department of health and human services centers … · (l4) (l5) (l6) 4. type of action: (l8) 1....

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: 00451

ID: XS0Q

PINE CITY, 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. Termination5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW 6. Complaint9. 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)

177550201

7

09/30

06/15/201706/21/2017

LAKESIDE MEDICAL CENTER 245374

02

129 EAST 6TH AVENUE 55063

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) :X 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/Room 12.Total Facility Beds 46 (L18)

13.Total Certified Beds 46 (L17) B. Not in Compliance with ProgramRequirements 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)

46

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

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

See Attached Remarks

29. INTERMEDIARY/CARRIER NO.

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

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVILRIGHTS 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

X

00-Active

02/01/1987

00

03001

06/19/2017

06/21/2017 09/22/2017

21.

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

James Anderson, DSFM

18. STATE SURVEY AGENCY APPROVAL

Susan Frericks, HPR SWS 09/21/2017

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: 00451

ID: XS0Q

C&T REMARKS - CMS 1539 FORM STATE AGENCY REMARKS

CCN: 24 5374

Health and Life Safety Code surveys were processed under separate enforcement cycles

On June 15, 2017 and June 21, 2017, Public Safety and Health completed revisits to verify the facility achieved and maintained compliance with Federal certification deficiencies issues pursuant to the April 21, 2017 Health survey and May 15, 2017 Public Safety survey. Based on the revisits we have determined all deficiencies, effective June 7, 2017. As a result of our revisits, we discontinued the Category 1 remedy of State monitoring as of June 7, 2017.

In addition, we recommended to the CMS Region V office, the following enforcement action as it relates to the remedy recommended in our letter of May 22, 2017:

- Civil money penalty for deficiency cited at F314, be indisposed

Effective June 7, 2017 the facility is certified for 46 skilled nursing facility beds.


CMS Certification Number (CCN): 245374

September 22, 2017

Mr. Max Blaufuss, Administrator

Lakeside Medical Center

129 East 6th Avenue

Pine City, MN 55063

Dear Mr. Blaufuss:

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 June 7, 2017 the above facility is certified for:

46 Skilled Nursing Facility/Nursing Facility Beds

Your facility’s Medicare approved area consists of all 46 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.

Feel free to contact me if you have questions related to this letter.

Sincerely,

Mark Meath, Enforcement Specialist

Program Assurance Unit

Licensing and Certification Program

Health Regulation Division

Email: [email protected]

Phone: (651) 201-4118 Fax: (651) 215-9697

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

September 22, 2017



129 East 6th Avenue

Pine City, MN 55063

RE: Project Number S5374027

Dear Mr. Blaufuss:

On May 22, 2017, we informed you that the following enforcement remedy was being imposed:

• State Monitoring effective May 27, 2017. (42 CFR 488.422)

In addition, on May 22, 2017, the Department recommended to the Centers for Medicare and

Medicaid Services (CMS) that the following enforcement remedy be imposed:

• Civil money penalty for the deficiency cited at F314. (42 CFR 488.430 through 488.444)

This was based on the deficiencies cited by this Department for a standard survey completed on April

21, 2017. The most serious deficiency was found to be isolated deficiencies that constituted actual

harm that was not immediate jeopardy (Level G), whereby corrections were required.

On June 21, 2017, 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 April 21, 2017. We presumed, based on your plan

of correction, that your facility had corrected these deficiencies as of June 7, 2017. We have

determined, based on our visit, that your facility has corrected the deficiencies issued pursuant to our

standard survey, completed on April 21, 2017, as of June 7, 2017.

As a result of the revisit findings, the Department is discontinuing the Category 1 remedy of state

monitoring, effective June 7, 2017.

In addition, this Department recommended to the CMS Region V Office the following action related to

the remedy outlined in our letter of May 22, 2017:

• Civil money penalty for deficiency cited at F314, be imposed. (42 CFR 488.430 through

488.444)

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


The CMS Region V Office will notify you of their determination regarding the imposed remedies, and

appeal rights.

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,





Minnesota Department of Health


Phone: (651) 201-4118 Fax: (651) 215-9697



September 22, 2017

Page 2

Electronically delivered June 21, 2017

Mr. Max Blaufuss, AdministratorLakeside Medical Center129 East 6th AvenuePine City, MN 55063

RE: Project Number F5374027

Dear Mr. Blaufuss:

On May 22, 2017, we informed you that we would recommend enforcement remedies based on thedeficiencies cited by the Department of Public Safety for a standard survey, completed on May 15, 2017. Thissurvey found the most serious deficiencies to be widespread deficiencies that constituted no actual harm withpotential for more than minimal harm that was not immediate jeopardy (Level F) whereby corrections wererequired.

On June 15, 2017, the Minnesota Department of Public Safety completed a Post Certification Revisit (PCR) byreview of your plan of correction to verify that your facility had achieved and maintained compliance withfederal certification deficiencies issued pursuant to a standard survey, completed on May 15, 2017. Wepresumed, based on your plan of correction, that your facility had corrected these deficiencies as of June 2,2017. Based on our PCR, we have determined that your facility has corrected the deficiencies issued pursuantto our standard survey, completed on May 15, 2017, effective June 2, 2017 and therefore remedies outlined inour letter to you dated May 22, 2017, will not be imposed.

Please note, it is your responsibility to share the information contained in this letter and the results of this visitwith the President of your facility's Governing Body.

Feel free to contact me if you have questions.

Sincerely,

Joanne Simon, Enforcement Specialist Minnesota Department of Health Licensing and Certification Program Program Assurance UnitHealth Regulation DivisionTelephone: 651-201-4161 Fax: 651-215-9697Email: [email protected]


PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS


Kathie Killoran, HFE NEII

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY I B E STATE SURVEY AGENCY

ID: XS0Q

Facility ID: 00451

C&T REMARKS - CMS 1539 FORM STATE AGENCY REMARKS

CCN: 245374

Health and Life Safety Code surveys were processed under separate enforcement cycles

On April 21, 2017, the Department of health completed a standard survey to verify compliance with Medicare participation regulations. The most serious deficiency was cited at a scope and severity level of G ( isolated deficiencies that constituted actual harm that was not immediate jeopardy), whereby significant corrections are required.

On May 15, 2017, the Department of Public Safety completed a survey to verify compliance with the National Fire Protection Associate (NFPA) for life safety code. The most serious deficiency was cited at a scope and severity level ofF (widespread deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy), whereby corrections are required.

As a result of the April 21, 2017 health standard survey fmdings, CMS policy requires the facility not be given an opportunity to correct when! deficiencies are identified on the current survey under 42 CFR 483 .25 Quality of Care. Therefore, the Department imposed the Category 1 remedy of State monitoring, effective May 27, 2017.

In addition, we recommended to the CMS Region V office, the following enforcement remedy for imposition:

- Civil money penalty for deficiency cited at F314.

Refer to the CMS 2567 forms for both health and life safety code along with the facility's plan of correction. Post Certification Revisit to follow.



May 22, 2017



129 East 6th Avenue

Pine City, MN 55063

RE: Project Number S5374027

Please note: The health and life safety code surveys will be processed under separate

enforcement cycles.

Dear Mr. Blaufuss:

On April 21, 2017, a standard survey was completed at your facility by the Minnesota Department of

Health 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 constituted actual harm that was not immediate jeopardy (Level G), as evidenced by the attached

CMS-2567, whereby significant corrections are required. A copy of the Statement of Deficiencies

(CMS-2567 and/or Form A) is enclosed.

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

the following issues:

No Opportunity to CorrectNo Opportunity to CorrectNo Opportunity to CorrectNo Opportunity to Correct - the facility will have remedies imposed immediately after a - the facility will have remedies imposed immediately after a - the facility will have remedies imposed immediately after a - the facility will have remedies imposed immediately after a

determination of noncompliance has been made;determination of noncompliance has been made;determination of noncompliance has been made;determination of noncompliance has been made;

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

Medicare and Medicaid Services (CMS); Medicare and Medicaid Services (CMS); Medicare and Medicaid Services (CMS); Medicare and Medicaid Services (CMS);

Plan of CorrectionPlan of CorrectionPlan of CorrectionPlan of Correction - when a plan of correction will be due and the information to be contained - when a plan of correction will be due and the information to be contained - when a plan of correction will be due and the information to be contained - when a plan of correction will be due and the information to be contained

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

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

after the survey date; andafter the survey date; andafter the survey date; andafter 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.





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:

Teresa Ament, Unit Supervisor

Duluth Survey Team




Duluth Technology Building

11 East Superior Street, Suite #290

Duluth, Minnesota 55802


Phone: (218) 302-6151 Fax: (218) 723-2359

NO OPPORTUNITY TO CORRECTNO OPPORTUNITY TO CORRECTNO OPPORTUNITY TO CORRECTNO OPPORTUNITY TO CORRECT - DATE OF CORRECTION - REMEDIES- DATE OF CORRECTION - REMEDIES- DATE OF CORRECTION - REMEDIES- DATE OF CORRECTION - REMEDIES

For all surveys completed after September 1, 2016, CMS policy requires that facilities will not be given

an opportunity to correct before remedies will be imposed when one or more of the following

circumstances exist:

• Immediate jeopardy (IJ) (scope and severity levels J, K, and L) is identified on the current survey; OROROROR

• Deficiencies of Substandard Quality of Care (SQC) that are not IJ are identified on the current

survey; OROROROR

• Any G level deficiency is identified on the current survey in 42 CFR 483.13, Resident Behavior and

Facility Practices, 42 CFR 483.15, Quality of Life, or 42 CFR 483.25 Quality of Care; OROROROR

• Deficiencies of actual harm or above (level G or above) on the current survey as well as having

deficiencies of actual harm or above on the previous standard health or Life Safety Code (LSC)

survey OR OR OR OR deficiencies of actual harm or above on any type of survey between the current survey

and the last standard survey. These surveys must be separated by a period of compliance (i.e.,

from different noncompliance cycles).; OR OR OR OR

• A facility is classified as a Special Focus Facility (SFF) ANDANDANDAND has a deficiency citation at level "F" or

higher on its current health survey or "G" or higher for the current LSC survey.

Note: the "current" survey is whatever Health and/or LSC survey is currently being performed, i.e.,

standard, revisit, or complaint.

Your facility meets one or more criterion and remedies will be imposed immediately. Therefore, this

Department is imposing the following remedy:


May 22, 2017

Page 2

• State Monitoring effective May 27, 2017. (42 CFR 488.422)

The Department recommended the enforcement remedy listed below to the CMS Region V Office for

imposition:

• Civil money penalty for the deficiency cited at F314. (42 CFR 488.430 through 488.444)

The CMS Region V Office will notify you of their determination regarding our recommendations,

Nursing Aide Training and/or Competency Evaluation Programs (NATCEP) prohibition, and appeal

rights.

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

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.

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 remedy be imposed:


May 22, 2017

Page 3

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

Failure to submit an acceptable PoC 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. 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 their respective deficiencies (if any) is acceptable.

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

Upon receipt of an acceptable ePoC, a revisit of your facility will be conducted to verify that substantial

compliance with the regulations has been attained. The revisit 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 we will recommend that the remedies imposed be

discontinued effective the date of the on-site verification. 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.

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 July 21, 2017 (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

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 October 21, 2017 (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.


May 22, 2017

Page 4

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



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 electronic 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.

Feel free to contact me if you have questions.

Sincerely,

Kamala Fiske-Downing





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




May 22, 2017

Page 5

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 06/16/2017FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

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

245374 04/21/2017STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

129 EAST 6TH AVENUELAKESIDE MEDICAL CENTER

PINE CITY, MN 55063

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG

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

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

The facility is enrolled in ePOC and therefore a signature is not required at the bottom of the first page of the CMS-2567 form. Electronic submission of the POC will be used as verification of compliance.

Upon receipt of an acceptable 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.

F 248SS=D

483.24(c)(1) ACTIVITIES MEET INTERESTS/NEEDS OF EACH RES

(c) Activities.

(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.This REQUIREMENT is not met as evidenced by:

F 248 6/7/17

Based on observation, interview and document review, the facility failed to ensure meaningful activities were provided for 1 of 3 residents (R38) reviewed for activities.

Findings include:

R38's Diagnosis Report printed 4/20/17, indicated R38's diagnoses included chronic obstructive

F 248R38’s TV was immediately connected to the cable box and currently has a radio at bedside. Activities Aides are changing out CDs to resident preference. R38 also has access to large variety of commercial free music channels on TV. A large print channel guide will be provided to R38 due to poor vision. Staff is available to assist

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

05/31/2017Electronically 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 XS0Q11Event ID: Facility ID: 00451 If continuation sheet Page 1 of 38

A. BUILDING ______________________






B. WING _____________________________




PINE CITY, MN 55063



(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG



F 248 Continued From page 1 F 248pulmonary disease and macular degeneration.

R38's admission Minimum Data Set (MDS) dated 3/9/17, indicated R38 had moderately impaired cognition, no mood indicators, and no behaviors. The MDS further indicated R38's activity preferences included it was important for R38 to have books, newspapers and magazines to read, but he was no longer able to do this. The MDS also indicated it was very important for R38 to listen to music, be around animals and pets, do his favorite activities, and go outside when the weather was nice. The MDS indicated it was somewhat important for R38 to do things with groups of people and R38 was independent with ambulation, bed mobility and transfers.

R38's care plan dated 2/24/17, indicated R38 had limited physical mobility related to weakness, macular degeneration and poor vision. The care plan directed to invite R38 to activity programs that encourage activity and physical mobility such as exercise group and walking activities. The care plan also indicated R38 and family had decided that R38 would reside at the facility long term. Interventions included: one to one visits, social services would be attentive and respectful of R38's wishes, and encourage family to bring familiar items from home as able to provide comfort

R38's Activity Participation Review dated 3/7/17, indicated R38 had not attended activities at that time as he was tired and had a hard time seeing. The review further indicated R38's hobbies included hunting, fishing, making ammunition and gardening.

R38's Cognitive Loss/Dementia Care Area

resident with changing to preferred channels as requested. 1:1 visits have been increased to 3 times weekly due to low vision and refusal of group activities. R38 is asked to attend all group activities regardless of history of refusals.

Activities director or activity aide completes an activities assessment within 5 days of admission to facility and annually with the annual MDS. Resident activities preferences will be documented in care plan along with activity goals for quarter.

All TVs and radios were assessed for connectivity on 5/24/2017. TV channel guides were also handed out to ensure all residents have a copy.

Activity participation documentation has been changed to document resident participation or refusal of each group activity. 1:1 visits have been increased for all residents that routinely do not leave their room to 3x/ week and 1x/week for those that do not routinely participate in group activities. All activities staff was educated on new procedures and documentation on 5/24-5/26/17.

Activities charting audit will be completed weekly x1 month, then every other week x 3months and then quarterly with care conference schedule until 100% compliance is achieved.

These audits will be completed by the


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F 248 Continued From page 2 F 248Assessment (CAA) dated 3/6/17, indicated R38 was alert and oriented to person, place and time but occasionally needed reminders from staff. R38 verbalized his wants and needs clearly and expressed his feelings effectively.

The Visual CAA dated 3/9/17, indicated R38 triggered due to impaired vision. R38 had difficulty seeing due to macular degeneration. R38 was independent in ambulation with the walker and felt for chair before sitting.

The Initial Activity Assessment dated 3/17/17, indicated R38's past interests included board games, cards, woodworking, shopping, crossword and jigsaw puzzles, news, sports, games and old TV on the television, reading science fiction and the bible and watching movies. R38's current activities he would like to do while at the facility included animals, pets, gardening, outings such as fishing and lunches, country and gospel music, parties and picnics, cooking, cleaning, decorating and reading science fiction. The assessment also noted books on tape and indicated the lack of vision had limited what R38 could do. The assessment further indicated R38 would like to play horse shoes if they were painted bright and he would like family and friends invited to facility functions.

A One to One Room Visit form indicated on 4/7/17, R38 discussed the men's group and making a bottle feeder. On 4/9/17, R38 talked about the weather. On 4/17/17, staff reviewed the Resident Bill of Rights with R38 for an hour.

On 4/17/17, at 5:58 p.m. R38 was interviewed. R38 stated he lays around and reminisces with himself because he could not see, read or write.

Activities Director.Activities Director will monitor for compliance and report results to the QA meetings for IDT review.


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F 248 Continued From page 3 F 248R38 liked to listen to music on the radio, and read when he could. R38 further stated he reloaded rifle shells and liked hunting and fishing. During the interview R38 was laying in his bed in flannel pajamas. There was not a radio in R38's room. There was a small television on a night stand by the wall near the foot of R38's bed. The television was not plugged in or connected to the antenna cable coming from the ceiling.

On 4/18/17, at 2:05 p.m. several residents were playing bingo in the main dining room. Staff informed another resident across the hall from R38 that bingo was going on. R38 was asked by the surveyor if he was aware bingo was going on. R38 stated, "No, I can't play bingo because I can't see." R38 was asked if anyone told him there was bingo. R38 stated no. R38 was asked if he ever played bingo. R38 stated he played with his sister in Texas and stated, "It's alright." R38 then asked what time it was, and then he counted the hours until the next meal. R38 stated that was all he had to look forward to. R38 stated he liked to listen to country western music on the radio, and watch old westerns and the news on the television. R38's smiled as he said this. R38's room continued to lack a radio and the television remained the same.

On 4/19/17, at 7:37 a.m. R38 put on the call light. R38 asked staff what time it was. R38 was angry because he wanted to be up by 7:00 a.m. Nursing assistant (NA)-B explained breakfast was from 7:00 a.m. to 9:00 a.m. R38 stated, "You're suppose to be here at 7:00 a.m." R38 then ambulated with the walker and NA-B to the main dining room. At 9:00 a.m. R38 ambulated back to his room with NA-B. R38 then ambulated independently to the bathroom, returned to the


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F 248 Continued From page 4 F 248bed, combed his hair and got into bed under the covers. At 9:22 a.m. activity staff were going room to room asking residents if they wanted to play a board game, and they informed some residents they were going to the Legion that afternoon. The activity staff did not enter R38's room. R38's room continued to lack a radio and the television remained the same. At 9:45 a.m. activity staff were playing a board game with one resident in the day room. R38 remained in bed sleeping. At 10:00 a.m. staff came into R38's room with his wife who was also his roommate. R38 asked what time it was. NA-A stated, "You have a half hour until lunch." R38 stated, "Okay." At 10:15 a.m. R38 ambulated with NA-B to the main dining room. Activity staff was playing a board game with two residents in the day room. R38's wife was also in the day room. R38 stated the fish are spawning now. R38 did not stop or speak to wife or anyone in the day room. At 1:35 p.m. R38 was on his bed sleeping. R38 was offered an afternoon snack but declined. Several residents were at the Legion outing.

On 4/20/17, at 12:20 p.m. the activity director (AD) stated she had been the AD since December 2016. The AD stated the activity aids did an interest inventory on each resident. The inventory included questions on what activities residents had done in the past and what they would like to do now. The AD further stated the activity aides should be telling all the residents what activities were going on. There was also an activity calendar on the bulletin board near the main dining room. Residents also get a daily calendar in the Chatterbug (monthly news letter). The AD stated residents should also be getting activity information and encouragement to attend from the nurses and NAs. The AD stated due to


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F 248 Continued From page 5 F 248R38's poor vision he could listen to the television, radio or books on tape using head phones. The AD stated activities was providing R38 with verbal discussions (1:1 visits), and if he wanted to do a craft an activity aide would help him. The AD stated the television should have been hooked up. The AD further stated she had not looked into books on tape, she would see if there was a radio for R38, and she would look into the television.

A policy on activities was requested and was not provided.

F 314SS=G

483.25(b)(1) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES

(b) Skin Integrity -

(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-

(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and

(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.This REQUIREMENT is not met as evidenced by:

F 314 6/7/17

Based on observation, interview and document review, the facility failed to provide care and services to prevent the development of pressure ulcers and promote healing of current pressure

F314R28’s pressure injury on her right heel is showing signs of healing. Current treatment plan includes cleansing of right


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F 314 Continued From page 6 F 314ulcers for 2 of 4 residents (R28, R46) reviewed for pressure ulcers. This caused actual harm for R28 due to development and worsening of a heel pressure ulcer, R46 also sustained harm due to the development of pressure ulcers to the heels and coccyx.

Findings include:

Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP):

Stage 3 Pressure Ulcer: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and/or eschar (dark, dead tissue) may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer.

Stage 4 Pressure Ulcer: Full-thickness skin and tissue lossFull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Ulcer.

Unstageable Pressure Ulcer: Obscured

heel wound with wound spray, pat dry, apply skin prep to surrounding intact skin, apply thin layer of medihoney to wound bed and cover with mepilex every other day. Skin prep to left heel every morning for prevention. R28 also has heel protectors on bilateral heels when in bed. Foot cradle at end of bed to promote comfort while wearing heal protectors. Nutritional supplement 4oz five times daily for healing, nutrition and weight maintenance. R28 has pressure reducing mattress and ROHO pressure reducing cushion in wheel chair when up. R46 expired as stated due to causes other than the pressure injuries. All residents at risk for developing pressure injuries have the potential to be affected. Full facility skin audit for pressure injuries was completed on 5/9/17 and no other residents were noted to be affected. “Tissue Tolerance” is/has been assessed via Braden Scale Assessments, Comprehensive Skin Risk Assessments, Daily Skin Observation, Weekly Skin Inspections and review of resident record on admission noting risk factors and history. Full facility review of Braden Scale scores were reviewed and updated on 5/31/17 and interventions were reviewed and updated based on resident individual needs. Nursing staff were re-educated on 5/25/17 and in-serviced on 4/25/17 regarding the need for daily skin inspection, following preventative skin interventions, such as floating heels and turning /repositioning schedules by the NAR’s per care


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F 314 Continued From page 7 F 314full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discolorationIntact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. R28's Admission Record printed 4/20/17, indicated R28's diagnoses included a hip fracture, edema, heart failure, osteoporosis (bone degeneration), and vitamin B12 deficiency anemia.

R28's admission Minimum Data Set (MDS)

plan/NAR Kardex as well as the policy regarding assessing skin risk potential by completion of the Braden Scale and Comprehensive Skin Risk Assessments upon admission, quarterly and with significant change of condition and Weekly Skin Audits by licensed nurses and evaluation of the data collected on these assessments will lead to implementation of interventions to prevent skin breakdown or worsening of current skin conditions and Wound Nurse notification of any new skin conditions. Weekly Wound Assessments will occur per policy on all pressure injuries where any wound noted to be deteriorating x1 week or stagnant x 2 weeks will be called to the MD/NP for new orders/change in treatment plan.Wound Audits will be done by DON/ADON/Licensed Nurses to ensure all residents at risk for pressure injury / with current pressure injury are receiving proper treatment and interventions to prevent skin breakdown / worsening of an existing wound on all residents with pressure injuries weekly x 1month, then every other week for 3 months and then quarterly thereafter or until 100% compliance is achieved. DON/ADON will monitor compliance and report results at the QA meetings for IDT review.


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F 314 Continued From page 8 F 314assessment dated 1/20/17, indicated R28 had a severe cognitive deficit, understood others and was understood by others, and had no rejection of care behaviors. R28's MDS further indicated R28 had no pressure ulcers, but was at risk for pressure ulcers. The MDS identified R28 required total assistance of 2 staff for bed mobility and transfers, and extensive assistance of 2 staff for toilet use. In addition, R28's MDS indicated R28 had a pressure reducing device in bed and in the chair, and received surgical wound care, however the MDS lacked indication of a turning and repositioning program.

R28's Care Area Assessment (CAA) for pressure ulcers dated 1/20/17, indicated R28 was admitted from the hospital following surgery for a fractured hip following a fall at home. The CAA further identified R28 was at risk for pressure ulcers due to decreased mobility, and required one to two staff to boost and turn in bed, transferred with the use of a mechanical lift, and was non-ambulatory.

R28's care plan revised 2/20/17, indicated R28 was at risk for skin breakdown related to weakness and poor oral intake. The care plan directed staff to apply bilateral blue heel boots or moon boots per resident preference, and float heels (elevate off the mattress, no pressure) when in bed. The care plan further directed staff to apply a cradle to the foot of the bed, and reposition every 2 hours and as necessary. The care plan also directed staff to observe skin daily with cares, and to report changes to the charge nurse. The care plan also directed weekly skin checks by nurses, and provide a pressure reduction cushion in the wheelchair and a pressure reduction mattress in bed. On 3/15/17,


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F 314 Continued From page 9 F 314the care plan was revised to include treatments as ordered for a heel wound. In addition, the care plan was revised on 4/4/17, and directed staff to provide assist of two staff to boost up in bed, assist of one to turn in bed, and extensive assist of one for transfers with a transfer belt and walker. The care plan further directed extensive assist of one staff for ambulation on an ambulation program, using a transfer belt and walker.

The Kardex Report used by nursing assistants (NAs) to direct cares dated 4/20/17, directed staff to apply bilateral blue heel boots or moon boots per resident preference, float heels when in bed, and reposition every 2 hours and as necessary, and apply the foot cradle at the foot of the bed. The Kardex Report further directed the nurse was to check skin weekly.

On 4/18/17 at 3:05 p.m. R28 was observed lying in bed with blue boots on.

R28's Hospital Discharge Summary dated 1/7/17, indicated R28 had been admitted with a right hip fracture after a fall and had surgery on her hip on 1/3/17. R28's Discharge Summary indicated R28 had edema in her lower extremities, pulses present in both lower extremities, and lacked indication of skin breakdown of heels.

R28's discharge instructions and After Discharge Orders from the hospital dated 1/7/17, directed nursing to monitor heel integrity, partial weight bearing of 50%, physical therapy for transfer training and bed mobility, and a nutritional supplement. The discharge instructions included indication of skin problems, closed right hip with a bruise, right hip incision with edges approximated


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F 314 Continued From page 10 F 314and steri strips.

R28's Admission/Readmission Nursing Evaluation form dated 1/7/17, indicated there were no pressure injuries or altered skin on R28's heels.

R28's Comprehensive Skin Risk Assessment dated 1/8/17, indicated R28 required extensive assistance of two staff with mobility related to the right hip fracture, was incontinent of bowel and bladder, was to be checked and changed every 2 hours and as needed. The assessment further indicated R28 required a dressing change every shift on the right hip incision. R28's skin risk assessment lacked documentation of any other alteration in skin.

R28's Braden Scale for Predicting Pressure Sore Risk (Braden Scale) dated 1/8/17, indicated R28 at moderate risk for pressure ulcers.

R28's Admission/Readmission Evaluation dated 1/9/17, indicated R28 had a right hip surgical incision with several areas of bruising in tissue surrounding the incision, extending to right posterior thigh and pelvis, but lacked documentation of altered skin of heels.

R28's Braden Scale dated 1/15/17, and 1/22/17, indicated R28 remained at moderate risk for pressure ulcers.

R28's Treatment Administration Record (TAR) from 1/7/17, through 1/31/17, directed nursing to monitor heel integrity. This order was written on the TAR as an FYI with no hours of administration. This was initialed on 1/7/17, and was not signed the rest of the month, indicating it


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F 314 Continued From page 11 F 314was not done. R28's TAR for 4/17, continued to direct nursing to monitor heel integrity as an FYI, and had not been initialed, indicating this was not done.

R28's progress notes by physical therapy (PT) dated 1/7/17, through 1/22/17, addressed skin integrity/altercations, but only included notes about R28's surgical incision and bruising related to surgery. R28's progress notes lacked indication of R28's skin integrity or altercation of the heels.

R28's progress notes dated 1/23/17, indicated R28 had a pressure area on the right heel and nursing was notified. Nursing documented acknowledgement of a new blister on the right heel due to pressure, on the same date.

R28's Wound Assessment Flow Sheet (WAFS) dated 1/24/17, indicated R28 had a pressure ulcer on the right heel that presented as a blister and measured 2.7 centimeters (cm) x 5.5 cm. The surrounding tissue was intact. R28 reported it hurt so much, and rated the pain at 10 out of 10 (0 being no pain and 10 worst pain). The positioning plan was to float heels, nutrition plan and pressure relieving mattress.

R28's progress note dated 1/24/17, indicated R28's pressure ulcer was a hematoma blister (bruise/blood with blister) measuring 2.7 x 5.5 cm and depth unknown. R28 stated the pain "hurts so much," and "I can't even touch it." Plan of care was to apply skin prep (a skin wipe used on intact skin to form a protective film to help reduce friction) to both heels every morning, wear blue heel protectors on both heels when in bed, and a foot cradle at the end of the bed for comfort while


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F 314 Continued From page 12 F 314wearing blue boots. In addition, R28 received a nutritional supplement daily for healing and nutrition. R28 had a pressure reducing mattress and pressure reducing cushion in the wheelchair. The nurse practitioner was updated on the pressure ulcer.

On 4/19/17, at 9:52 a.m. R28's room was observed. There was a pressure relieving mattress and a foot cradle on the bed.

R28's TAR for January 2017, indicated the interventions of skin prep to both heels in the morning and the blue heel protectors on both heels when in bed or floated on pillows, were initiated on 1/24/17.

R28's TAR documentation on 1/25/17, indicated R28 refused to wear the blue boots, so heels were floated with two pillows instead.

R28's progress notes dated 1/27/17, indicated PT had approached R28 in her room for therapy. R28 was lying on her back in bed, complained of increased discomfort in her right heel. PT removed R28's sock, and noted a blister on the heel. PT immediately called nursing and the heel protector boot was immediately put on. PT educated staff due to heels not being floated correctly.

R28's Braden Scale dated 1/29/17, indicated R28 remained at moderate risk for pressure injuries.

R28's signed physician orders dated 1/31/17, indicated R28's orders for blue heel protectors to be on bilateral heels when in bed every shift, and skin prep to bilateral heels every morning were initiated 1/24/17.


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F 314 Continued From page 13 F 314

R28's progress note dated 1/31/17, indicated R28's pressure ulcer was acquired at the facility, and measured 2.7 x 5.5 cm, and presented as a hematoma blister, with depth unknown. R28 stated her heel did not hurt as much. Interventions remained the same, and R28 was educated not to lay in the same position and to wear blue boots when in bed. R28's WAFS reflected the same information.

R28's MDS completed 2/1/17, for the assessment reference date (ARD) of 1/20/17, indicated there were no pressure ulcers prior to 1/20/17, but R28 was at risk for pressure ulcers and had no repositioning program.

R28's progress notes dated 2/2/17, indicated PT entered R28's room to find her lying on her back in bed. PT educated staff due to heels not being floated correctly and no pressure reducing boots on. PT explained the importance of compliance with pressure ulcers.

R28's MDS completed 2/18/17, for ARD of 2/4/17, indicated R28 had an unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar measuring 3.8 cm x 2.7 cm. The MDS indicated R28 was at risk for pressure ulcers, did not have a pressure ulcer on the prior assessment and had no repositioning program. The MDS further indicated R28 did have pressure ulcer wound care, pressure reducing mattress and cushion, and nutrition and hydration to manage skin conditions.

R28's progress notes dated 2/8/17, indicated R28 had an acquired blister that was now open and unstageable on her right heel, measuring 2.7 cm


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F 314 Continued From page 14 F 314x 3.8 cm. The wound bed was 100% eschar. The treatment was changed to a mepilex (foam) dressing. R28's WAFS reflected the same information.

R28's pressure ulcer was measured weekly and was documented in progress notes and the WAFS. R28's pressure injury was noted on 3/9/17, to have decreasing eschar. The eschar became 100% slough on 3/22/17. On 4/5/17, the wound bed changed to 50% slough and 50% granulation tissue (red, new healing tissue). R28 complained of pain with assessments on 2/24/17, through 4/12/17. R28's WAFS indicated the treatment was changed on 3/29/17. Undermining was first noted on 4/5/17, at 1 o'clock to 3 o'clock and was 0.2 cm in depth.

R28's Braden Risk assessment dated 4/10/17, indicated R28 was at low risk for pressure ulcer development, but continued to require extensive assist of one staff for transfers and ambulation, was frequently incontinent of bladder, had poor oral intake and weight loss. R28's Braden assessment further indicated R28 had a Stage II pressure ulcer located on the right heel.

R28's progress notes on 4/12/17, indicated the unstageable pressure ulcer of the right heel was a Stage III, and measured 1 cm x 1.2 cm. The pressure ulcer had undermining of 0.2 cm at 1 to 2 o'clock. R28 complained of pain when standing up or walking on the pressure ulcer, but had no pain when in bed. R28's WAFS indicated there was 75% granulation tissue and continued with 25% slough, so the depth was not yet determined.

On 4/19/17, at 11:36 a.m. during an observation


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F 314 Continued From page 15 F 314of R28's wound care by registered nurse (RN)-A, the treatment was completed as ordered. RN-A measured and described the pressure ulcer on R28's right heel. RN-A stated the pressure ulcer measured 0.8 cm x 1.9 cm, had 75% granulation, and 25% slough with undermining of 0.1 cm from 12 o'clock to 3 o'clock. RN-A stated the surrounding skin was intact, there was a small amount of yellowish residue, and the pressure ulcer was improved from the previous week. When the treatment was completed, RN-A offered to put R28's shoes on. R28 stated she could not wear shoes yet, due to the sore on her heel. RN-A asked R28 if she had pain in her heel, and R28 stated she had pain when she stepped on it. During an interview at that time, RN-A stated the pressure ulcer was identified on approximately 1/28/17, and verified that was a couple of weeks after R28 was admitted to the facility. RN-A verified a repositioning program, heel protectors and foot cradle were not initiated upon admission, but were initiated after the identification of the pressure ulcer. RN-A stated it was not a part of their policy to initiate a repositioning program upon admission for a resident at risk for skin breakdown, but should be. RN-A verified a resident who had a hip fracture and had limited mobility would be at risk for pressure ulcers.

R28's nurse progress notes following the wound care dated 4/19/17, indicated the pressure ulcer acquired 1/23/17, was a Stage 3 and measured 0.7 cm x 1.9 cm, was 75% granulation tissue and 25% slough, with undermining of 0.1 cm from 12 to 3 o'clock. RN-A documented R28 had pain of her heel when walking on it and rated it at 4 out of 10, but stated it didn't hurt so much when resting.


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F 314 Continued From page 16 F 314On 4/20/17, at 12:03 p.m. NA-E stated they monitored residents for skin breakdown during toileting and during baths, and would notify nurses if skin breakdown was noted.

On 4/20/17, at 12:53 p.m. the director of nursing (DON) stated upon admission a comprehensive skin assessment and Braden Risk assessment was done, and those should show if a resident is at risk for pressure ulcers. The DON stated they do skin checks and when a pressure ulcer is identified, they have a checklist to follow and put interventions in place. If moderate or low risk when admitted, they go by the Braden assessment, but that is not a complete indicator all of the time. If a resident is in therapy, a cushion would be issued by therapy, incontinent barrier cream would be used if a resident was at risk. If the resident is not eating enough, it is also a dietary issue and dietary gets involved. The DON stated repositioning and off-loading (alleviating pressure to allow for tissue reperfusion) would be done during toileting cares every 2-3 hours. Every 2-3 hours is the facility routine, but if the resident developed redness, then the repositioning would be increased and the resident would be checked again. The DON verified they did not assess the residents' individual tissue perfusion or tolerance, to determine their individual tolerance of remaining in one position without damage to the resident's tissue. The DON verified R28 was admitted with a hip fracture and had limited mobility, and stated she should have had barrier cream applied, and would have been put on a repositioning program with toileting, every 2 hours. The DON stated everyone was at risk for developing pressure ulcers, but did not respond when questioned if R28 was at an increased risk. The DON stated


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F 314 Continued From page 17 F 314nursing should be looking at skin weekly and with cares. The DON stated she was unable to respond to lack of nursing documentation on the TAR regarding monitoring of heel integrity, at that time. The DON stated if a pressure ulcer is identified, they use a checklist to determine appropriate interventions to initiate and who to notify, and RN-A would do weekly wound rounds to assess the pressure ulcer. When asked if there were specific interventions for residents at risk prior to prevent the development of pressure ulcers, the DON stated they did not want to add a bunch of "stuff," as residents do not always want those things. The DON stated residents can not move in bed well with the heel protectors on, so they may float heels on pillows. The DON stated the information should be put on the Kardex. In response to PT notes regarding finding R28 without blue heel protectors and heels not floated properly, the DON stated if a resident refused an intervention, staff should reapproach or offer education and staff should have documented if R28 had refused interventions.

On 4/20/17, at 1:32 p.m. the DON stated interventions needed to be initiated if a resident is at risk for a pressure ulcers, and the facility needs to use the data collected during an assessment to develop a plan. The DON verified the interventions for R28 had not been increased until the pressure ulcer worsened.

On 4/20/17, at 3:28 p.m. physical therapist (PT)-F verified PT had found R28's pressure ulcer, immediately informed nursing of the pressure ulcer, and assisted nursing with initiating the interventions. PT-F stated R28's pressure ulcer probably had an impact on her ambulation or ability to progress in therapy, because it caused


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F 314 Continued From page 18 F 314her pain when walking on it, but also stated it was difficult to tell because R28 was self-limiting due to her behaviors. PT-F described how heel slides are done, and stated when R28 did heel slides, the therapists hand held R28's heels so they did not slide on the mattress. PT-F verified there was not pressure on R28's heels during heel slides. PT-F verified when entering R28's room to do therapy, they had found R28 at times without heel protectors/boots on her heels and without her heels floated when R28 was in bed. PT-F stated she reported it to nursing at that time and re-educated staff.

The facility policy and procedure for Braden Scale/Comprehensive Skin Risk reviewed 9/15, directed the Braden was to be completed on all residents upon admission and readmission weekly for four weeks, quarterly, and with a change in condition, and the resident's risk level would be determined and the "Protocols by Level of Risk" would be used as a guide to develop interventions. The information from the Braden Scale/Comprehensive Skin Risk Assessment and weekly body audits would be used to determine appropriate repositioning and interventions for the resident. The Braden Scale Protocols (sic) by Level of Risk directed for a resident at moderate risk (13-14) interventions would include a turning schedule, protect heels, manage moisture, nutrition and friction and shearing, and pressure-reduction support surfaces.

The facility policy and procedure for Pressure Ulcers reviewed 2/16, directed all residents with a pressure ulcer would have a pressure ulcer checklist initiated and interventions implemented. The procedure further directed the Braden Scale and Comprehensive Skin Risk Assessment would


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F 314 Continued From page 19 F 314be completed, and the Wounds Assessment Flowsheet would be completed weekly, and the resident would be placed on an appropriate treatment plan and/or positioning schedule. In addition, the residents with pressure ulcers would be discussed daily at the interdisciplinary team meeting. The Pressure Ulcer Checklist directed nursing to complete if resident had a pressure ulcer, and included directives to add an appropriate repositioning schedule to resident's care plan/kardex.

National Pressure Ulcer Advisory Panel (NPUAP) Stage II pressure ulcer definition:

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

R46's Admission Record printed 4/20/17, indicated diagnoses that included peripheral vascular disease and cellulitis.

R46's admission MDS dated 1/19/17, indicated R46 had severely impaired cognition, and was at risk of pressure ulcers.

R46's CAA for pressure ulcers dated 1/25/17, indicated R46 was at risk for pressure ulcers due to extensive assistance with bed mobility and decreased mobility. R46's diagnoses of cellulitis (skin infection) of left lower extremity, completed antibiotics, essential hypertension and cognitive impairment also contributed to R46's potential for development of pressure ulcers. The CAA further identified the need for a special mattress or seat cushion to reduce or relieve pressure and that a


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F 314 Continued From page 20 F 314care plan should be developed for goals and interventions.

R46's care plan dated 2/3/17, indicated alteration in activities of daily living (ADL's) and mobility related to weakness, pain, cellulitis in lower extremities and possible CVA/TIA (stroke) with left sided weakness. The care plan also indicated an alteration in skin integrity related to bilateral cellulitis, shearing and occasional bladder incontinence. The care plan directed staff to assist with turning and repositioning in bed every 2-3 hours, to apply barrier cream to R46's coccyx with cares and to complete a daily skin inspection with cares. The care plan lacked further interventions to reduce the risk of development of pressure ulcers.

R46's undated Comprehensive Skin Risk Assessment, indicated R46 was able to move in bed very minimally by self and staff were to help to reposition, R46 required a pressure reducing device for chair and bed, had dementia, used an incontinence product, and used a wheelchair for locomotion.

R46's 1/13/17, Braden Scale for Predicting Pressure Sore Rick (Braden Scale), indicated R46 was at low risk for pressure ulcers.

R46's Admission/Readmission Evaluation dated 1/12/17, indicated R46 had pitting (the indentation persists after pressure is applied and released) edema (fluid beneath the skin that can cause swelling and pain), in left lower extremity, and non pitting edema in the right lower extremity. The evaluation also indicated R46 had dry, cracked heels and a known open area from cellulitis on his left leg.


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R46's TAR dated 1/17, directed staff to apply skin prep to R46's left and right heels every day starting on 1/19/17 for diagnosis of ulcer. The TAR indicated to float R46's heels when in bed as tolerated beginning 1/30/17.

R46's TAR dated 2/17, continued with the above treatments, and added the application of barrier cream to coccyx with cares and reposition every 2-3 hours as tolerated except meals, activity and off unit destinations.

R46's TAR dated 3/17, added to wear blue boots as tolerated beginning on 3/1/17, and continued to implement the January and February interventions.

A 1/17/17, skin wound note indicated R46 was admitted with four separate wounds of left lower extremity related to cellulitis.

A 1/25/17, fall note indicated R46 fell at noon on 1/25/17; a follow-up note indicated R46 was displaying stroke symptoms. R46 and his family declined hospitalization and R46 was hoyered into bed. Further progress notes indicate an additional fall on 1/25/17, and further falls in the following days.

A Skin/wound note dated 2/2/17, indicated, in addition to cellulitis wounds and an unstageable pressure ulcer on heel which was present upon admission, R46 had developed an unstageable pressure ulcer located on left and right lateral heel and a Stage II pressure ulcer with two open areas at the coccyx (tailbone) on 2/1/17. The nurse practitioner was updated.


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F 314 Continued From page 22 F 314The 2/2/17, note described the pressure ulcers located on the left and right heel, measured from left to right: 1.1 centimeters (cm) x 0.8 cm with wound bed 25% granulation tissue (new connective tissues) and 75% eschar tissue (dead tissue) and 2 cm x 2.1 cm with the wound bed being 100% eschar tissue. A minimal amount of drainage was noted in the left wound with none in the right wound. The surrounding skin was described as intact with 4 cm erythematous (red) tissues that blanched. The depth was unknown and there was a foul door. R46 flinched during the assessment but verbally denied pain.

The 2/2/17, note further indicated the pressure ulcer on the coccyx was measured from superior to inferior: 0.5 cm x 0.3 cm with no drainage and 3.1 cm x 0.6 cm with no drainage. The wound bed was 100% epithelial (new, pink) tissue and the site appeared to be from friction and shearing as evidenced by the residents "scooting" down in his chair during attempts to self-transfer. The surrounding skin was described as intact with 2 cm erythmatous tissue that blanched. There was no odor and no pain noted at the site.

The 2/2/17, note indicated the nurse practitioner (NP) updated orders to include barrier cream and to monitor. The NP also indicated to continue to attempt to float heels and if R46 was non-compliant, to administer blue boots to improve healing and decrease pressure.

R46's Braden score dated 2/3/17, indicated the facility rated him at low risk of developing a pressure ulcer.

A skin/wound note dated 2/10/17, indicated R46's left and right heel pressure ulcers measured from


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F 314 Continued From page 23 F 314left to right: 1.0 cm x 0.7 cm with a wound bed of 100% slough (yellow to white and may be stringy or thick and may appear as a layer over the wound bed) and 2.3 cm x 2.1 cm with the wound bed being 100% eschar tissue. There was no drainage, but there was a foul odor. The surrounding skin was described as intact with 4 cm erythematous tissue that blanches; the depth was unknown and R46 flinched during the assessment but verbally denied pain. The note indicated the nurse practitioner would assess on her next visit.

The 2/10/17, note indicated the pressure ulcer on coccyx was described as having only one open area measured at 0.5 cm x 0.4 cm with no drainage. The wound bed was 100% epithelial tissue and the surrounding skin was intact with 2 cm of erythmatous tissue that blanched. There was no odor and no pain was noted.

The 2/10/17, note indicated that R46 was compliant with wound treatments such as repositioning, offloading and floating heels but would often forget that he was supposed to be on a different side or floating heels and would go back to previous position. The current plan of care was to apply skin prep to left and right heel every day and barrier cream to coccyx and reposition every 2-3 hours as tolerated, pressure reducing cushion in wheelchair and pressure reducing mattress in place. The resident was also started on 1 scoop of Propass (protein supplement powder) twice a day.

A 2/13/17, Medicare/Managed Care/Skilled Nursing Charting note indicated R46 was an extensive assist of 1 with transfers and ADL's. R46's skin was described as having ulcers of the


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F 314 Continued From page 24 F 314left leg related to cellulitis and other skin clean, dry and intact.

On 2/14/17, the nurse practitioner observed R 46's pressure ulcers and gave orders for wet to dry dressing changes every morning.

Other Medicare notes that indicated R46's skin was "clean dry and intact" other than cellulitis wounds were on 2/2/17, 2/4/17, 2/6/17, 2/7/17, 2/8/17, 2/10/17, and 2/13/17.

A skin/wound note dated 2/17/17, indicated R46's left and right heel pressure ulcers measured left to right: 1.2 cm x 1 cm with the wound bed at 25% granulation tissue and 75% slough and 2.5 cm x 2 cm with the wound bed at 100% eschar tissue. There was no drainage, and the surrounding skin was intact with 4 cm erythematous tissues that blanched. The depth was unknown and there was a foul odor. R46 flinched during assessment but verbally denied pain.

The 2/17/17, note indicated the coccyx pressure ulcer was described as nonblanchable tissue measured at 2 cm x 1 cm with surrounding skin intact with 2 cm erythmatous tissues that blanched. There was no odor and no pain, and no open area at the time of the 2/17/17 note.

A 2/23/17, skin/wound note indicated R46's left and right heel pressure ulcers measured from left to right: 1 cm x 1.5 cm with wound bed at 25% slough and 75% eschar and 2.5 cm x 2.5 cm with the wound bed at 75% eschar tissue and 25% slough. There was no drainage and the surrounding skin was intact with +4 pitting edema in both lower extremities. The depth of the


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F 314 Continued From page 25 F 314wounds was unknown, there was a foul odor and R46 flinched during assessment, and verbally complained of pain.

The 2/23/17, note indicated the coccyx pressure ulcer was described as blanchable redness, and the wound was healed. Staff were directed to continue to apply barrier cream prophylacticly.

A skin/wound note dated 3/3/17, indicated the left heel pressure ulcer measured at 1.3 cm x 1.5 cm with a wound bed that was 50% slough and 50% eschar, and the right heel pressure ulcer measured at 2.3 cm x 2 cm with the wound bed at 75% eschar tissue and 25% slough. There was a minimal amount of serous drainage from both wounds; the depth was unknown; and there was a foul odor from the right heel wound. R46 flinched during the assessment and verbally complained of pain.

A skin/wound note dated 3/8/17, indicated R46's left lateral and right heel pressure ulcers were measured from left to right: 1.9 cm x 2.1 cm with a wound bed at 75% slough and 25% eschar and 2.2 cm and 2 cm with the wound bed being 75% eschar tissue and 25% slough. There was a minimal amount of serous (clear) drainage from both wounds, and the depth of the wounds was unknown, there was foul odor from both the left and right heel, R46 flinched during the assessment and verbally complained of pain. The note indicated R46 enjoyed sitting in his wheelchair and did not like laying down in bed. The nurse practitioner did not provide new wound orders, and had previously stated the blue boots were not as helpful without a stabilizing bar in back to raise his heels off the mattress but if R46's wounds worsened, staff were to encourage


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F 314 Continued From page 26 F 314R46 to wear the blue boots when in bed or sitting in his room with feet on the floor as he did not remember to float heels when in bed.

A behavior note dated 3/9/17, indicated R46 went to bed with blue boots on and took them off shortly after. The note further indicated R46 was not able to be educated as he would forget shortly after.

A skin/wound note dated 3/14/17, indicated R46 had a new pressure ulcer on his buttocks, described as a 0.3 cm open area on right inner buttocks. The note lacked staging. There was no redness, just a circular area surrounded by whitish tissue, and no drainage. Calmospeptine was applied on the area and surrounding tissue. This area was noted to be below the area that had healed. The note also indicated a foul odor from the pressure areas on R46's feet.

A second skin/wound noted dated 3/14/17, indicated a new Stage II pressure ulcer on the coccyx was measured at 0.3 cm x 0.2 cm with no drainage. The wound bed was 100% epithelial tissue, there was no odor, and no pain at the site. The surrounding skin was described as intact with 0.5 cm erythematous tissue that blanches.

R46's care plan update dated 3/14/17, indicted an increase in supplement for weight loss and to assist with healing pressure ulcers.

A skin/wound note dated 3/19/17, indicated no change to the pressure ulcer on R46's right inner buttocks and the continued presence of pressure ulcers on bilateral heels.

A skin/wound note dated 3/22/17, indicated


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F 314 Continued From page 27 F 314pressure ulcers on left lateral heel and right heel were measured from left to right: 1.3 cm x 1.4 cm with wound bed at 100% slough and 2.7 cm x 1.8 cm with wound bed being 25% granulation tissue and 75% slough. There was a minimal amount of purulent (thick, opaque) drainage from both wounds the depth of the wound was unknown. The surrounding skin was intact with a callous on the plantar side of heels measuring from left to right: 2.4 cm x 2.4 cm and 2.5 cm x 3.0 cm with a dark black area in center of callous. There was a foul odor from the right heel. R46 flinched during the assessment and verbally complained of pain.

The note further indicated the Stage II pressure ulcer located on R46's coccyx was healed with blanchable redness.

The note indicated the current plan of care included to encourage R46 to float his heels or wear blue boots when in bed but acknowledged R46 refused to float his heels or wear boots for longer than a half an hour. The current plan of care was updated to include repositioning every 1-2 hours as tolerated except at meals, activities and off unit destinations. However, this was not added to the care plan.

A skin/wound note dated 3/30/17, indicated the pressure ulcers located at R46's left lateral heel and right heel measured from left to right: 1.0 cm x 1.4 cm with wound bed 100% eschar and 3.0 cm x 2.1 cm with the wound bed being 25% granulation tissues, 25% eschar tissue and 50% slough. There was a minimal amount of purulent (pus) drainage for the right wound and no drainage from the left, the depth of the wounds was unknown, the surrounding skin was intact with a callous on the plantar side of heels


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F 314 Continued From page 28 F 314measuring from left to right 2.4 cm x 2.4 cm and 1 cm x 2 cm with no dark areas noted, a foul odor was present from the right heel, facial grimacing was noted during the assessment, but no flinching away.

R46's Braden score on 4/3/17 indicated the facility assessed him at moderate risk for development of a pressure ulcer.

A skin/wound note dated 4/7/17, indicated R46 was admitted with three separate open areas on his left lower extremity related to cellulitis of bilateral lower extremities and an unstageable pressure injury on his heel. R46 also developed unstageable pressure injury located on his left lateral heel and right lateral heel and two Stage II pressure ulcers on the coccyx on 2/1/17. The note also indicated the coccyx pressure ulcer healed on 2/23/17, and a new Stage II pressure ulcer developed on 3/13/17, and healed on 3/22/17.

On 4/7/17, the left lateral heel pressure ulcer measured 1.0 x 1.4 cm with no drainage. The wound bed was 100% eschar. The surrounding skin was intact with 0.3 cm dark, black tissue. R46 also had a callous on the bottom of his heel measuring 2.4 cm x 2.4 cm with 0.5 cm dark black tissue notes in the center. There was no odor. R46 flinched away during assessment but did not verbally complain of pain.

On 4/7/17, the pressure ulcer on R46's right heel measured 2.1 cm x 1.5 cm with a wound bed of 25% granulation (pink or beef red) tissue, 25% eschar tissue and 50% slough (yellow or white). There was a minimal amount of purulent drainage and there was a foul odor. The wound depth was


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F 314 Continued From page 29 F 314unknown. The surrounding was was intact with a callous on the plantar side of the heel measuring 1 cm x 2 cm with no dark areas noted. R46 flinched away during assessment.

R46 expired on 4/8/17.

On 4/20/17, at 11:14 a.m. licensed practical nurse (LPN)-A stated R46 didn't like putting his feet up, did not like laying in bed, but they had applied skin prep, a pressure reducing mattress on R46's bed, and a pressure reducing cushion in his wheelchair. LPN-A also indicated they had called dietary for a supplement and that they used the "standard interventions" for pressure ulcers.

On 4/20/17, at 1:08 p.m. the DON acknowledged they use standardized interventions to prevent pressure ulcers for all admissions. The DON stated they do not provide any individualized interventions in case the resident does not want to do extra things. The DON confirmed that R46 developed pressure ulcers on his heels and coccyx after admission and after a change in abilities. The DON stated a comprehensive skin assessment would not be triggered again until a change in status had taken place and no comprehensive skin assessment was done after R46's stroke on 1/25/17. The DON stated R46 had PVD and edema, and he also was non-compliant with interventions. When asked if these conditions were taken into account in determining R46's risk for pressure ulcers the DON did not reply.

F 441SS=D

483.80(a)(1)(2)(4)(e)(f) INFECTION CONTROL, PREVENT SPREAD, LINENS

(a) Infection prevention and control program.

F 441 6/7/17


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The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2);

(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:

(i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility;

(ii) When and to whom possible incidents of communicable disease or infections should be reported;

(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;

(iv) When and how isolation should be used for a resident; including but not limited to:

(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the


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F 441 Continued From page 31 F 441least restrictive possible for the resident under the circumstances.

(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and

(vi) The hand hygiene procedures to be followed by staff involved in direct resident contact.

(4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility.

(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review the facility failed to ensure hand hygiene was maintained for 1 of 1 residents (R28) observed for wound care, and 1 of 3 residents (R12) observed for personal cares, and 1 of 1 residents observed for catheter care (R11).

Findings include:

R28's Admission Record printed 4/20/17, indicated R28's diagnoses included a hip fracture, osteoporosis (bone degeneration), and vitamin B12 deficiency anemia.

F441There were no negative outcomes noted for R28, R12 or R11 due to this deficiency. Direct observation of hand hygiene was observed with R28’s wound care which was completed to standards, wound is healing. R28 and has not been treated nor had signs or symptoms of infection in last 3 months or more. R11 no longer has indwelling catheter. R11 has not been treated for infection since re-entry on 5/3/17 after planned procedure and is discharging home on 6/1/17.


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F 441 Continued From page 32 F 441R28's signed physician orders dated 3/30/17, included orders for wound care to the right heel: Cleanse right heel wound with wound spray, pat dry, apply skin pep to surrounding skin, apply Medihoney (used to fight germs and improve healing) to wound and cover with Mepiliex (foam dressing) every other day.

On 4/19/17, at 11:36 a.m. registered nurse (RN)-A entered R28's room to provide wound care to the right heel. R28 was sitting in her wheelchair. RN-A sanitized her hands, placed a pad on the floor, and donned gloves. RN-A removed R28's compression stockings, removed the soiled dressing, sprayed R28's heel wound with wound cleanser, and removed her gloves. RN-A put on new gloves without sanitizing or washing hands between glove changes. RN-A wiped heel wound with gauze, changed gloves without sanitizing or washing hands, and measured R28's heel pressure injury. RN-A proceeded to apply barrier wipe around the wound, applied Medihoney to the wound with a cotton tipped applicator, and placed R28's foot on the pad. RN-A removed the soiled gloves, did not do hand hygiene, opened the room door, left the room and went to the treatment cart. RN-A unlocked the treatment with keys, opened drawers, removed dressings, locked the cart, sanitized her hands and returned to the room. RN-A donned new gloves, dated the Mepilex dressing and applied it to R28's right heel pressure injury. RN-A put R28's compression socks and gripper socks on while wearing the soiled gloves. RN-A offered R28 a blanket and removed the gloves. RN-A left the room, went to the tub room, opened the door, took a clean blanket and gave it to R28, then sanitized her hands. At that time, RN-A verified she had not

R12 perineal care was observed to standards and has not been treated nor had signs or symptoms of infection in last 3 months or more.All residents have the potential to be affected by proper hand washing. Pocket hand sanitizers were purchased and staff was educated to use for hand hygiene between glove changes as directed in the hand hygiene policy.Staff was inserviced on proper hand washing infection prevention practices on 4/25/17 and 5/9/17. Dressing Change Competency Checklist Audits will be completed weekly x1 month, every other week x 3 months then quarterly or until 100% compliance is achieved. Peri Care Hand Hygiene Competency Audits will completed on NAR’s completed weekly x1 month, every other week x 3 months then quarterly or until 100% compliance is achieved. Catheter care audits will be completed weekly x1 month, every other week x 3 months then quarterly or until 100% compliance is achieved.Infection Control Hand Washing Audits will be completed by Licensed Nurses weekly x1 month, every other week x 3 months then quarterly or until 100% compliance is achieved. DON/ADON will monitor compliance and report results at the QA meetings for IDT review.


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F 441 Continued From page 33 F 441sanitized her hands between glove changes and should have.

On 4/20/17, at 1:38 p.m. the director of nursing (DON) verified hands should be washed or sanitized between glove changes.

R12's Diagnosis Report dated 4/20/17, indicated R12's diagnoses included dementia, chronic kidney disease, and an open wound on the nose.

The significant change Minimum Data Set (MDS) dated 1/26/17, indicated R12 had severely impaired cognition. The MDS further indicated needed extensive assistance of one staff with bed mobility, dressing and personal hygiene. The MDS indicated R12 needed extensive assistance of two staff with transfers, and total assistance of one staff with locomotion and toileting.

On 4/19/17, at 8:20 a.m. R12's morning cares were observed with nursing assistant (NA)-A. NA-A washed her hands and donned gloves. NA-A retrieved R12's clothes, lowered the head of the bed using the bed controls and removed the pillows under R12. NA-A removed R12's soiled incontinent brief, cleansed R12's buttocks, then R12's peri area and applied a new brief. NA-A did not wash or sanitize her hands or change gloves. With the same soiled gloves, NA-A removed R12's gown, washed under R12's arms, and applied R12's shirt. R12 had a scabbed area on her nose that began to bleed. With the soiled gloved hands, NA-A wiped the blood away with a wet wipe. NA-A then returned the wet wipes to the bedside stand, opening the drawer with the soiled gloved hands. NA-A rolled R12 side to side,


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F 441 Continued From page 34 F 441pulled up R12's pants, and wiped blood from R12's nose with a tissue. NA-A removed her gloves, and did not wash or sanitize her hands. NA-A sat on edge of R12's bed, took a walkie talkie from her pocket, talked into it and then returned it to her pocket. NA-A lowered the bed using the bed controls, wiped blood from R12's nose with a tissue, and transferred R12 to the chair. NA-A again took the walkie talkie from her pocket, talked into it, and returned it to her pocket. NA-A applied the transfer belt to herself, gave R12 a drink of water through a straw, and wiped blood from R12's cheek with a wet wipe. NA-A applied R12's glasses, wiped blood from R12's nose with a paper towel, and exited the room without washing or sanitizing her hands. NA-A retrieved a towel from the clean linen room, opened the linen room door touching the door knob, returned with the towel and placed the towel on R12's chest. NA-A donned new gloves without washing or sanitizing her hands. NA-A set up the toothbrush with toothpaste and brushed R12's teeth. NA-B entered R12's room and handed NA-A a bottle of hand sanitizer. NA-A placed the hand sanitizer in her pocket. NA-A rinsed the basin, turned off the bathroom light, gathered the soiled linen, exited R12's room and opened the soiled utility room door with the soiled gloved hands. NA-A then removed her gloves and washed her hands.

On 4/19/17, at 8:45 a.m. NA-A verified she did not remove her gloves until after cares were done, and did not remove her gloves or wash or sanitize her hands until she was in the soiled utility room. NA-A stated she sometimes does wash or sanitize her hands after removing the gloves but it was difficult to get the gloves back on after washing or sanitizing her hands.


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On 4/20/17, at 1:36 p.m. the director of nursing (DON) was informed of the above scenario. The DON stated she would expect staff to wash residents from clean to dirty, and wash the peri area last. The DON would expect staff to wash or sanitize their hands after peri care, after removing gloves and before exiting the room. The DON further stated NA-A could have carried the soiled linen with a gloved hand and manage the door with the ungloved hand or NA-A could have put the soiled linen in a bag.

The facility's Hand Hygiene policy dated 10/25/10, directed hand hygiene was the most effective method of preventing the transfer of infection. The policy directed hand hygiene must be done before applying and after removing gloves, following contact with contaminated areas and when going from one task to another.

R11's Diagnosis Report printed 4/20/17, indicated diagnoses that included congestive heart failure and retention of urine.

R11's admission Minimum Data Set (MDS) dated 3/16/17, indicated R11 had moderately impaired cognition. The MDS indicated R11 had an indwelling catheter for bladder.

R11's care plan indicated R11 had a Foley catheter due to urinary retention, and required extensive assistance of 1 with perineal cares.

On 4/19/17, at 7:40 a.m. nursing assistant (NA)-D entered R11's room. NA-D donned gloves and put


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F 441 Continued From page 36 F 441R11's catheter bag through the leg of his pants and removed her gloves. R11 informed NA-D that he needed a leg bag for his catheter instead of the larger bag used at night. Without washing her hands, NA-D pulled the curtain to block visual to the door, opened the room door by touching the handle and left the room to get a leg bag. At 7:54 a.m. NA-D re-entered the room with a leg bag and donned gloves without washing or sanitizing her hands. NA-D unhooked the larger bag from the catheter connection, opened an alcohol wipe pack, wiped the catheter connection with the alcohol wipe, connected the leg bag and took the larger catheter bag to the bathroom to empty it into the toilet. NA-D removed the soiled gloves, and did not wash or sanitize her hands. NA-D donned new gloves, untied R11's gown in the back, and used disposable wipes to wash his back, arms, and armpits. NA-D then put an undershirt, shirt and transfer belt on R11 and assisted him to standing. NA-D removed her gloves and without washing or sanitizing her hands, tucked in R11's shirt, pulled up and buckled his pants, pulled up and locked R11's wheelchair. NA-D guided R11 into his wheelchair, moved R11's overbed table next to his wheelchair, put his call light within reach, and put on R11's glasses on his face. NA-D then removed R11's transfer belt, opened the privacy curtain, opened the bathroom door by using the handle, put the disposable wipes back in the bathroom and washed her hands.

On 4/19/17, at 8:13 a.m. NA-D confirmed she had not done hand hygiene between glove changes while providing cares to R11.

On 4/19/17, at 8:28 a.m. the director of nursing (DON) confirmed staff are to remove soiled


A. BUILDING ______________________






B. WING _____________________________




PINE CITY, MN 55063



(X5)COMPLETION

DATE

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TAG

(X4) IDPREFIX

TAG



F 441 Continued From page 37 F 441gloves and wash or sanitize their hands prior to donning clean gloves.



May 31, 2017



129 East 6th Avenue

Pine City, MN 55063


Dear Mr. Blaufuss:

Please note: The health survey and life safety code survey are being processed under separate

enforcement cycles.

On May 15, 2017, a standard survey was completed at your facility by the Minnesota Department of

Public Safety to determine if your facility was in compliance with Federal participation requirements for


programs.

This survey found the most serious deficiencies in your facility to be widespread deficiencies that

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

(Level F), 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.



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





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 June 24, 2017, the Department of Health will

impose the following remedy:

• State Monitoring. (42 CFR 488.422)

In addition, the Department of Health is recommending to the CMS Region V Office that if your facility

has not achieved substantial compliance by June 24, 2017 the following remedy will be imposed:

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



Your ePoC must:










May 31, 2017

Page 2










and,




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));


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



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

acceptable.


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.


May 31, 2017

Page 3


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.



If substantial compliance with the regulations is not verified by August 15, 2017 (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




this date.


May 31, 2017

Page 4


Services that your provider agreement be terminated by November 15, 2017 (six months after the











P.O. Box 64900











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

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

Telephone: (651) 430-3012 Fax: (651) 215-0525 Telephone: (651) 430-3012 Fax: (651) 215-0525 Telephone: (651) 430-3012 Fax: (651) 215-0525 Telephone: (651) 430-3012 Fax: (651) 215-0525


May 31, 2017

Page 5


Sincerely,







Phone: (651) 201-4118 Fax: (651) 215-9697


May 31, 2017

Page 6


May 22, 2017



129 East 6th Avenue

Pine City, MN 55063


Dear Mr. Blaufuss:

Please note: The health survey and life safety code survey are being processed under separate Please note: The health survey and life safety code survey are being processed under separate Please note: The health survey and life safety code survey are being processed under separate Please note: The health survey and life safety code survey are being processed under separate

enforcement cycles. enforcement cycles. enforcement cycles. enforcement cycles.

On May 15, 2017, a standard survey was completed at your facility by the Minnesota Department of

Public Safety to determine if your facility was in compliance with Federal participation requirements for


programs.

This survey found the most serious deficiencies in your facility to be widespread deficiencies that

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

(Level F), 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.



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





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 June 24, 2017, the Department of Health will

impose the following remedy:

• State Monitoring. (42 CFR 488.422)

In addition, the Department of Health is recommending to the CMS Region V Office that if your facility

has not achieved substantial compliance by June 24, 2017 the following remedy will be imposed:

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



Your ePoC must:










May 22, 2017

Page 2










and,




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));


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



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

acceptable.


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.


May 22, 2017

Page 3


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.



If substantial compliance with the regulations is not verified by August 15, 2017 (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




this date.


May 22, 2017

Page 4


Services that your provider agreement be terminated by November 15, 2017 (six months after the











P.O. Box 64900











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

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

Telephone: (651) 430-3012 Fax: (651) 215-0525 Telephone: (651) 430-3012 Fax: (651) 215-0525 Telephone: (651) 430-3012 Fax: (651) 215-0525 Telephone: (651) 430-3012 Fax: (651) 215-0525


May 22, 2017

Page 5


Sincerely,







Phone: (651) 201-4118 Fax: (651) 215-9697


May 22, 2017

Page 6

department of health and human services centers … · (l4) (l5) (l6) 4. type of action: (l8) 1....

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