acceptable POC

2. Technical Personnel 6. Scope of Services Limit

3. 24 Hour RN 7. Medical Director

4. 7-Day RN (Rural SNF) 8. Patient Room Size

5. Life Safety Code 9. Beds/Room12.Total Facility Beds 45 (L18)

13.Total Certified Beds 45 (L17) B. Not in Compliance with Program

Requirements and/or Applied Waivers: * Code: A* (L12)

14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS

18 SNF 18/19 SNF 19 SNF ICF IID 1861 (e) (1) or 1861 (j) (1): (L15)

45

(L37) (L38) (L39) (L42) (L43)

16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):

29. INTERMEDIARY/CARRIER NO.

PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

18. STATE SURVEY AGENCY APPROVAL Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL

RIGHTS ACT:

1. Statement of Financial Solvency (HCFA-2572)

2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)

3. Both of the Above : 1. Facility is Eligible to Participate

2. Facility is not Eligible(L21)

22. ORIGINAL DATE

OF PARTICIPATION

23. LTC AGREEMENT

BEGINNING DATE

24. LTC AGREEMENT

ENDING DATE

(L24) (L41) (L25)

27. ALTERNATIVE SANCTIONS25. LTC EXTENSION DATE:

(L27)

A. Suspension of Admissions:

(L44)

B. Rescind Suspension Date:

(L45)

26. TERMINATION ACTION: (L30)

VOLUNTARY

01-Merger, Closure

02-Dissatisfaction W/ Reimbursement

03-Risk of Involuntary Termination

04-Other Reason for Withdrawal

INVOLUNTARY

05-Fail to Meet Health/Safety

06-Fail to Meet Agreement

OTHER

07-Provider Status Change

28. TERMINATION DATE:

(L28) (L31)

31. RO RECEIPT OF CMS-1539 32. DETERMINATION OF APPROVAL DATE

(L32) (L33)

30. REMARKS

00-Active

03/01/1991

00

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21.

FORM CMS-1539 (7-84) (Destroy Prior Editions) 020499

Kamala Fiske-Downing, Enforcement SpecialistDebra Vincent, HFE II

CMS Certification Number (CCN): 245550

March 14, 2018

Mr. Mark Bichler, Administrator

North Star Manor

410 South McKinley Street

Warren, MN 56762

Dear Mr. Bichler:

The Minnesota Department of Health assists the Centers for Medicare and Medicaid Services (CMS) by

surveying skilled nursing facilities and nursing facilities to determine whether they meet the requirements for

participation. To participate as a skilled nursing facility in the Medicare program or as a nursing facility in the

Medicaid program, a provider must be in substantial compliance with each of the requirements established by

the Secretary of Health and Human Services found in 42 CFR part 483, Subpart B.

Based upon your facility being in substantial compliance, we are recommending to CMS that your facility be

recertified for participation in the Medicare and Medicaid program.

Effective February 14, 2018 the above facility is certified for:

45 Skilled Nursing Facility/Nursing Facility Beds

Your facility’s Medicare approved area consists of all 45 skilled nursing facility beds.

You should advise our office of any changes in staffing, services, or organization, which might affect your

certification status.

If, at the time of your next survey, we find your facility to not be in substantial compliance your Medicare and

Medicaid provider agreement may be subject to non-renewal or termination.

Please contact me if you have any questions.

Sincerely,

Kamala Fiske-Downing

Licensing and Certification Program

Minnesota Department of Health

P.O. Box 64900

St. Paul, MN 55164-0900

Telephone: (651) 201-4112 Fax: (651) 215-9697

Email: [email protected]

cc: Licensing and Certification File

P r o t e c t i n g , M a i n t a i n i n g a n d I m p r o v i n g t h e H e a l t h o f A l l M i n n e s o t a n s

An equal opportunity employer.

Electronically delivered March 14, 2018


North Star Manor


Warren, MN 56762

REVISED LETTERREVISED LETTERREVISED LETTERREVISED LETTER

RE: Project Number S5550030

Dear Mr. Bichler:

On January 23, 2018, we informed you that we would recommend enforcement remedies based on the

deficiencies cited by this Department for a standard survey, completed on January 5, 2018. This survey found

the most serious deficiencies to be isolated deficiencies that constituted no actual harm with potential for more

than minimal harm that was not immediate jeopardy (Level D) whereby corrections were required.

On March 6, 2018, the Minnesota Department of Health completed a Post Certification Revisit (PCR) to verify

that your facility had achieved and maintained compliance with federal certification deficiencies issued pursuant

to a standard survey, completed on January 5, 2018. We presumed, based on your plan of correction, that your

facility had corrected these deficiencies as of February 14, 2018. Based on our PCR, we have determined that

your facility has corrected the deficiencies issued pursuant to our standard survey, completed on January 5,

2018, effective March 6, 2018 and therefore remedies outlined in our letter to you dated January 23, 2018, will

not be imposed.

Please note, it is your responsibility to share the information contained in this letter and the results of this visit

with the President of your facility's Governing Body.

Feel free to contact me if you have questions.

Sincerely,




P.O. Box 64900

St. Paul, MN 55164-0900

Telephone: (651) 201-4112 Fax: (651) 215-9697





Electronically delivered March 13, 2018


North Star Manor


Warren, MN 56762


Dear Mr. Bichler:

Please note that this facility has been chosen as a Special Focus Facility (SFF). CMS' policy of progressivePlease note that this facility has been chosen as a Special Focus Facility (SFF). CMS' policy of progressivePlease note that this facility has been chosen as a Special Focus Facility (SFF). CMS' policy of progressivePlease note that this facility has been chosen as a Special Focus Facility (SFF). CMS' policy of progressive

enforcement means that any SFF nursing home that reveals a pattern of persistent poor quality is subject toenforcement means that any SFF nursing home that reveals a pattern of persistent poor quality is subject toenforcement means that any SFF nursing home that reveals a pattern of persistent poor quality is subject toenforcement means that any SFF nursing home that reveals a pattern of persistent poor quality is subject to

increasingly stringent enforcement action, including stronger civil monetary penalties, denial of payment forincreasingly stringent enforcement action, including stronger civil monetary penalties, denial of payment forincreasingly stringent enforcement action, including stronger civil monetary penalties, denial of payment forincreasingly stringent enforcement action, including stronger civil monetary penalties, denial of payment for

new admissions and/or termination of the Medicare provider agreement.new admissions and/or termination of the Medicare provider agreement.new admissions and/or termination of the Medicare provider agreement.new admissions and/or termination of the Medicare provider agreement.

On January 23, 2018, we informed you that we would recommend enforcement remedies based on the

deficiencies cited by this Department for a standard survey, completed on January 5, 2018. This survey found

the most serious deficiencies to be isolated deficiencies that constituted no actual harm with potential for more

than minimal harm that was not immediate jeopardy (Level D) whereby corrections were required.

On March 6, 2018, the Minnesota Department of Health completed a Post Certification Revisit (PCR) to verify

that your facility had achieved and maintained compliance with federal certification deficiencies issued pursuant

to a standard survey, completed on January 5, 2018. We presumed, based on your plan of correction, that your

facility had corrected these deficiencies as of February 14, 2018. Based on our PCR, we have determined that

your facility has corrected the deficiencies issued pursuant to our standard survey, completed on January 5,

2018, effective March 6, 2018 and therefore remedies outlined in our letter to you dated January 23, 2018, will

not be imposed.

Please note, it is your responsibility to share the information contained in this letter and the results of this visit

with the President of your facility's Governing Body.


Sincerely,




P.O. Box 64900

St. Paul, MN 55164-0900

Telephone: (651) 201-4112 Fax: (651) 215-9697





Electronically delivered

March 13, 2018


North Star Manor


Warren, MN 56762

Re: Reinspection Results - Project Number S5550030

Dear Mr. Bichler:

On March 6, 2018 survey staff of the Minnesota Department of Health, Licensing and Certification

Program completed a reinspection of your facility, to determine correction of orders found on the

survey completed on January 5, 2018, with orders received by you on January 23, 2018. At this time

these correction orders were found corrected and are listed on the accompanying Revisit Report Form

submitted to you electronically.

Please note, it is your responsibility to share the information contained in this letter and the results of

this visit with the President of your facility’s Governing Body.

Please feel free to call me with any questions.

Sincerely,




P.O. Box 64900

St. Paul, MN 55164-0900

Telephone: (651) 201-4112 Fax: (651) 215-9697





DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL

PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00356

ID: K1PP

WARREN, MN

1. MEDICARE/MEDICAID PROVIDER NO.

(L1)

2.STATE VENDOR OR MEDICAID NO.

(L2)

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

304842000

2

12/31

01/05/2018

NORTH STAR MANOR245550

02

410 SOUTH MCKINLEY STREET

56762

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

11. .LTC PERIOD OF CERTIFICATION 10.THE FACILITY IS CERTIFIED AS:

From (a) :

To (b) :

A. In Compliance With And/Or Approved Waivers Of The Following Requirements:

Program Requirements

Compliance Based On:

1. Acceptable POC

2. Technical Personnel 6. Scope of Services Limit

3. 24 Hour RN 7. Medical Director

4. 7-Day RN (Rural SNF) 8. Patient Room Size

5. Life Safety Code 9. Beds/Room12.Total Facility Beds 45 (L18)

13.Total Certified Beds 45 (L17) X B. Not in Compliance with Program

Requirements and/or Applied Waivers: * Code: B* (L12)

14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS

18 SNF 18/19 SNF 19 SNF ICF IID 1861 (e) (1) or 1861 (j) (1): (L15)

45

(L37) (L38) (L39) (L42) (L43)

16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):

29. INTERMEDIARY/CARRIER NO.

PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

18. STATE SURVEY AGENCY APPROVAL Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL

RIGHTS ACT:

1. Statement of Financial Solvency (HCFA-2572)

2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)

3. Both of the Above : 1. Facility is Eligible to Participate

2. Facility is not Eligible(L21)

22. ORIGINAL DATE

OF PARTICIPATION

23. LTC AGREEMENT

BEGINNING DATE

24. LTC AGREEMENT

ENDING DATE

(L24) (L41) (L25)

27. ALTERNATIVE SANCTIONS25. LTC EXTENSION DATE:

(L27)

A. Suspension of Admissions:

(L44)

B. Rescind Suspension Date:

(L45)

26. TERMINATION ACTION: (L30)

VOLUNTARY

01-Merger, Closure

02-Dissatisfaction W/ Reimbursement

03-Risk of Involuntary Termination

04-Other Reason for Withdrawal

INVOLUNTARY

05-Fail to Meet Health/Safety

06-Fail to Meet Agreement

OTHER

07-Provider Status Change

28. TERMINATION DATE:

(L28) (L31)

31. RO RECEIPT OF CMS-1539 32. DETERMINATION OF APPROVAL DATE

(L32) (L33)

30. REMARKS

00-Active

03/01/1991

00

00140

02/02/2018 02/23/2018

21.

FORM CMS-1539 (7-84) (Destroy Prior Editions) 020499

Debby Baker, Enforcement SpecialistLisa Carey, HFE NE II


January 23, 2018


North Star Manor


Warren, MN 56762


Dear Mr. Bichler:

Please note that this facility has been chosen as a Special Focus Facility (SFF). CMS' policy of progressive

enforcement means that any SFF nursing home that reveals a pattern of persistent poor quality is subject to

increasingly stringent enforcement action, including stronger civil monetary penalties, denial of payment for

new admissions and/or termination of the Medicare provider agreement.

On January 5, 2018, a standard survey was completed at your facility by the Minnesota Departments of

Health and Public Safety to determine if your facility was in compliance with Federal participation

requirements for skilled nursing facilities and/or nursing facilities participating in the Medicare and/or

Medicaid programs. This survey found the most serious deficiencies in your facility to be isolated

deficiencies that constitute no actual harm with potential for more than minimal harm that is not

immediate jeopardy (Level D) as evidenced by the electronically delivered CMS-2567 whereby

corrections are required.

Please note that this notice does not constitute formal notice of imposition of alternative remedies orPlease note that this notice does not constitute formal notice of imposition of alternative remedies orPlease note that this notice does not constitute formal notice of imposition of alternative remedies orPlease note that this notice does not constitute formal notice of imposition of alternative remedies or

termination of your provider agreement. Should the Centers for Medicare & Medicaid Servicestermination of your provider agreement. Should the Centers for Medicare & Medicaid Servicestermination of your provider agreement. Should the Centers for Medicare & Medicaid Servicestermination of your provider agreement. Should the Centers for Medicare & Medicaid Services

determine that termination or any other remedy is warranted, it will provide you with a separatedetermine that termination or any other remedy is warranted, it will provide you with a separatedetermine that termination or any other remedy is warranted, it will provide you with a separatedetermine that termination or any other remedy is warranted, it will provide you with a separate

formal notification of that determination.formal notification of that determination.formal notification of that determination.formal notification of that determination.

This letter provides important information regarding your response to these deficiencies and addresses

the following issues:

Opportunity to CorrectOpportunity to CorrectOpportunity to CorrectOpportunity to Correct - the facility is allowed an opportunity to correct identified deficiencies - the facility is allowed an opportunity to correct identified deficiencies - the facility is allowed an opportunity to correct identified deficiencies - the facility is allowed an opportunity to correct identified deficiencies

before remedies are imposed;before remedies are imposed;before remedies are imposed;before remedies are imposed;

Electronic Plan of CorrectionElectronic Plan of CorrectionElectronic Plan of CorrectionElectronic Plan of Correction - when a plan of correction will be due and the information to be - when a plan of correction will be due and the information to be - when a plan of correction will be due and the information to be - when a plan of correction will be due and the information to be

contained in that document; contained in that document; contained in that document; contained in that document;

RemediesRemediesRemediesRemedies - the type of remedies that will be imposed with the authorization of the - the type of remedies that will be imposed with the authorization of the - the type of remedies that will be imposed with the authorization of the - the type of remedies that will be imposed with the authorization of the

Centers for Medicare and Medicaid Services (CMS) if substantial compliance is not attained atCenters for Medicare and Medicaid Services (CMS) if substantial compliance is not attained atCenters for Medicare and Medicaid Services (CMS) if substantial compliance is not attained atCenters for Medicare and Medicaid Services (CMS) if substantial compliance is not attained at

the time of a revisit;the time of a revisit;the time of a revisit;the time of a revisit;



Potential ConsequencesPotential ConsequencesPotential ConsequencesPotential Consequences - the consequences of not attaining substantial compliance 3 and 6 - the consequences of not attaining substantial compliance 3 and 6 - the consequences of not attaining substantial compliance 3 and 6 - the consequences of not attaining substantial compliance 3 and 6

months after the survey date; andmonths after the survey date; andmonths after the survey date; andmonths after the survey date; and

Informal Dispute ResolutionInformal Dispute ResolutionInformal Dispute ResolutionInformal Dispute Resolution - your right to request an informal reconsideration to dispute the - your right to request an informal reconsideration to dispute the - your right to request an informal reconsideration to dispute the - your right to request an informal reconsideration to dispute the

attached deficiencies.attached deficiencies.attached deficiencies.attached deficiencies.

Please note, it is your responsibility to share the information contained in this letter and the results of

this visit with the President of your facility's Governing Body.

DEPARTMENT CONTACTDEPARTMENT CONTACTDEPARTMENT CONTACTDEPARTMENT CONTACT

Questions regarding this letter and all documents submitted as a response to the resident care

deficiencies (those preceded by a "F" tag), i.e., the plan of correction should be directed to:

Lyla Burkman, Unit SupervisorLyla Burkman, Unit SupervisorLyla Burkman, Unit SupervisorLyla Burkman, Unit Supervisor

Bemidji Survey TeamBemidji Survey TeamBemidji Survey TeamBemidji Survey Team

Licensing and Certification ProgramLicensing and Certification ProgramLicensing and Certification ProgramLicensing and Certification Program

Health Regulation DivisionHealth Regulation DivisionHealth Regulation DivisionHealth Regulation Division

Minnesota Department of HealthMinnesota Department of HealthMinnesota Department of HealthMinnesota Department of Health

705 5th Street Northwest, Suite A705 5th Street Northwest, Suite A705 5th Street Northwest, Suite A705 5th Street Northwest, Suite A

Bemidji, Minnesota 56601-2933Bemidji, Minnesota 56601-2933Bemidji, Minnesota 56601-2933Bemidji, Minnesota 56601-2933

Email: [email protected]: [email protected]: [email protected]: [email protected]

Phone: (218) 308-2104Phone: (218) 308-2104Phone: (218) 308-2104Phone: (218) 308-2104

Fax: (218) 308-2122Fax: (218) 308-2122Fax: (218) 308-2122Fax: (218) 308-2122

OPPORTUNITY TO CORRECTOPPORTUNITY TO CORRECTOPPORTUNITY TO CORRECTOPPORTUNITY TO CORRECT - DATE OF CORRECTION - REMEDIES- DATE OF CORRECTION - REMEDIES- DATE OF CORRECTION - REMEDIES- DATE OF CORRECTION - REMEDIES

As of January 14, 2000, CMS policy requires that facilities will not be given an opportunity to correct

before remedies will be imposed when actual harm was cited at the last standard or intervening survey

and also cited at the current survey. Your facility does not meet this criterion. Therefore, if your

facility has not achieved substantial compliance by February 14, 2018, the Department of Health will

impose the following remedy:

• State Monitoring. (42 CFR 488.422)

ELECTRONIC PLAN OF CORRECTION (ePoC)ELECTRONIC PLAN OF CORRECTION (ePoC)ELECTRONIC PLAN OF CORRECTION (ePoC)ELECTRONIC PLAN OF CORRECTION (ePoC)

An ePoC for the deficiencies must be submitted within ten calendar daysten calendar daysten calendar daysten calendar days of your receipt of this letter.

Your ePoC must:

- Address how corrective action will be accomplished for those residents found to have

been affected by the deficient practice;

- Address how the facility will identify other residents having the potential to be affected

North Star Manor

January 23, 2018

Page 2

by the same deficient practice;

- Address what measures will be put into place or systemic changes made to ensure that

the deficient practice will not recur;

- Indicate how the facility plans to monitor its performance to make sure that solutions

are sustained. The facility must develop a plan for ensuring that correction is achieved

and sustained. This plan must be implemented, and the corrective action evaluated for

its effectiveness. The plan of correction is integrated into the quality assurance system;

- Include dates when corrective action will be completed. The corrective action

completion dates must be acceptable to the State. If the plan of correction is

unacceptable for any reason, the State will notify the facility. If the plan of correction is

acceptable, the State will notify the facility. Facilities should be cautioned that they are

ultimately accountable for their own compliance, and that responsibility is not alleviated

in cases where notification about the acceptability of their plan of correction is not

made timely. The plan of correction will serve as the facility’s allegation of compliance;

and,

- Submit electronically to acknowledge your receipt of the electronic 2567, your review

and your ePoC submission.

The state agency may, in lieu of a revisit, determine correction and compliance by accepting the

facility's ePoC if the ePoC is reasonable, addresses the problem and provides evidence that the

corrective action has occurred.

If an acceptable ePoC is not received within 10 calendar days from the receipt of this letter, we will

recommend to the CMS Region V Office that one or more of the following remedies be imposed:

• Optional denial of payment for new Medicare and Medicaid admissions (42 CFR

488.417 (a));

• Per day civil money penalty (42 CFR 488.430 through 488.444).

Failure to submit an acceptable ePoC could also result in the termination of your facility’s Medicare

and/or Medicaid agreement.

PRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCEPRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCEPRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCEPRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCE

The facility's ePoC will serve as your allegation of compliance upon the Department's acceptance. Your

signature at the bottom of the first page of the CMS-2567 form will be used as verification of

compliance. In order for your allegation of compliance to be acceptable to the Department, the ePoC

must meet the criteria listed in the plan of correction section above. You will be notified by the

Minnesota Department of Health, Licensing and Certification Program staff and/or the Department of

Public Safety, State Fire Marshal Division staff, if your ePoC for the respective deficiencies (if any) is

North Star Manor

January 23, 2018

Page 3

acceptable.

VERIFICATION OF SUBSTANTIAL COMPLIANCEVERIFICATION OF SUBSTANTIAL COMPLIANCEVERIFICATION OF SUBSTANTIAL COMPLIANCEVERIFICATION OF SUBSTANTIAL COMPLIANCE

Upon receipt of an acceptable ePoC, an onsite revisit of your facility may be conducted to validate that

substantial compliance with the regulations has been attained in accordance with your verification. A

Post Certification Revisit (PCR) will occur after the date you identified that compliance was achieved in

your plan of correction.

If substantial compliance has been achieved, certification of your facility in the Medicare and/or

Medicaid program(s) will be continued and remedies will not be imposed. Compliance is certified as of

the latest correction date on the approved ePoC, unless it is determined that either correction actually

occurred between the latest correction date on the ePoC and the date of the first revisit, or correction

occurred sooner than the latest correction date on the ePoC.

Original deficiencies not correctedOriginal deficiencies not correctedOriginal deficiencies not correctedOriginal deficiencies not corrected

If your facility has not achieved substantial compliance, we will impose the remedies described above.

If the level of noncompliance worsened to a point where a higher category of remedy may be imposed,

we will recommend to the CMS Region V Office that those other remedies be imposed.

Original deficiencies not corrected and new deficiencies found during the revisitOriginal deficiencies not corrected and new deficiencies found during the revisitOriginal deficiencies not corrected and new deficiencies found during the revisitOriginal deficiencies not corrected and new deficiencies found during the revisit

If new deficiencies are identified at the time of the revisit, those deficiencies may be disputed through

the informal dispute resolution process. However, the remedies specified in this letter will be imposed

for original deficiencies not corrected. If the deficiencies identified at the revisit require the imposition

of a higher category of remedy, we will recommend to the CMS Region V Office that those remedies be

imposed.

Original deficiencies corrected but new deficiencies found during the revisitOriginal deficiencies corrected but new deficiencies found during the revisitOriginal deficiencies corrected but new deficiencies found during the revisitOriginal deficiencies corrected but new deficiencies found during the revisit

If new deficiencies are found at the revisit, the remedies specified in this letter will be imposed. If the

deficiencies identified at the revisit require the imposition of a higher category of remedy, we will

recommend to the CMS Region V Office that those remedies be imposed. You will be provided the

required notice before the imposition of a new remedy or informed if another date will be set for the

imposition of these remedies.

FAILURE TO ACHIEVE SUBSTANTIAL COMPLIANCE BY THE THIRD OR SIXTH MONTH AFTER THE LASTFAILURE TO ACHIEVE SUBSTANTIAL COMPLIANCE BY THE THIRD OR SIXTH MONTH AFTER THE LASTFAILURE TO ACHIEVE SUBSTANTIAL COMPLIANCE BY THE THIRD OR SIXTH MONTH AFTER THE LASTFAILURE TO ACHIEVE SUBSTANTIAL COMPLIANCE BY THE THIRD OR SIXTH MONTH AFTER THE LAST

DAY OF THE SURVEYDAY OF THE SURVEYDAY OF THE SURVEYDAY OF THE SURVEY

If substantial compliance with the regulations is not verified by April 5, 2018 (three months after the

identification of noncompliance), the CMS Region V Office must deny payment for new admissions as

mandated by the Social Security Act (the Act) at Sections 1819(h)(2)(D) and 1919(h)(2)(C) and Federal

regulations at 42 CFR Section 488.417(b). This mandatory denial of payments will be based on the

failure to comply with deficiencies originally contained in the Statement of Deficiencies, upon the

North Star Manor

January 23, 2018

Page 4

identification of new deficiencies at the time of the revisit, or if deficiencies have been issued as the

result of a complaint visit or other survey conducted after the original statement of deficiencies was

issued. This mandatory denial of payment is in addition to any remedies that may still be in effect as of

this date.

We will also recommend to the CMS Region V Office and/or the Minnesota Department of Human

Services that your provider agreement be terminated by July 5, 2018 (six months after the

identification of noncompliance) if your facility does not achieve substantial compliance. This action is

mandated by the Social Security Act at Sections 1819(h)(2)(C) and 1919(h)(3)(D) and Federal

regulations at 42 CFR Sections 488.412 and 488.456.

INFORMAL DISPUTE RESOLUTIONINFORMAL DISPUTE RESOLUTIONINFORMAL DISPUTE RESOLUTIONINFORMAL DISPUTE RESOLUTION

In accordance with 42 CFR 488.331, you have one opportunity to question cited deficiencies through

an informal dispute resolution process. You are required to send your written request, along with the

specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies, to:

Nursing Home Informal Dispute Process


Health Regulation Division

P.O. Box 64900

St. Paul, Minnesota 55164-0900

This request must be sent within the same ten days you have for submitting an ePoC for the cited

deficiencies. All requests for an IDR or IIDR of federal deficiencies must be submitted via the web at:

http://www.health.state.mn.us/divs/fpc/profinfo/ltc/ltc_idr.cfm

You must notify MDH at this website of your request for an IDR or IIDR within the 10 calendar day

period allotted for submitting an acceptable plan of correction. A copy of the Department’s informal

dispute resolution policies are posted on the MDH Information Bulletin website at:

http://www.health.state.mn.us/divs/fpc/profinfo/infobul.htm

Please note that the failure to complete the informal dispute resolution process will not delay the

dates specified for compliance or the imposition of remedies.

Questions regarding all documents submitted as a response to the Life Safety Code deficiencies (those

preceded by a "K" tag), i.e., the plan of correction, request for waivers, should be directed to:

Mr. Tom Linhoff, Fire Safety SupervisorMr. Tom Linhoff, Fire Safety SupervisorMr. Tom Linhoff, Fire Safety SupervisorMr. Tom Linhoff, Fire Safety Supervisor

Health Care Fire Inspections Health Care Fire Inspections Health Care Fire Inspections Health Care Fire Inspections

Minnesota Department of Public Safety Minnesota Department of Public Safety Minnesota Department of Public Safety Minnesota Department of Public Safety

State Fire Marshal Division State Fire Marshal Division State Fire Marshal Division State Fire Marshal Division

445 Minnesota Street, Suite 145 445 Minnesota Street, Suite 145 445 Minnesota Street, Suite 145 445 Minnesota Street, Suite 145

St. Paul, Minnesota 55101-5145 St. Paul, Minnesota 55101-5145 St. Paul, Minnesota 55101-5145 St. Paul, Minnesota 55101-5145

North Star Manor

January 23, 2018

Page 5

Email: [email protected] Email: [email protected] Email: [email protected] Email: [email protected]

Telephone: (651) 430-3012 Telephone: (651) 430-3012 Telephone: (651) 430-3012 Telephone: (651) 430-3012

Fax: (651) 215-0525 Fax: (651) 215-0525 Fax: (651) 215-0525 Fax: (651) 215-0525


Sincerely,

Joanne Simon, Enforcement Specialist



Program Assurance Unit


Telephone: 651-201-4161 Fax: 651-215-9697



North Star Manor

January 23, 2018

Page 6

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 02/22/2018FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

245550 01/05/2018STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

410 SOUTH MCKINLEY STREETNORTH STAR MANOR

WARREN, MN 56762

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

E 000 Initial Comments E 000

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted 1/2/18, through 1/5/18, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

F 000 INITIAL COMMENTS F 000

A recertification survey was conducted January 2nd, 3rd, 4th, and 5th, 2018.

Upon receipt of an acceptable electronic POC, an on-site revisit of your facility may be conducted to validate that substantial compliance with the regulations has been attained in accordance with your verification.

The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Because you are enrolled in ePOC, your signature is not required at the bottom of the first page of the CMS-2567 form. Your electronic submission of the POC will be used as verification of compliance.

The North Star Manor is a Special Focus Facility (SFF) and a certification survey was conducted on 1/2/18- 1/5/18.

F 578SS=D

Request/Refuse/Dscntnue Trmnt;Formlte Adv DirCFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be

F 578 2/14/18

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

02/01/2018Electronically Signed

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete K1PP11Event ID: Facility ID: 00356 If continuation sheet Page 1 of 32

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F 578 Continued From page 1 F 578construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.This REQUIREMENT is not met as evidenced by: Based on document review and interview, the facility failed to ensure resident resuscitation wishes were correctly identified in the electronic health record (EHR) based on signed advanced

1.--A. R12'S EHR Advance Directive was updated on 1.12.18 by the physician to be consistent with the "DNR Order" per the 6.11.04 Living Will Declaration. A new MN


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F 578 Continued From page 2 F 578directives for 2 of 6 residents (R12, R182) reviewed for advanced directives.

Findings include:

R12's EHR Admission Record dated 1/3/18, indicated R12's advance directive was to resuscitate (CPR-cardiopulmonary resuscitation).

R12's signed Living Will Declaration dated 6/11/04, indicated R12 did not want cardiac resuscitation, mechanical respiration or artificial feeding or fluids by tubes. The Living Will also indicated R12 specifically did not want any life-prolonging treatment if it was determined R12 had Alzheimer's disease.

The Admission Record/EHR was inconsistent with the signed Living Will Declaration which indicated R12 did not want cardiac resuscitation.

On 1/5/18, at 3:14 p.m. the licensed social worker (LSW) confirmed the admission record/EHR was inconsistent with R12's Living Will Declaration and verified they should be consistent. R182's EHR Admission Record dated 1/4/18, indicated R182's advance directive was to not resuscitate (DNR).

R182's signed paper copy of Health Care Directives dated 3/6/07, indicated R182 did not want CPR or artificial respiration necessary to revive him performed more than twice.

R182's EHR physician order dated 12/28/17, reflected the advance directive "DNR" (do not resuscitate).

The physician order and Admission Record were

Health Directive was received by the facility on 1.31.18 and entered into the EHR and the 6.11.04 Living Will Declaration was removed. Both the physician order of 1.12.18 and the new MN Health Care Directive dated 1.31.18 are now entered correctly into the EHR to reflect resident wishes for DNR.

1.--B. R182'S Advance Directive is replaced as of 1.31.18 to reflect the medical provider's EHR "DNR order" dated 12.18.17. Advance Directive dated 3.06.07 is replaced with a new MN Health Care Directive form with clarified DNR wishes.

2. All residents have the potential to be adversely affected by deficient practice of not having correct Advance Directives that are clearly stated and ordered by a physician/provider. All Advance Directives and medical orders will be reviewed for inconsistencies by 2.14.18. If inconsistencies are found, clarifications will be made with the primary physician/provider and family/POA. The clarifications will be uploaded into the EHR by 2.14.18.

3. The facility will review and revise the policy for Advance Directives. The facility will create an Advance Directive Book. The hard copy of the new Advance Directive physician/provider order will be placed in the Book. This book will be located in the nurses communication room. All residents Advance


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F 578 Continued From page 3 F 578inconsistent with the signed advance directives which indicated resuscitation efforts should be performed, but not more than twice.

On 1/4/17, at 11:37 p.m. the LSW verified the signed advance directives were inconsistent with the physician orders and Admission Record, and stated they should be consistent.

Facility policy dated Advance Care Planning and Advance Directives last revised 4/2016 included: -Residents an resident surrogate or proxy decision makers have the right to make decisions concerning medical care, including the right to accept or to refuse medical or surgical treatment. Residents have the right to formulate advance directives.-Admission or Readmission1. At the time of admission or readmission the social worker asks the resident/healthcare decision maker whether he or she has prepared an advance directive such as a living will, durable power of attorney for healthcare decisions, guardianship, portable and enduring order form ect. 5. If an advance directive has been formulated, a copy will be scanned into the medical record. -During Stay3 (f). Completed portable and enduring order forms will be treated as physican's orders an placed in the medical record. 9. Once the staff member has determined the wishes of the resident/healthcare decision maker, the physician will be notified of the resident's wishes and asked to give orders. 10. Physician's orders in response to resident's requests and/or advance directives regarding life sustaining measures must be specific, e.g. do

Directives/physicians orders will be reviewed upon admission or re-admissions, significant changes, quarterly care conference, and during the residents annual care conference to ensure consistent Advance Directives are in our EHR.

4. The Admission Checklist will be revised to include Advance Directives that match physician/provider orders, and that they are received upon Admission/Re-Admission. For 8 weeks, all new Admissions/Re-Admissions, will be reviewed for Advance Directives by two nurses to ensure compliance, with results reported to QAPI committee that the current Advance Directives are signed by a physician/provider, uploaded into the EHR, and a written copy of the order and Advance Directive placed in the Advance Directive Book. If compliance is found after 8 weeks then residents' code status will be reviewed monthly during the QAPI meeting to assure continued compliance.Employees will be trained on the Plan of Correction at staff meetings scheduled for 2.07.18. Those not in attendance will be required to view the taped meeting prior to working their next shift.

5. Correction by 2.14.18


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F 578 Continued From page 4 F 578resuscitate or do not resuscitate, whether to hospitalize, whether antibiotics are to be used, ect. "code" or "no code" order do not have a universally accepted definition and therefore will not be accepted. 6. As necessary, physicians will be contacted for orders that reflect the resident's wishes.

F 607SS=D

Develop/Implement Abuse/Neglect PoliciesCFR(s): 483.12(b)(1)-(3)

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,This REQUIREMENT is not met as evidenced by:

F 607 2/14/18

Based on interview, and document review, the facility failed to operationalize their Abuse Prevention Plan related to immediately reporting of an elopement to the administrator and State agency for 1 of 1 resident (R30) who had eloped from the facility.

The findings include:

Review of the facilities Abuse and Neglect policies and procedures last revised 11/2016, indicated any employee that has knowledge of neglect of a resident or has reasonable cause to the believe that a resident has been neglected,

1. Due to the fact that we failed to follow our Policy, the incident was not reported to the Administrator or state agency in a timely manner. It cannot be corrected now. For the future, to operationalize our policy, all incidents of abuse, neglect, or elopement will be reported timely to the Administrator according to our policy. Wanderguard band use and placement is now on the Treatment Record to be checked each shift by the nurse or CMA to ensure the band is on the resident as ordered.2. All incidents of suspected abuse,


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F 607 Continued From page 5 F 607after safeguarding the resident, must report the information to the supervisor who in turn would immediately report the allegation or incident to the facility administrator in accordance with state law. The policy also indicated if there was an allegation or suspicion of neglect it would be reported no later than two hours to the state officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long term care centers) in accordance with state law.

R30's admission record dated, 1/5/17 indicated R30's diagnoses included Alzheimer's disease with early onset and wandering.

R30's progress note (subtype: incident note) dated 11/5/17, at 15:47 p.m. indicated R30's family member had been at the facility to visit. When the family member left the facility, staff witnessed R30 attempt to follow family member outside at which time staff noticed the wander guard which alerted staff when R30 attempted to leave the facility, was not on R30's ankle. Staff kept R30 preoccupied by sweeping the 400 hallway while they searched his room for 5-10 minutes for the wander guard which was found at the bottom of the garbage can in his room. After staff had found the wander guard, they discovered R30 was no longer in the hallway sweeping, and had asked another nursing assistant where R30 was. That nursing assistant thought R30 was in the 200 hallway. While searching the 200 hallway, through a window, staff had visualized R30 standing outside in the parking lot. R30 was brought back inside the building.

R30's Elopement incident report indicated the

neglect, or elopement have the potential to not be reported to the Administrator and/or state agency in a timely manner according to our policy.3. The Administrator, DON, SW and others meet daily to review and sign off on all Risk Management issues including potential abuse, neglect or elopement, to ensure that proper notification has been made to the Administrator, family/responsible party, and physician/provider. Staff nurses are being trained on how to complete the required on line initial reports within 2 hours to the state agency and to inform the Administrator of any reportable issues according to our policy. Further mandatory training will occur 2 times on 2.7.18 for all staff. Any staff not able to attend will be required to view the taped training meeting prior to working their next shift.4. All incidences of potential abuse, neglect, or elopement will be reviewed by the Risk Management committee Monday -Friday for compliance to notify the Administrator in a timely manner for 8 weeks so that a report can be made within the two hour required time frame to the state agency if necessary. If an incident occurs on a weekend, the staff are trained to report it to the Administrator and it will be determined if a report needs to be filed with the state agency at that time. Every Monday-Friday Risk Management team will ensure that the Administrator and DON were notified of any potential incidents, and that a timely report was sent to the state agency if required, with


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F 607 Continued From page 6 F 607incident occurred on 11/5/17, at 2:30 p.m. The incident description mirrored the incident report note. The investigation indicated R30 did not have any injuries and R30 had removed the wander guard with nail clippers that were found in his bathroom, which staff removed upon discovery. The report indicated the director of nursing, the physician, and R30's family were notified timely, however, did not indicate the administrator or State agency was notified.

On 1/5/18, at 1:46 p.m. administrator stated he had been aware of R30's witnessed attempt to go outside after a family visit, however was not aware R30 had made it outside unwitnessed after the first attempt. The administrator verified the elopement was not reported to the State agency and should have been and would have been if he would have had knowledge of it.

results reported to the QAPI committee for further review and/or recommendations. To ensure compliance is sustained Risk Management Team will continue to meet Monday thru Friday and decisions continue to be made on the weekends in conjunction with the charge nurse, and Administrator and/or DON. The QAPI team will review incidents monthly for proper notification of the Administrator and if a report was filed timely if necessary.5. Completion by 02.14.18

F 609SS=D

Reporting of Alleged ViolationsCFR(s): 483.12(c)(1)(4)

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and

F 609 2/14/18


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F 609 Continued From page 7 F 609adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.This REQUIREMENT is not met as evidenced by: Based on interview, and document review, the facility failed to report an elopment immediately to the administrator and the State agency for 1 of 1 resident (R30) who had eloped from the facility.

Findings include:

R30's progress note (subtype: incident note) dated 11/5/17, at 15:47 p.m. indicated R30's family member had been at the facility to visit. When the family member left the facility, staff witnessed R30 attempt to follow family member outside at which time staff noticed the wander guard which alerted staff of R30's attempt to leave the facility, was not on R30's ankle. The note indicated staff kept R30 preoccupied by sweeping the 400 hallway while they searched his room for 5-10 minutes for the wander guard which was found at the bottom of the garbage can in his room. After staff had found the wander guard, they discovered R30 was no longer in the hallway sweeping and asked another nursing assistant where R30 was. That nursing assistant thought R30 was in the 200 hallway. While searching the 200 hallway, through a window,

1. Due to the fact that we failed to follow our Policy, the elopement was not reported to the Administrator or state agency in the two hour time frame. The time frame for timely reporting has lapsed, therefore it cannot be submitted timely now. For the future, all suspected incidents of abuse, neglect, or elopement will be reported timely to the Administrator according to our reviewed policy so that they can be reported to the state agency timely. 2. All incidents of suspected abuse, neglect, or elopement have the potential to not be reported to the Administrator and/or state agency in a timely manner according to our policy.3. The Administrator, DON, SW and others meet daily to review and sign off on all Risk Management issues including suspected abuse, neglect or elopement, to ensure that proper notification has been made to the Administrator, family/responsible party, and physician/provider. Staff nurses, including


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F 609 Continued From page 8 F 609staff had visualized R30 standing outside in the parking lot. R30 was brought back inside the building.

R30's Elopement incident report indicated the incident occurred on 11/5/17, at 2:30 p.m. The incident description mirrored the incident report note. The investigation indicated R30 did not have any injuries and R30 had removed the wander guard with nail clippers that were found in his bathroom, which staff removed upon discovery. The report indicated the director of nursing, the physician and R30's family member were notified of the incidnent, timely. However, the report did not indicate the administrator or State agency had been notified.

On 1/5/18, a 1:46 p.m. the administrator stated he had been aware of R30's witnessed attempt to go outside after a familyu visit, however was not aware R30 had made it outside unwitnessed after the first attempt. The administrator verified the elopement was not reported to the State agency and should have been and would have been if he would have had knowledge of it.

Facility policy Abuse Definitions last revised 9/16, indicated the definition of neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental abuse.

Facility policy and procedure Abuse and Neglect last revised on 11/2016, indicated any employee that has knowledge of neglect of a resident or has reasonable cause to the believe that a resident has been neglected, after safeguarding the resident, must report the information to the supervisor who in turn would immediately report the allegation or incident to the facility

the DON and Social Worker, are being trained on how to complete the required on line initial reports within 2 hours to the state agency and to inform the Administrator of any reportable issues according to our policy. Further mandatory training will occur 2 times on 2/7/18 for all staff. Any staff not able to attend will be required to view the taped training meeting prior to working their next shift.4. All incidences of potential abuse, neglect, or elopement will be reviewed by the Risk Management committee Monday -Friday for compliance to notify the Administrator in a timely manner for 8 weeks so that a report can be made within the two hour required time frame to the state agency if necessary. If an incident occurs on a weekend, the staff are trained to report it to the Administrator and it will be determined if a report needs to be filed with the state agency at that time. Every Monday-Friday Risk Management team will ensure that the Administrator and DON were notified of any potential incidents, and that a timely report was sent to the state agency if required, with results reported to the QAPI committee for further review and/or recommendations. To ensure compliance is sustained Risk Management Team will continue to meet Monday thru Friday and decisions continue to be made on the weekends in conjunction with the charge nurse, and Administrator and/or DON. The QAPI team will review incidents monthly for proper notification of the Administrator and if a report was filed timely if


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F 609 Continued From page 9 F 609administrator in accordance with state law. The policy also indicated if there was an allegation or suspicion of neglect it would be reported no later than two hours to the state officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long term care centers) in accordance with state law.

necessary.

5. Completion by 02.14.18

F 655SS=D

Baseline Care PlanCFR(s): 483.21(a)(1)-(3)

§483.21 Comprehensive Person-Centered Care Planning§483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-(i) Be developed within 48 hours of a resident's admission.(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-(A) Initial goals based on admission orders.(B) Physician orders.(C) Dietary orders.(D) Therapy services.(E) Social services.(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-(i) Is developed within 48 hours of the resident's admission.(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of

F 655 2/14/18


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F 655 Continued From page 10 F 655this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:(i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions.(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.(iv) Any updated information based on the details of the comprehensive care plan, as necessary.This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to develop a baseline/admission care plan for wandering for 1 of 2 residents (R182) reviewed for wandering behaviors.

Findings include:

R182's facility Admission Record dated 1/4/18, included diagnoses of Alzheimer's and dementia with a history of falling.

R182's admission Minimum Data Set (MDS) dated 12/5/17, indicated severe cognitive impairment and had wandering behaviors four to six days during the assessment period that significantly intruded on the privacy and activities of others. The MDS further indicated, R182 walked independently in his room, however, required supervision when walking in the corridor, and when walking on and off the unit.

R182's delirium Care Area Assessment (CAA)

1. R182 now has Care Plan that includes goals and interventions for wandering dated 1/8/18.

2. All Residents admitted with diagnosis of Alzheimer's/dementia with wandering could be adversely affected by not having a baseline plan of care developed within 48 hours.

3. The facility policy will be reviewed and to ensure that a baseline plan care to meet the residents immediate needs shall be developed for each resident within 48 hours. The staff will be retrained and educated at the mandatory staff meeting to be held 2/7/18. Those not in attendance will be required to watch the video before they work their next scheduled shift.This policy change will be added to the Admission checklists. The Wandering Risk Scale, and the Vulnerable Adult


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F 655 Continued From page 11 F 655dated 12/29/17, indicated R182 had dementia, and because he couldn't remember where his room was, personal identifiers were placed on his door. The CAA also indicated R182 had a wanderguard on his ankle related to excessive wandering and looking for his wife.

R182's physician orders included; wanderguard placed for safety. The order was dated 12/18/17. R182's Wandering Risk Scale dated 12/18/17, indicated high risk for wandering, and a wanderguard was applied to left ankle due to confusion and wanting to find his wife. The assessment also indicated R182 was very confused and disorientated.

R182's Vulnerable Adult Assessment dated 12/18/17, indicated R182 was vulnerable to abuse/neglect related to wandering, impaired judgment, confusion, forgetfulness, dementia diagnosis, and cognition varied.

R182's Wandering Risk Scale dated 12/21/17, indicated R182 was at high risk for wandering with risk factors that included a history of wandering and medical diagnosis of dementia or cognitive impairment. R182's baseline care plan lacked a plan of care for wandering that included goals and interventions.

On 1/3/18, at 9:10 a.m. R182 had a wanderguard on his left ankle, he was observed walking with his walker up and down the 400 hallway stopping and looking in other residents rooms for his wife.

On 1/5/18, at 8:48 a.m. R182 walked with his

Assessment will be done with in 48 hours of admission to identify goals and interventions.

4. All new admissions since 1/5/18 will be audited to ensure that a Wandering Risk Scale and Vulnerable Adult Assessments, and a baseline Plan of Care have been completed within 48 hours of admission. DON or designee will review all charts of admissions for 8 weeks with results being given to the Risk Management team weekly. Risk Management Team will provide audit results to the QAPI committee for further review and recommendations. If 100% compliance is achieved after 8 weeks then the QAPI will continue to review all admissions for compliance at the regular monthly meetings.

5. Correction by 2/14/18.


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F 655 Continued From page 12 F 655walker down the 400 hallway; R182 stopped and looked in every room. R182 stated he was looking for his room. At 8:50 a.m. registered nurse (RN)-B escorted R182 back to his room.

Progress note dated 12/18/17, indicated R182 was walking in the hallway and stated he was lost looking for his wife. Progress note dated 12/20/17, indicated R182 continued to wander around the facility, had to be repeatedly redirected, and had very short-term memory.

Occupational therapy progress note dated 12/21/17, indicated R182 was found in another resident's room and was redirected.

Progress note dated 12/25/17, indicated R182 repeatedly asked to call his wife and location of room. The note further indicated the resident was redirected from calling his wife and staff continued to show R182 the location of his room.

On 1/5/18, at 2:14 p.m. director of nursing (DON) verified the lack of a baseline care plan for wandering and it should have been developed within 48 hours of admission.

Facility policy Care Plans-Baseline (not dated) indicated the following: -A baseline plan of care to meet the resident's immediete needs shall be developed for each resident within forty eight hour of admission.-The interdisciplinary team would review the healcare practioner's orders and implement a baseline care plan to meet the resident's immediate care needs including but not limited to:


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F 655 Continued From page 13 F 655initial goals based on admission orders, physician order, dietary orders, therapy services, and social services. -The baseline care plan will be used until staff can conduct the comprehensive assessment and develop an interdisciplinary person centered care plan. -The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to initial goals of the resident, any services and treatments to be administered by the facility and personnel acting on behalf of the facility and any updated information based on the details of the comprehensive care plan as necessary.

F 684SS=D

Quality of CareCFR(s): 483.25

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.This REQUIREMENT is not met as evidenced by:

F 684 2/14/18

Based on observation, interview, and document review the facility failed to provide appropriate wheelchair positioning for 1 of 1 resident (R15) reviewed for positioning. In addition, the facility failed to ensure edema (swelling) management program was followed for 1 of 1 resident (R182) who had bilateral lower extremity edema with pretense of blood clot in left lower extremity.

1. A.--R15's wheelchair was assessed on 1/4/18 by Occupational Therapist for positioning concerns. R15 received a different wheelchair 1/4/18. Trial with wider wheelchair and pressure reducing cushion was implemented with a positive results for proper positioning. R15's care plan was updated on 1/4/18. Care Plan was completed 1/23/18 with updates.


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F 684 Continued From page 14 F 684Findings include:

R15 was not provided appropriate wheelchair (w/c) positioning.

R15's Admission record dated 1/5/18, included diagnoses of osteoarthritis, pain, and dementia.

R15's annual Minimum Data Set (MDS) dated 10/11/17, indicated severe cognitive impairment, required extensive assist with transfers, utilized a manual w/c, and required staff supervision and cues once in w/c.

R15's careplan dated 10/25/17, indicated R15 had limited physical mobility and utilized a w/c for locomotion and was able to self propel. The care plan further indicated R15 had the potential for pressure ulcer development related to incontinence and limitations in mobility. The care plan directed staff to monitor for significant changes in mobility, positioning device, stand and sitting and Physical Therapy to evaluate quarterly for proper w/c alignment/fit.

On 1/3/17, from 3:15 p.m. to 4:20 p.m. R15 was observed seated in the w/c, sliding forward with thighs pressing against the sides of the w/c. R15's wheelchair appears too small for her. Staff was not observed to provide/assist with repositioning.

On 1/4/18, at 9:45 a.m. R15 was observed seated in the w/c. R15 looked uncomfortable with a sliding forward position and the lateral aspects of both thighs were pressing into the sides of the w/c.

-10:07 a.m. R15 appeared to be sliding down in

1. B.--R182's Care Plan Focus for edema/blood clot was updated on 1/7/18 by RN to include monitoring signs of edema in left leg. The provider's order was obtained on 1/3/18 for clarification for left compression stocking use to be applied daily in the morning and removed at night. Two compression stockings have been provided. R182 was seen on 1-15-18 for blood clot follow up. The TAR has been reviewed to include placement of the compression stockings to his left lower leg. No orders are received for the right leg. Placement of the compression stocking is placed on the TAR and changed from calf to thigh high on 1/16/18 for left leg. Physician Orders are clarified.

2. All residents have the potential to be affected by improper wheelchair positioning and/or failure to ensure edema management.

3. A. & B. The facility will review/evaluate and identify all residents in wheelchairs(A), or who have edema(B), who could potentially have poor wheelchair positioning or edema and be affected by these deficient practices. Complete referrals to Physical Therapy or Occupational Therapy have been made as needed. These will be completed by 2/14/18.The policies/procedures relating to appropriate wheelchair positioning and compression stockings will be reviewed & updated by the DON, MDS Coordinator, Physical Therapy and Occupational Therapy and approved by the


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F 684 Continued From page 15 F 684w/c, R15 attempted to reposition self in w/c, but was unable to do so. Staff was not observed to provide assistance with repositioning.

-10:24 a.m. nursing assistant (NA)-B was observed to assist R15 with toileting needs. NA-B assisted resident to her room. NA-B applied a transfer belt and provided a four wheeled walker for resident to hold on to and assisted R15 to a standing position. NA-B lowered R15's pants. R15's left leg was observed to have a reddened area from approximately 4 inches above her knee to the buttocks on the lateral thigh. The outer aspect of right thigh was observed to have an area of redness approximately 4 inches by 1 inch in size. The reddened areas were blanchable and no open areas were observed. NA-B confirmed the areas were reddened. NA-B stated he had not previously observed any reddened areas during provisions of cares and would inform the nurse. NA-B stated R15's w/c was very snug, was too small and R15 appeared as though she was sliding out of it.

-10:34 a.m. occupational aide (OA)- A stated the occupational therapist completed the R15's initial assessment and would not have reassessed R15 unless there was a complaint from nursing or another cause for a re-evaluation. OA-A stated R15 scooted down when she was in her w/c in order to self propel. OA-A confirmed R15's w/c was a firm fit with not much room for movement and was not an appropriate size for the resident. OA-A stated R15 should have had side adjustments made to w/c to allow for a better fit.

-10:45 a.m. family member (FM)-A laughed and stated R15 looked like she was stuffed into the chair but had managed to get around in it, ok.

Administrator. The updated policy/procedures will be submitted to the QAPI committee for final review and approval, followed by mandatory training of all staff on 2/7/18. Staff that do not attend will watch the video and sign off before working their next shift. Completion date 2.14.18.Review/revisions of the current PT/OT referral form will be updated to include the new guidelines. Assessments will include looking for areas of concern during cares, toileting, compromised skin integrity and repositioning concerns for those who are at risk and can't reposition themselves.Nursing will document in the progress notes the treatment response for edema if a change is noticed.

4. A. Facility will identify and assess all residents who use a wheelchair for proper positioning and use with a Roster of residents who use wheelchairs. Any resident identified with improper positioning will be referred to OT for an evaluation and recommendations by 2/14/18. On going review of positioning will be added to their respective Care Plans and placed on the nurse aides plan of care in EHR and looked daily. QAPI team will review monthly the roster and the plan care to ensure that residents are in fact positioned properly. To ensure sustainability we will review concerns at the morning Risk Management committee weekly for 4 weeks and results given to the QAPI for any further recommendations.4. B. HIM will run a report of all residents


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F 684 Continued From page 16 F 684FM-A stated last summer they had tried to change her w/c, but that had not seemed to work and confirmed there had been no attempts to change it.

-11:57 a.m. the occupational therapist (OT) confirmed R15's w/c did not fit her appropriately as R15 leaned to the side, slid down in it, and was not able to reposition herself in it. The OT stated on July 3, 2017, an attempt was made to refit R15 with a different w/c due to improper fit. OT stated the attempt failed and R15 cried and upon returning R15 to her previous w/c she appeared more content. OT stated we wondered if the pressures from the sides of her w/c was a comfort issue for her. OT confirmed R15 has positioning issues with her current w/c, and no attempts had been implemented to try to provide a different w/c since July 2017. The OT stated "Every time I walked by her I said we need to do something about that w/c."

-2:40 P.M. the Director of Nursing (DON) confirmed R15 had poor w/c positioning and interventions should have been implemented and attempts made for positioning and proper fit of her w/c.

A policy related to appropriate w/c positioning was requested and none was provided. R182's Admission Record included diagnoses that were present on admission were Alzheimer's disease, atrial fibrillation, and edema (swelling).

R182's admission Minimum Data Set (MDS) indicated R182 had severe cognitive impairment, and required extensive assistance from one staff member for dressing.

who have a diagnosis of edema or ted hose/compression stockings. DON or designee will audit the roster daily for 8 weeks to ensure edema monitoring per the care plans are followed. Results will be reported to the Risk Management team weekly who will report findings to the QAPI team monthly for any further actions.

5. Correction will be completed by 2/14/18.


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F 684 Continued From page 17 F 684R182's admission physician history and physical dated 12/14/17, indicated R182 had a history of chronic atrial fibrillation and DVT (deep vein thrombosis or blood clot) and on physical exam R182's extremities did not have edema.

Occupational therapy progress note dated 12/28/17, indicated R182 had pitting edema throughout the left lower leg and foot; because of the edema, his shoe did not latch properly. The note also indicated R182 had not previously worn compression stockings, was fitted for a knee high opened toe compression stocking as a trial, and R182 had stated it felt good to have it on. The note also included he was given two stockings so one could be washed out and one to wear. The note further informed staff R182, had a blood clot in the left leg below the knee that was getting smaller according to an ultrasound performed on 12/27/17.

Occupational therapy progress note dated 12/29/17, indicated nursing was asked to monitor and be in-charge of the wearing schedule of the compression stocking. The occupational therapist had viewed R182's lower extremity with the stocking on and it was much more flexible with minimal swelling noted where the stocking had been in place. The note indicated the plan to continue to monitor left lower extremity swelling.

Nursing progress note dated 12/29/17, indicated the physician ordered compression stockings to both leg, on in the morning and off at bedtime. According to R182's physician orders on 1/3/18, the order was changed to apply compression stocking to the left leg, on in the morning and off at bedtime.


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F 684 Continued From page 18 F 684R182's baseline circulatory care plan dated 12/29/17, indicated R182 had circulatory problems, informed staff R182 had problems with left leg swelling, and directed staff to apply a knee high compression stocking to the left leg. The care plan also directed staff to monitor the left leg for edema, warmth, and discoloration with each donning and removal of the stockings each morning and night. The care plan also directed staff to notify the MD with any change in condition of the leg regarding color, heat/cold, increased edema or increased pain.

R182's record lacked evidence of edema monitoring per the care plan with the exception of the occupational therapy note dated 12/29/17.

Nursing progress note dated 1/2/18, indicated compression stockings to both lower extremities were not applied because they were in the wash.

R182's treatment administration record (TAR) indicated R182's compression stockings were not applied on the morning of 1/2/18 or the morning of 1/3/18.

On 1/3/18, at 10:23 a.m. R182 sat in his wheelchair in his room. R182 was wearing white cotton socks and not the compression socks per physician order. R182 had swelling in both of his legs from ankle to lower calf. R182's left shoe was tight due to the edema.

On 1/4/18, at 7:38 a.m. R182 was walking back to his room with nursing assistant (NA)-D. R182 had on cotton socks; both lower extremities remained edematous. NA-D assisted R182 with morning cares and put on the left compression stocking. NA-D indicated R182 was supposed to have


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F 684 Continued From page 19 F 684them on in the morning. R182's left shoe remained tight related to the swelling.

On 1/4/18, at 11:09 a.m. director of nursing (DON) stated occupational therapy initiated the compression sock related to swelling. DON stated R182 should have more than one pair of compression stockings on hand and the facility had extras if he did not. DON expected staff to communicate the absence of the stockings to her or obtain a replacement at the time. DON indicated there was not really a reason for R182 to go without and expected daily application according to physician order. DON also expected nurses to document daily on edema in order to determine worsening or improvement.

On 1/4/18, at 12:22 p.m. occupational therapist (OT) stated R182 had left lower extremity pitting edema and she had initiated the trial of the compression stocking on 12/28/17, and when viewed the next day the edema had decreased. The OT indicated nursing should be monitoring the amounts of edema daily.

Facility policy was requested and not received.F 685SS=D

Treatment/Devices to Maintain Hearing/VisionCFR(s): 483.25(a)(1)(2)

§483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to

F 685 2/14/18


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F 685 Continued From page 20 F 685and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids were available to maintain hearing/communication needs for 1 of 1 resident (R20) reviewed for hearing.

Findings include:

R20's quarterly Minimum Data Set (MDS) dated 10/27/17, indicated R20 was cognitively intact and had diagnoses which included anxiety, depression and bilateral conductive hearing loss. The MDS also indicated R20 used a hearing aid or other hearing appliance and had minimal difficulty hearing in some environments (e.g. when person speaks softly or setting is noisy) when the hearing aid/appliance was used.

R20's Communication Care Area Assessment (CAA) dated 4/26/17, indicated R20 had a hearing deficit and had bilateral hearing aides which she needed encouragement to wear. The CAA also indicated R20 had minimal difficulties when hearing aides were in place.

R20's undated Care Plan indicated R20 had a communication problem related to a hearing deficit. The Care Plan directed staff to ensure hearing aid(s) bilateral were in place and to assist to place. The Care Plan also indicated R20 needed encouragement to wear the hearing aids and often refused her hearing aids.

1. R20 Nursing will offer resident Left hearing aide daily and will document her acceptance or denial on the EHR. EHR, Communication Care Assessment Area (CAA)of MDS, TAR, Physician orders, and Care Plan will all be updated to show that resident only has one hearing aide, to be offered for her left ear. Batteries will be checked when offering her the left ear aide daily.

2. All residents with a hearing loss have the potential to not have their hearing aides offered to them and with working batteries. The facility will develop a roster list and identify all other residents who have hearing aides by 2.14.18. Each resident will be offered their hearing aides daily and compliance will be documented in the EHR.

3. Employees will be trained on the Plan of Correction at staff meetings scheduled for 2.07.18. Those not in attendance will be required to view the taped meeting prior to working their next shift. All EHR's for residents that have hearing aides will be reviewed and/or updated as needed to reflect the requirement to ensure that working hearing aides are available as ordered to maintain resident hearing and communication needs.


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F 685 Continued From page 21 F 685On 1/2/18, at 4:21 p.m. R20 was interviewed as she sat in a recliner in her room. R20 was not observed to be wearing hearing aids and requested questions be repeated several times during the interview. R20 indicated she had a hearing aid but stated she very rarely wore it. R20 stated the staff did not bring it to her and indicated the last time she had wanted to wear it, they were out of batteries.

On 1/4/18, at 8:23 a.m. R20 was again observed without her hearing aids. R20 stated she would like to wear her hearing aids, if staff would bring them to her.

R20's record lacked documentation of hearing aid refusal.

--at 8:25 a.m. nursing assistant (NA)-A and NA-B indicated residents' hearing aids were kept in the medication cart and the nurses gave them to the residents. NA-A stated if a resident asked her about their hearing aids she would remind the nurse. NA-A confirmed she was caring for R20, however, indicated she didn't deal with the hearing aids, the nurse did.

--at 8:32 a.m. registered nurse (RN)-A stated residents' hearing aids were kept in the medication cart and the nurses brought them to the residents each day except for the residents who did not wear them. RN-A indicated R20 did not wear her hearing aids and they were still in the drawer. When told R20 had indicated she would wear her hearing aids if brought to her, RN-A indicated he would bring her the hearing aids. --at 8:43 a.m. R20 propelled herself from the

4. By placing hearing aide use on the Treatment Record, as ordered, it will be charted that the resident either accepted or refused the hearing aide. Those residents with Hearing Aides will be place on a Roster list to be developed for assurance that the working hearing aides are being offered as ordered. All residents who are admitted with hearing aides will be added to the Roster. The QAPI committee or designee will audit hearing aide use via the EHR weekly for 8 weeks to ensure compliance with results given to the QAPI committee for review and/or further recommendations. When compliance is 100% after 8 weeks, then periodic monitoring will be done with results presented to the QAPI committee.

5. Corrected by 2/14/18.


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F 685 Continued From page 22 F 685dining room with her feet. R20 stated she was wearing her hearing aid, could hear much better, and liked wearing her hearing aids.

On 1/5/17, at 8:46 a.m. R20 was seated in a wheelchair in the common area, reading a newspaper and wearing her hearing aid. R20 stated the nurse had asked her today if she wanted to wear her hearing aid and she had said yes.

--at 2:56 p.m. the director of nursing stated she would have expected hearing aids be offered daily and refusals be documented as directed by the care plan.

The undated Care of Hearing Aid policy indicated the purpose of caring for a hearing aid was to maintain the resident's hearing at the highest attainable level and directed staff to document resident refusal in the medical record.

F 688SS=D

Increase/Prevent Decrease in ROM/MobilityCFR(s): 483.25(c)(1)-(3)

§483.25(c) Mobility. §483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility

F 688 2/14/18


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F 688 Continued From page 23 F 688receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to provide range of motion (ROM) services for 1 of 2 residents (R3) observed for mobility.

Findings include:

R3's significant change Minimum Data Set (MDS) dated 11/7/17, indicated R3 had moderate cognitive impairment and diagnoses which included arthritis, pain, and depression. The MDS also indicated R3 required extensive assist of 1 staff for most activities of daily living and had no impairments in functional range of motion for upper or lower extremities. The MDS further indicated R3 had not received physical therapy (PT), occupational therapy (OT) or restorative nursing programs during the assessment period.

R3's Activities of Daily Living (ADL)/Functional Rehabilitation Care Area Assessment (CAA) dated 11/7/17 indicated R3 would frequently refuse activities but did come out for meals. She would then want/request return to room and bed soon as meal was done. The CAA indicated R3 needed increased limited to extensive assist of one staff with all ADL other than eating and needed encouragement to participate with care as able.

R3's undated Care Plan indicated R20 had a need for restorative intervention due to limited physical mobility related to osteoporosis as

1. Restorative Aide has been employed as 01/01/18 to provide ROM to residents 4 days per week as ordered. R3 had Care Plan updated on 1/17/18 to reflect the 4x per week ROM. 1/25/18 OT Assessment evaluation recommended that R3 receive hand therapy, splinting, therapeutic exercises/ROM, resident/family education, and Restorative Nursing program development. R3's Restorative program addresses services to improve left upper extremities as well as her wrist drop and weakness in the left hand.

2. All residents have the potential to not be provided ROM as necessary to maintain functional mobility.

3. The systemic change is that the facility has now employed a Restorative CNA to provide ROM services 4 x/week. Restorative CNA is instructed to inform nursing staff of any resident refusals for ROM services as ordered. All staff will be educated on the POC at the mandatory staff meeting scheduled for 2/7/18. All staff unable to attend will be required to watch the video and sign off on the education before working their next scheduled shift.

4. Restorative CNA will report to nursing


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F 688 Continued From page 24 F 688evidenced by limited range of motion (ROM). The Care Plan directed R3 was to received a program of seated lower extremity (LE) exercises and upper extremity (UE) ROM exercises one time weekly. The program included:--seated LE exercises: 15 repetitions (reps) bilateral legs dorsiflexion (DF), plantar flexion (PF), Marching, long arc quad (LAQ), hip abduction with red or green tubing and hamstring curl with red or green tubing 1 x per week.--UE ROM: perform active ROM or active assisted ROM or passive ROM if needed to bilateral UEs x 10 reps each: Shoulder: flexion, abduction, internal rotation/external rotation 1 x weeklyElbow: flexion/extension 1 time weeklyWrist/hand: flexion/extension, hand open and closed 1 time weekly.

On 1/3/18, at 9:40 a.m. R3 stated she had limited of range of motion in her left hand. R3's left fingers were observed to be curled into the palm, especially the left little finger. R2 indicated she had not received any type of services or exercises for her hand, nor did she wear a splint on the hand. When asked if she was able to straighten her fingers to a flat position, R3 was observed to open her left hand, however the last two fingers would not completely straighten. R3 took her right hand and fully open the 4th and 5th fingers of her left hand.

On 1/5/18, at 2:10 p.m. restorative nursing assistant (NA)-F stated she had started working with R3 more than a month ago and indicated she completed upper and lower extremity exercises with her once a week. NA-F indicated she had been off work but had just recently returned to full time so hoped to increase the frequency with

for each resident receiving Restorative programs to ensure that provider orders are being followed. HIM will run a report of those who have Restorative Therapy orders and give it the DON or designee. The DON or designee will cross check the HIM report with the daily logs from Restorative aide to ensure Restorative therapy is being done as ordered. This will be done for 8 weeks with all reports given to the Risk Management Team on a daily basis on rehab days (4days/wk) and then given to QAPI for review and further recommendations. If compliance is 100% after 8 weeks then the Restorative Logs will be reviewed at the monthly QAPI meeting to ensure sustainability.

5. Completion by 2/14/18.


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F 688 Continued From page 25 F 688which she worked with R3. NA-F stated she had previously used the Nu-Step with R3 but had to have PT/OT discontinue this as R3 couldn't hang on the to the handles of the machine. NA-F indicated she had a worksheet which identified the services she provided R3. NA-F provided an untitled, undated worksheet with a list of residents names. Handwritten next to R3's name was "leg exercises". NA-F confirmed she assisted R3 with leg exercises as written on the worksheet. When asked if she had specific orders of the exercises to be provided R3, NA-F opened a desk drawer and withdrew a document with R3's name. The Therapy Daily/PRN [as needed] Documentation Notes dated 12/7/17, was reviewed with NA-F and revealed the following:

RA [restorative nursing] Program--discontinue NuStep--Goals: Maintain strength, maintain joint integrity--seated LE exercise: see attached handout, 15 reps bilateral, DF/PF, marching, LAQ, hip abduction with red or green tubing, hamstring curl with red or green tubing--UE ROM: perform AROM [active range of motion] if able or offer AAROM [active, assisted range of motion] or PROM [passive range of motion] if needed to bilateral UEs x 10 reps each. Shoulder: flexion, abduction, IR/ER. Elbow: Flexion/extension. Wrist/hand: flexion/extension, hand open/close--Complete 1 x/week.

NA-F stated this was the first time she had seen these orders as she had recently returned to work and confirmed she had not provided the UE exercises listed. NA-F indicated she documented the services provided in the resident progress notes and stated she was not sure if anyone


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F 688 Continued From page 26 F 688provided the restorative program to R3 while she was gone.

On 1/5/18, at 2:20 p.m. NA-C stated she had noted R3's hand was not opening all the way and indicated R3 had been weaker. NA-C indicated she had not been asked to provide any restorative/exercise program for R3 and wasn't sure if anyone was providing restorative services while NA-F had been off duty.

R3's progress notes from 12/1/17 to 1/5/18 were reviewed and revealed the following:

1/5/18 3:28 p.m. Restorative Program Note: Restorative aide did leg exercises and upper extremities for 15 minutes. Stated she has no pain when I was working on her.

R3's record lacked documentation of any other restorative services provided

On 1/5/18, at 3:05 p.m. the director of nursing stated she would have expected R3 to have received restorative services as directed by the care plan.

The undated Restorative Nursing Services policy indicated residents would receive restorative nursing care as needed to help promote optimal safety and independence.

F 758SS=D

Free from Unnec Psychotropic Meds/PRN UseCFR(s): 483.45(c)(3)(e)(1)-(5)

§483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include,

F 758 2/14/18


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F 758 Continued From page 27 F 758but are not limited to, drugs in the following categories:(i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic


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F 758 Continued From page 28 F 758drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review the facility failed to ensure a clinical rationale for the extended use of an as needed (PRN) antianxiety medication (Xanax) beyond 14 days and a specific duration for use was documented for 1 of 5 residents (R20) whose medication regimen was reviewed.

Findings include:

R20's quarterly Minimum Data Set (MDS) dated 10/27/17, indicated R20 was cognitively intact and had diagnoses which included chronic obstructive pulmonary disease, depression and anxiety. The MDS also indicated R20 received antianxiety medication 4 days during the assessment period.

R20's Psychotropic Drug Use Care Area Assessment (CAA) dated 4/26/17, indicated R20 had a diagnosis of anxiety and received Xanax (alprazolam) in the morning. The CAA also indicated R20 exhibited anxiety throughout the day and staff offered non-medication interventions.

R20's Medication Review Report dated 1/5/17, included an order for alprazolam 0.5 milligrams (mg) give one tablet daily as needed for anxiety. The start date of the order was 8/8/17. The order lacked a duration for use.

R20's Medication Records dated 10/1/17

1. R 20's PRN Xanax order was initially ordered on 8/8/17 and lacked a duration for use. On 12/6/17, nursing requested that the medication be reviewed by the MD to clarify the order to include the clinical rational for the extended use of the as needed prn anti-anxiety medication beyond 14 days and state a specific duration for its use per the Pharmacist Consultant report dated 11/6/17. Providers will be instructed to include the clinical rationale for extended use beyond 14 days and a specific duration when ordering PRN anti-anxiety medications by 2/14/18.

2. All residents who receive anti-anxiety PRN medications could be adversely affected by not having the provider orders written according to the regulation regarding the need for clinical rationale for extended use.

3. The facility will review/evaluate all residents who are prescribed PRN anti-anxiety medication for behavioral concerns. This will comply with any with regulatory requirements. Nursing will request new orders for PRN anti-anxiety medications which will include the clinical rationale for extended use and duration(limit 14days) for medication. Any requests for continuation of the


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F 758 Continued From page 29 F 758-10/31/17, 11/1/17-11/30/17, 12/1/17-12/31/17 and 1/1/18 to 1/4/18, indicated R20 received PRN alprazolam 14 times in October, 15 times in November, 10 times and December and 2 times in January.

On 1/3/18, at 3:50 p.m. R20 was observed in her room, seated in a recliner with the foot raised. R20 was resting with her eyes shut and the television on. No adverse mood or behaviors were observed.

On 1/4/18, at 12:29 p.m. R20 was eating the noon meal independently. She was seated at a table with her husband and another gentleman and conversing with tablemates. No adverse mood or behaviors were observed. R20's Consultant Pharmacist Medication Review dated 11/6/17, included the following pharmacist recommendations: Please clarify duration of Xanax PRN order and rationale for long term use if it's continued greater than 14 days. The physician (MD) response dated 11/13/17, indicated Xanax was used only as needed for anxiety and should be continued long term. The MD had not included a clinical rationale for the long term use nor a duration for the use of the medication.

R20's Psychopharmacological Medications Tapering Attempts form dated 12/6/17, included a nursing summary which indicated R20 had requested PRN alprazolam 15 times in November and once in December at that time. The summary also indicated "new rule requires reorder of PRN every 14 days". The MD response dated 12/13/17, indicated a checkmark next to the option NO (If NO, clinical rationale

medication beyond the 14 days will require a physician/provider assessment prior to refilling the prescription. This will be completed by 2/14/18.

4. Revisions of the current pharmacy/referral form will be updated to include the new guidelines as stated above. Medications prescribed for behavioral symptoms will include a clinical rationale for the use and the duration of the medication and this will be documented on the referral form. This will provide a consistent response from each of the practioners/MD. The correction will be completed by 2/14/18. Audits of the use of PRN Anti-anxiety medications will be completed weekly for 8 weeks. HIM will run a list of those residents and each resident will be reviewed for proper provider/MD orders per the regulation. If after 8 weeks all orders show that 100% compliance has been achieved, then audits will be periodically done to ensure sustainability. All audits will be reported to the QAPI committee for further review or recommendation.

5. Completion by 2/14/18


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F 758 Continued From page 30 F 758MUST be documented below or in a progress note). The MD included a handwritten note to "continue alprazolam 0.5 mg by mouth PRN". The MD had not included a clinical rationale for the long term use nor a duration for the use of the medication.

R20's record lacked physician documentation of a clinical rationale for the long term use or a duration for the use of Xanax.

On 1/5/18, at 2:46 p.m. nursing assistant (NA)-C stated R20 could be anxious at times and tended to get worked up if she had somewhere to go. NA-C stated R20 sometimes worried about her back or her breathing. NA-C stated R20's mood was "pretty good".

--at 3:00 p.m. the director of nursing stated she would have expected there to be a documented rational and duration for the continued use of PRN Xanax as required.

--at 3:29 p.m. R20 stated she had a nervous breakdown 40-50 years ago and has had problems with anxiety since then. R20 described herself as a chronic worrier and indicated the Xanax helped her relax. R20 also indicated she only took the medication at night and indicated she was happy with her medication regimen.

The undated Behavioral Assessment, Intervention and Monitoring Policy indicated the facility would comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy also indicated when medications were prescribed for behavioral symptoms, rationale for use and duration would be included as part of the documentation.


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January 23, 2018


North Star Manor


Warren, MN 56762

Re: State Nursing Home Licensing Orders - Project Number S5550030

Dear Mr. Bichler:

The above facility was surveyed on January 2, 2018 through January 5, 2018 for the purpose of

assessing compliance with Minnesota Department of Health Nursing Home Rules and Statutes. At the

time of the survey, the survey team from the Minnesota Department of Health, Health Regulation

Division, noted one or more violations of these rules or statutes that are issued in accordance with

Minn. Stat. § 144.653 and/or Minn. Stat. § 144A.10. If, upon reinspection, it is found that the

deficiency or deficiencies cited herein are not corrected, a civil fine for each deficiency not corrected

shall be assessed in accordance with a schedule of fines promulgated by rule and/or statute of the

Minnesota Department of Health.

To assist in complying with the correction order(s), a “suggested method of correction” has been

added. This provision is being suggested as one method that you can follow to correct the cited

deficiency. Please remember that this provision is only a suggestion and you are not required to follow

it. Failure to follow the suggested method will not result in the issuance of a penalty assessment. You

are reminded, however, that regardless of the method used, correction of the order within the

established time frame is required. The “suggested method of correction” is for your information and

assistance only.

You have agreed to participate in the electronic receipt of State licensure orders consistent with the

Minnesota Department of Health Informational Bulletin 14-01, available at

http://www.health.state.mn.us/divs/fpc/profinfo/infobul.htm . The State licensing orders are

delineated on the Minnesota Department of Health State Form and are being delivered to you

electronically. The Minnesota Department of Health is documenting the State Licensing Correction

Orders using federal software. Tag numbers have been assigned to Minnesota state statutes/rules for

Nursing Homes.

The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute/rule

number and the corresponding text of the state statute/rule out of compliance is listed in the

"Summary Statement of Deficiencies" column and replaces the "To Comply" portion of the correction

order. This column also includes the findings that are in violation of the state statute or rule after the

statement, "This MN Requirement is not met as evidenced by." Following the surveyors findings are

the Suggested Method of Correction and the Time Period For Correction.



PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER'S PLAN OF

CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE.

THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA

STATE STATUTES/RULES.

Although no plan of correction is necessary for State Statutes/Rules, please enter the word "corrected"

in the box available for text. You must then indicate in the electronic State licensure process, under the

heading completion date, the date your orders will be corrected prior to electronically submitting to

the Minnesota Department of Health. We urge you to review these orders carefully, item by item, and

if you find that any of the orders are not in accordance with your understanding at the time of the exit

conference following the survey, you should immediately contact Lyla Burkman at (218) 308-2104 or

email: [email protected].

You may request a hearing on any assessments that may result from non-compliance with these orders

provided that a written request is made to the Department within 15 days of receipt of a notice of

assessment for non-compliance.

Please note it is your responsibility to share the information contained in this letter and the results of

this visit with the President of your facility’s Governing Body.

Please feel free to call me with any questions.

Sincerely,

Joanne Simon, Enforcement Specialist



Program Assurance Unit


Telephone: 651-201-4161 Fax: 651-215-9697



North Star Manor

January 23, 2018

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NAME OF PROVIDER OR SUPPLIER

NORTH STAR MANOR

STREET ADDRESS, CITY, STATE, ZIP CODE

410 SOUTH MCKINLEY STREETWARREN, MN 56762



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2 000 Initial Comments

*****ATTENTION******

NH LICENSING CORRECTION ORDER

In accordance with Minnesota Statute, section 144A.10, this correction order has been issued pursuant to a survey. If, upon reinspection, it is found that the deficiency or deficiencies cited herein are not corrected, a fine for each violation not corrected shall be assessed in accordance with a schedule of fines promulgated by rule of the Minnesota Department of Health.

Determination of whether a violation has been corrected requires compliance with all requirements of the rule provided at the tag number and MN Rule number indicated below. When a rule contains several items, failure to comply with any of the items will be considered lack of compliance. Lack of compliance upon re-inspection with any item of multi-part rule will result in the assessment of a fine even if the item that was violated during the initial inspection was corrected.

You may request a hearing on any assessments that may result from non-compliance with these orders provided that a written request is made to the Department within 15 days of receipt of a notice of assessment for non-compliance.

INITIAL COMMENTS:

2 000

You have agreed to participate in the electronic receipt of State licensure orders consistent with the Minnesota Department of Health Informational Bulletin 14-01, available at <http://www.health.state.mn.us/divs/fpc/profinfo/infobul.htm> The State licensing orders are delineated on the attached Minnesota

Minnesota Department of HealthLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

02/01/18Electronically Signed

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2 000Continued From page 1 2 000

Department of Health orders being submitted to you electronically. Although no plan of correction is necessary for State Statutes/Rules, please enter the word "corrected" in the box available for text. You must then indicate in the electronic State licensure process, under the heading completion date, the date your orders will be corrected prior to electronically submitting to the Minnesota Department of Health.

On 1/2/18-1/5/18, surveyors of this Department's staff, visited the above provider and the following correction orders are issued. Please indicate in your electronic plan of correction that you have reviewed these orders, and identify the date when they will be completed.

Minnesota Department of Health is documenting the State Licensing Correction Orders using federal software. Tag numbers have been assigned to Minnesota state statutes/rules for Nursing Homes.

The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute/rule out of compliance is listed in the "Summary Statement of Deficiencies" column and replaces the "To Comply" portion of the correction order. This column also includes the findings which are in violation of the state statute after the statement, "This Rule is not met as evidence by." Following the surveyors findings are the Suggested Method of Correction and Time period for Correction.

PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES, "PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE.

Minnesota Department of HealthIf continuation sheet 2 of 176899STATE FORM K1PP11

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THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES/RULES.

2 895 MN Rule 4658.0525 Subp. 2.B Rehab - Range of Motion

Subp. 2. Range of motion. A supportive program that is directed toward prevention of deformities through positioning and range of motion must be implemented and maintained. Based on the comprehensive resident assessment, the director of nursing services must coordinate the development of a nursing care plan which provides that: B. a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion.

This MN Requirement is not met as evidenced by:

2 895 2/12/18

Based on observation, interview, and document review, the facility failed to provide range of motion (ROM) services for 1 of 2 residents (R3) observed for mobility.

Findings include:

R3's significant change Minimum Data Set (MDS) dated 11/7/17, indicated R3 had moderate cognitive impairment and diagnoses which included arthritis, pain, and depression. The MDS also indicated R3 required extensive assist of 1 staff for most activities of daily living and had no impairments in functional range of motion for

Corrected by 2/12/18.


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upper or lower extremities. The MDS further indicated R3 had not received physical therapy (PT), occupational therapy (OT) or restorative nursing programs during the assessment period.

R3's Activities of Daily Living (ADL)/Functional Rehabilitation Care Area Assessment (CAA) dated 11/7/17 indicated R3 would frequently refuse activities but did come out for meals. She would then want/request return to room and bed soon as meal was done. The CAA indicated R3 needed increased limited to extensive assist of one staff with all ADL other than eating and needed encouragement to participate with care as able.

R3's undated Care Plan indicated R20 had a need for restorative intervention due to limited physical mobility related to osteoporosis as evidenced by limited range of motion (ROM). The Care Plan directed R3 was to received a program of seated lower extremity (LE) exercises and upper extremity (UE) ROM exercises one time weekly. The program included:--seated LE exercises: 15 repetitions (reps) bilateral legs dorsiflexion (DF), plantar flexion (PF), Marching, long arc quad (LAQ), hip abduction with red or green tubing and hamstring curl with red or green tubing 1 x per week.--UE ROM: perform active ROM or active assisted ROM or passive ROM if needed to bilateral UEs x 10 reps each: Shoulder: flexion, abduction, internal rotation/external rotation 1 x weeklyElbow: flexion/extension 1 time weeklyWrist/hand: flexion/extension, hand open and closed 1 time weekly.

On 1/3/18, at 9:40 a.m. R3 stated she had limited of range of motion in her left hand. R3's left


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fingers were observed to be curled into the palm, especially the left little finger. R2 indicated she had not received any type of services or exercises for her hand, nor did she wear a splint on the hand. When asked if she was able to straighten her fingers to a flat position, R3 was observed to open her left hand, however the last two fingers would not completely straighten. R3 took her right hand and fully open the 4th and 5th fingers of her left hand.

On 1/5/18, at 2:10 p.m. restorative nursing assistant (NA)-F stated she had started working with R3 more than a month ago and indicated she completed upper and lower extremity exercises with her once a week. NA-F indicated she had been off work but had just recently returned to full time so hoped to increase the frequency with which she worked with R3. NA-F stated she had previously used the Nu-Step with R3 but had to have PT/OT discontinue this as R3 couldn't hang on the to the handles of the machine. NA-F indicated she had a worksheet which identified the services she provided R3. NA-F provided an untitled, undated worksheet with a list of residents names. Handwritten next to R3's name was "leg exercises". NA-F confirmed she assisted R3 with leg exercises as written on the worksheet. When asked if she had specific orders of the exercises to be provided R3, NA-F opened a desk drawer and withdrew a document with R3's name. The Therapy Daily/PRN [as needed] Documentation Notes dated 12/7/17, was reviewed with NA-F and revealed the following:

RA [restorative nursing] Program--discontinue NuStep--Goals: Maintain strength, maintain joint integrity--seated LE exercise: see attached handout, 15 reps bilateral, DF/PF, marching, LAQ, hip


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abduction with red or green tubing, hamstring curl with red or green tubing--UE ROM: perform AROM [active range of motion] if able or offer AAROM [active, assisted range of motion] or PROM [passive range of motion] if needed to bilateral UEs x 10 reps each. Shoulder: flexion, abduction, IR/ER. Elbow: Flexion/extension. Wrist/hand: flexion/extension, hand open/close--Complete 1 x/week.

NA-F stated this was the first time she had seen these orders as she had recently returned to work and confirmed she had not provided the UE exercises listed. NA-F indicated she documented the services provided in the resident progress notes and stated she was not sure if anyone provided the restorative program to R3 while she was gone.

On 1/5/18, at 2:20 p.m. NA-C stated she had noted R3's hand was not opening all the way and indicated R3 had been weaker. NA-C indicated she had not been asked to provide any restorative/exercise program for R3 and wasn't sure if anyone was providing restorative services while NA-F had been off duty.

R3's progress notes from 12/1/17 to 1/5/18 were reviewed and revealed the following:

1/5/18 3:28 p.m. Restorative Program Note: Restorative aide did leg exercises and upper extremities for 15 minutes. Stated she has no pain when I was working on her.

R3's record lacked documentation of any other restorative services provided

On 1/5/18, at 3:05 p.m. the director of nursing Minnesota Department of Health

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stated she would have expected R3 to have received restorative services as directed by the care plan.

The undated Restorative Nursing Services policy indicated residents would receive restorative nursing care as needed to help promote optimal safety and independence.

SUGGESTED METHOD FOR CORRECTION: The director of nursing (DON) and/or designee could review/revise policy and provide education for staff regarding providing range of motion services for identified residents. The Quality Assessment and Assurance (QAA) committee could do random audits to ensure compliance.

TIME PERIOD FOR CORRECTION: Twenty-one (21) days.

21530 MN Rule 4658.1310 A.B.C Drug Regimen Review

A. The drug regimen of each resident must be reviewed at least monthly by a pharmacist currently licensed by the Board of Pharmacy. This review must be done in accordance with Appendix N of the State Operations Manual, Surveyor Procedures for Pharmaceutical Service Requirements in Long-Term Care, published by the Department of Health and Human Services, Health Care Financing Administration, April 1992. This standard is incorporated by reference. It is available through the Minitex interlibrary loan system. It is not subject to frequent change. B. The pharmacist must report any irregularities to the director of nursing services and the attending physician, and these reports

21530 2/12/18


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21530Continued From page 7 21530

must be acted upon by the time of the next physician visit, or sooner, if indicated by the pharmacist. For purposes of this part, "acted upon" means the acceptance or rejection of the report and the signing or initialing by the director of nursing services and the attending physician. C. If the attending physician does not concur with the pharmacist's recommendation, or does not provide adequate justification, and the pharmacist believes the resident's quality of life is being adversely affected, the pharmacist must refer the matter to the medical director for review if the medical director is not the attending physician. If the medical director determines that the attending physician does not have adequate justification for the order and if the attending physician does not change the order, the matter must be referred for review to the quality assessment and assurance committee required by part 4658.0070. If the attending physician is the medical director, the consulting pharmacist must refer the matter directly to the quality assessment and assurance committee.

This MN Requirement is not met as evidenced by:Based on observation, interview and document review the facility failed to ensure a clinical rationale for the extended use of an as needed (PRN) antianxiety medication (Xanax) beyond 14 days and a specific duration for use was documented for 1 of 5 residents (R20) whose medication regimen was reviewed.

Findings include:

R20's quarterly Minimum Data Set (MDS) dated 10/27/17, indicated R20 was cognitively intact and had diagnoses which included chronic



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obstructive pulmonary disease, depression and anxiety. The MDS also indicated R20 received antianxiety medication 4 days during the assessment period.

R20's Psychotropic Drug Use Care Area Assessment (CAA) dated 4/26/17, indicated R20 had a diagnosis of anxiety and received Xanax (alprazolam) in the morning. The CAA also indicated R20 exhibited anxiety throughout the day and staff offered non-medication interventions.

R20's Medication Review Report dated 1/5/17, included an order for alprazolam 0.5 milligrams (mg) give one tablet daily as needed for anxiety. The start date of the order was 8/8/17. The order lacked a duration for use.

R20's Medication Records dated 10/1/17 -10/31/17, 11/1/17-11/30/17, 12/1/17-12/31/17 and 1/1/18 to 1/4/18, indicated R20 received PRN alprazolam 14 times in October, 15 times in November, 10 times and December and 2 times in January.

On 1/3/18, at 3:50 p.m. R20 was observed in her room, seated in a recliner with the foot raised. R20 was resting with her eyes shut and the television on. No adverse mood or behaviors were observed.

On 1/4/18, at 12:29 p.m. R20 was eating the noon meal independently. She was seated at a table with her husband and another gentleman and conversing with tablemates. No adverse mood or behaviors were observed. R20's Consultant Pharmacist Medication Review dated 11/6/17, included the following pharmacist


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recommendations: Please clarify duration of Xanax PRN order and rationale for long term use if it's continued greater than 14 days. The physician (MD) response dated 11/13/17, indicated Xanax was used only as needed for anxiety and should be continued long term. The MD had not included a clinical rationale for the long term use nor a duration for the use of the medication.

R20's Psychopharmacological Medications Tapering Attempts form dated 12/6/17, included a nursing summary which indicated R20 had requested PRN alprazolam 15 times in November and once in December at that time. The summary also indicated "new rule requires reorder of PRN every 14 days". The MD response dated 12/13/17, indicated a checkmark next to the option NO (If NO, clinical rationale MUST be documented below or in a progress note). The MD included a handwritten note to "continue alprazolam 0.5 mg by mouth PRN". The MD had not included a clinical rationale for the long term use nor a duration for the use of the medication.

R20's record lacked physician documentation of a clinical rationale for the long term use or a duration for the use of Xanax.

On 1/5/18, at 2:46 p.m. nursing assistant (NA)-C stated R20 could be anxious at times and tended to get worked up if she had somewhere to go. NA-C stated R20 sometimes worried about her back or her breathing. NA-C stated R20's mood was "pretty good".

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PRN Xanax as required.

--at 3:29 p.m. R20 stated she had a nervous breakdown 40-50 years ago and has had problems with anxiety since then. R20 described herself as a chronic worrier and indicated the Xanax helped her relax. R20 also indicated she only took the medication at night and indicated she was happy with her medication regimen.

The undated Behavioral Assessment, Intervention and Monitoring Policy indicated the facility would comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy also indicated when medications were prescribed for behavioral symptoms, rationale for use and duration would be included as part of the documentation.

SUGGESTED METHOD FOR CORRECTION: The administrator, director of nursing (DON) and consulting pharmacist could review and revise policies and procedures for proper monitoring of medication usage. Nursing staff could be educated as necessary to the importance of PRN medication use. The DON or designee, along with the pharmacist, could audit medication reviews on a regular basis to ensure compliance.


21840 MN St. Statute 144.651 Subd. 12 Patients & Residents of HC Fac.Bill of Rights

Subd. 12. Right to refuse care. Competent residents shall have the right to refuse treatment based on the information required in subdivision

21840 2/12/18


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9. Residents who refuse treatment, medication, or dietary restrictions shall be informed of the likely medical or major psychological results of the refusal, with documentation in the individual medical record. In cases where a resident is incapable of understanding the circumstances but has not been adjudicated incompetent, or when legal requirements limit the right to refuse treatment, the conditions and circumstances shall be fully documented by the attending physician in the resident's medical record.

This MN Requirement is not met as evidenced by:Based on document review and interview, the facility failed to ensure resident resuscitation wishes were correctly identified in the electronic health record (EHR) based on signed advanced directives for 2 of 6 residents (R12, R182) reviewed for advanced directives.

Findings include:

R12's EHR Admission Record dated 1/3/18, indicated R12's advance directive was to resuscitate (CPR-cardiopulmonary resuscitation).

R12's signed Living Will Declaration dated 6/11/04, indicated R12 did not want cardiac resuscitation, mechanical respiration or artificial feeding or fluids by tubes. The Living Will also indicated R12 specifically did not want any life-prolonging treatment if it was determined R12 had Alzheimer's disease.

The Admission Record/EHR was inconsistent with the signed Living Will Declaration which indicated R12 did not want cardiac resuscitation.



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On 1/5/18, at 3:14 p.m. the licensed social worker (LSW) confirmed the admission record/EHR was inconsistent with R12's Living Will Declaration and verified they should be consistent.

R182's EHR Admission Record dated 1/4/18, indicated R182's advance directive was to not resuscitate (DNR).

R182's signed paper copy of Health Care Directives dated 3/6/07, indicated R182 did not want CPR or artificial respiration necessary to revive him performed more than twice.

R182's EHR physician order dated 12/28/17, reflected the advance directive "DNR" (do not resuscitate).

The physician order and Admission Record were inconsistent with the signed advance directives which indicated resuscitation efforts should be performed, but not more than twice.

On 1/4/17, at 11:37 p.m. the LSW verified the signed advance directives were inconsistent with the physician orders and Admission Record, and stated they should be consistent.

Facility policy dated Advance Care Planning and Advance Directives last revised 4/2016 included: -Residents an resident surrogate or proxy decision makers have the right to make decisions concerning medical care, including the right to accept or to refuse medical or surgical treatment. Residents have the right to formulate advance directives.-Admission or Readmission1. At the time of admission or readmission the social worker asks the resident/healthcare


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decision maker whether he or she has prepared an advance directive such as a living will, durable power of attorney for healthcare decisions, guardianship, portable and enduring order form ect. 5. If an advance directive has been formulated, a copy will be scanned into the medical record. -During Stay3 (f). Completed portable and enduring order forms will be treated as physican's orders an placed in the medical record. 9. Once the staff member has determined the wishes of the resident/healthcare decision maker, the physician will be notified of the resident's wishes and asked to give orders. 10. Physician's orders in response to resident's requests and/or advance directives regarding life sustaining measures must be specific, e.g. do resuscitate or do not resuscitate, whether to hospitalize, whether antibiotics are to be used, ect. "code" or "no code" order do not have a universally accepted definition and therefore will not be accepted. 6. As necessary, physicians will be contacted for orders that reflect the resident's wishes.

SUGGESTED METHOD OF CORRECTION: The administrator, director of nursing (DON), or designee could review the facility policy related to advanced directives and provide education to all staff. The quality assurance designee could monitor records for ongoing compliance.

TIME PERIOD FOR CORRECTION: Twenty-one (21) day

21995 MN St. Statute 626.557 Subd. 4a Reporting - Maltreatment of Vulnerable Adults

21995 2/12/18


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Subd. 4a. Internal reporting of maltreatment. (a) Each facility shall establish and enforce an ongoing written procedure in compliance with applicable licensing rules to ensure that all cases of suspected maltreatment are reported. If a facility has an internal reporting procedure, a mandated reporter may meet the reporting requirements of this section by reporting internally. However, the facility remains responsible for complying with the immediate reporting requirements of this section.

This MN Requirement is not met as evidenced by:Based on interview, and document review, the facility failed to report an elopment immediately to the administrator and the State agency for 1 of 1 resident (R30) who had eloped from the facility.

Findings include:

R30's progress note (subtype: incident note) dated 11/5/17, at 15:47 p.m. indicated R30's family member had been at the facility to visit. When the family member left the facility, staff witnessed R30 attempt to follow family member outside at which time staff noticed the wander guard which alerted staff of R30's attempt to leave the facility, was not on R30's ankle. The note indicated staff kept R30 preoccupied by sweeping the 400 hallway while they searched his room for 5-10 minutes for the wander guard which was found at the bottom of the garbage can in his room. After staff had found the wander guard, they discovered R30 was no longer in the hallway sweeping and asked another nursing assistant where R30 was. That nursing assistant thought R30 was in the 200 hallway. While searching the 200 hallway, through a window,



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staff had visualized R30 standing outside in the parking lot. R30 was brought back inside the building.

R30's Elopement incident report indicated the incident occurred on 11/5/17, at 2:30 p.m. The incident description mirrored the incident report note. The investigation indicated R30 did not have any injuries and R30 had removed the wander guard with nail clippers that were found in his bathroom, which staff removed upon discovery. The report indicated the director of nursing, the physician and R30's family member were notified of the incidnent, timely. However, the report did not indicate the administrator or State agency had been notified.

On 1/5/18, a 1:46 p.m. the administrator stated he had been aware of R30's witnessed attempt to go outside after a familyu visit, however was not aware R30 had made it outside unwitnessed after the first attempt. The administrator verified the elopement was not reported to the State agency and should have been and would have been if he would have had knowledge of it.

Facility policy Abuse Definitions last revised 9/16, indicated the definition of neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental abuse.

Facility policy and procedure Abuse and Neglect last revised on 11/2016, indicated any employee that has knowledge of neglect of a resident or has reasonable cause to the believe that a resident has been neglected, after safeguarding the resident, must report the information to the supervisor who in turn would immediately report the allegation or incident to the facility administrator in accordance with state law. The


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policy also indicated if there was an allegation or suspicion of neglect it would be reported no later than two hours to the state officials (including the state survey agency and adult protective services where state law provides for jurisdiction in long term care centers) in accordance with state law.

SUGGESTED METHOD OF CORRECTION: The administator and/or director of nursing (DON) or designee could review the abuse policy and provide re-training to staff. The administrator and/or DON then could develop and implement an auditing system to ensure ongoing compliance.



22 clia 03/06/2018mr. mark bichler, administrator north star manor 410 south mckinley street warren,...

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