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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: 00982

ID: D6O7

BALATON, MN

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

7

07/01/2015

12/31

12/4/2017

COLONIAL MANOR OF BALATON

1. MEDICARE/MEDICAID PROVIDER

NO.(L1) 245552

2. STATE VENDOR OR MEDICAID NO.

(L2) 570014100

02

HIGHWAY 14 EAST PO BOX 219

56115

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

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

From (a) :

To (b) :

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

Program Requirements

Compliance Based On:

1. Acceptable POC

2. Technical Personnel 6. Scope of Services Limit

3. 24 Hour RN 7. Medical Director

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

5. Life Safety Code 9. Beds/Room12.Total Facility Beds 33 (L18)

13.Total Certified Beds 33 (L17) B. Not in Compliance with Program

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

14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS

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

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

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

29. INTERMEDIARY/CARRIER NO.

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

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

18. STATE SURVEY AGENCY APPROVAL Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL

RIGHTS ACT:

1. Statement of Financial Solvency (HCFA-2572)

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

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

2. Facility is not Eligible(L21)

22. ORIGINAL DATE

OF PARTICIPATION

23. LTC AGREEMENT

BEGINNING DATE

24. LTC AGREEMENT

ENDING DATE

(L24) (L41) (L25)

27. ALTERNATIVE SANCTIONS25. LTC EXTENSION DATE:

(L27)

A. Suspension of Admissions:

(L44)

B. Rescind Suspension Date:

(L45)

26. TERMINATION ACTION: (L30)

VOLUNTARY

01-Merger, Closure

02-Dissatisfaction W/ Reimbursement

03-Risk of Involuntary Termination

04-Other Reason for Withdrawal

INVOLUNTARY

05-Fail to Meet Health/Safety

06-Fail to Meet Agreement

OTHER

07-Provider Status Change

28. TERMINATION DATE:

(L28) (L31)

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

(L32) (L33)

30. REMARKS

00-Active

04/01/1991

00

06201

12/13/2017

21.

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

Shellae Dietrich, Certification Specialist 02/26/2018Kathryn Serie, Unit Supervisor

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

Midwest Division of Survey and Certification

Chicago Regional Office

233 North Michigan Avenue, Suite 600

Chicago, IL 60601-5519

CMS Certification Number (CCN): 245552

December 8, 2017

By ePOC

Colonial Manor of Balaton

Attention: Administrator

Highway 14 East Po Box 219

Balaton, MN 56115

Dear Administrator:

SUBJECT: FEDERAL MONITORING SURVEY RESULTS AND

NOTICE OF IMPOSITION OF REMEDY

Cycle Start Date: November 29, 2017

FEDERAL MONITORING SURVEY

On November 29, 2017, a surveyor representing this office of the Centers for Medicare &

Medicaid Services (CMS) completed a Federal Monitoring Survey (FMS) at Colonial Manor of

Balaton to determine if your facility was in compliance with the Federal requirements for nursing

homes participating in the Medicare and Medicaid programs. As the surveyor informed you

during the exit conference, the FMS revealed that your facility was not in substantial compliance

with the most serious deficiency at Scope and Severity (S/S) level F, cited as follows:

• K521 -- S/S: F -- NFPA 101 -- HVAC

The findings from the FMS will be posted on the ePOC system. Enclosed is a list of the “resident

identifiers” used in writing the Statement of Deficiencies. The “resident identifiers” will enable

you to identify any specific residents referred to in the CMS-2567.

ELECTRONIC PLAN OF CORRECTION (ePOC)

Within ten (10) calendar days after your receipt of this notice, you must submit an acceptable

ePOC for the enclosed deficiencies cited at the FMS. An acceptable ePOC will serve as your

allegation of compliance. Upon receipt of an acceptable ePOC, we will authorize a revisit to your

facility to determine if substantial compliance has been achieved. The failure to submit an

acceptable ePOC can lead to termination of your Medicare and Medicaid participation.

To be acceptable, a provider's ePOC must include the following:

• How corrective action will be accomplished for those residents found to have been affected

by the deficient practice

• How the facility will identify other residents having the potential to be affected by the same

deficient practice

• What measures will be put into place, or systemic changes made, to ensure that the deficient

practice will not recur

• How the facility will monitor its corrective actions to ensure that the deficient practice is

being corrected and will not recur

• The date that each deficiency will be corrected

• An electronic acknowledgement signature and date by an official facility representative

INFORMAL DISPUTE RESOLUTION (IDR)

CMS has established an IDR process to give providers one opportunity to informally refute

deficiencies cited at a Federal survey, in accordance with the regulation at 42 CFR §488.331. To

use this process, you must send your written request, identifying the specific deficiencies you are

disputing to Stephen Pelinski, Branch Manager, at [email protected]. The request

must set forth in detail your reasons for disputing each deficiency and include copies of all

relevant documents supporting your position. A request for IDR will not delay the effective date

of any enforcement action, nor can you use it to challenge any other aspect of the survey process,

including the following:

• Scope and Severity assessments of deficiencies, except for the deficiencies constituting

immediate jeopardy and substandard quality of care

• Remedies imposed

• Alleged failure of the surveyor to comply with a requirement of the survey process

• Alleged inconsistency of the surveyor in citing deficiencies among facilities

• Alleged inadequacy or inaccuracy of the IDR process

You must submit your request for IDR within the same ten (10) calendar day timeframe for

submitting your ePOC. You must provide an acceptable ePOC for all cited deficiencies,

including those that you dispute. We will advise you in writing of the outcome of the IDR.

Should the IDR result in a change to the Statement of Deficiencies, we will send you a revised

CMS-2567 reflecting the changes.

LIFE SAFETY CODE (LSC) WAIVERS

If you request an annual waiver for a LSC deficiency cited during the FMS, the request must

indicate why correcting would impose an unreasonable hardship on the facility; if high cost is the

hardship, you must include recent, bona fide cost estimates. In addition, the request must indicate

how continued non-correction of the deficiency will not pose a risk to resident safety, based on

additional compensating features or other reasons.

Each cited deficiency (other than those which receive annual waivers) must be corrected within a

reasonable timeframe. If a reasonable correction date falls beyond your enforcement cycle’s three

month date, you may request a temporary waiver to allow correction by the reasonable date, and

without the noncompliance leading to the imposition of remedies. Include a request for a

temporary waiver as part of your POC, indicating the basis for the length of correction time

needed, and include a timetable for correction. A temporary waiver may be granted if the POC

date extends beyond your enforcement cycle’s three month date, and if the correction timeframe

is reasonable, in CMS’ judgment. Your enforcement cycle’s three month date is March 1, 2018.

Page 2

DENIAL OF PAYMENT FOR NEW ADMISSIONS

The remedy of denial of payment for all new Medicare and Medicaid admissions will be imposed

effective March 1, 2018 should your facility not achieve substantial compliance by March 1,

2018. This action is mandated by the Act at §§ 1819(h)(2)(D) and 1919(h)(2)(C) and Federal

regulations at 42 CFR § 488.417(b).

TERMINATION PROVISION

If your facility has not attained substantial compliance by May 29, 2018, your Medicare and

Medicaid participation will be terminated effective with that date. This action is mandated by the

Act at §§ 1819(h) and 1919(h) and Federal regulations at 42 CFR § 488.456 and § 489.53.

We are required to provide the general public with notice of an impending termination and will

publish a notice in a local newspaper prior to the effective date of termination. If termination

goes into effect, you may take steps to come into compliance with the Federal requirements for

long term care facilities and reapply to establish your facility's eligibility to participate as a

provider of services under Title XVIII of the Social Security Act. Should you seek re-entry into

the Medicare program, the Federal regulation at 42 CFR § 489.57 will apply.

NURSE AIDE TRAINING PROHIBITION

Please note that Federal law, as specified in the Act at §§ 1819(f)(2)(B) and 1919(f)(2)(B),

prohibits approval of nurse aide training and competency evaluation programs and nurse aide

competency evaluation programs offered by, or in, a facility which, within the previous two

years, has operated under a § 1819(b)(4)(C)(ii)(II) or § 1919(b)(4)(C)(ii) waiver (i.e., waiver of

full-time registered professional nurse); has been subject to an extended or partial extended

survey as a result of a finding of substandard quality of care; has been assessed a total civil

money penalty of not less than $10,483; has been subject to a denial of payment, the appointment

of a temporary manager or termination; or, in the case of an emergency, has been closed and/or

had its residents transferred to other facilities. We will notify you if any of these circumstances

results in a prohibition at your facility.

CONTACT INFORMATION

If you have any questions, please contact me at (312) 353-1502 or at

[email protected]. Information may also be faxed to (443) 380-6614.

Sincerely,

Tamika J. Brown

Principal Program Representative

Long Term Care Certification

& Enforcement Branch

Page 3

CMS Certification Number (CCN): 245552

December 13, 2017

Mr. Charles Ness, Administrator

Colonial Manor Of Balaton

Highway 14 East Po Box 219

Balaton, MN 56115

Dear Mr. Ness:

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 November 30, 2017 the above facility is certified for;

33 Skilled Nursing Facility/Nursing Facility Beds

Your facility’s Medicare approved area consists of all 33 skilled nursing facility beds.

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

certification status.

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

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

Please contact me if you have any questions.

Sincerely,

Kamala Fiske-Downing

Minnesota Department of Health

Licensing and Certification Program

Program Assurance Unit

Health Regulation Division

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

Email: [email protected]

cc: Licensing and Certification File

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

An equal opportunity employer.

Electronically delivered

December 13, 2017


Colonial Manor of Balaton

Highway 14 East PO Box 219

Balaton, MN 56115

RE: Project Number S5552029

Dear Mr. Ness:

On November 3, 2017, we informed you that we would recommend enforcement remedies based on the

deficiencies cited by this Department for a standard survey, completed on October 20, 2017. This survey found

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

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

On December 4, 2017, the Minnesota Department of Health completed a Post Certification Revisit (PCR) by

review of your plan of correction and on December 1, 2017 the Minnesota Department of Public Safety

completed a PCR to verify that your facility had achieved and maintained compliance with federal certification

deficiencies issued pursuant to a standard survey, completed on October 20, 2017. We presumed, based on

your plan of correction, that your facility had corrected these deficiencies as of November 30, 2017. Based on

our PCR, we have determined that your facility has corrected the deficiencies issued pursuant to our standard

survey, completed on October 20, 2017, effective November 30, 2017 and therefore remedies outlined in our

letter to you dated November 3, 2017, will not be imposed.

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

with the President of your facility's Governing Body.

Feel free to contact me if you have questions.

Sincerely,

Kamala Fiske-Downing





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





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

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL

PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00982

ID: D6O7

BALATON, MN

1. MEDICARE/MEDICAID PROVIDER NO.

(L1)

2.STATE VENDOR OR MEDICAID NO.

(L2)

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

570014100

2

07/01/2015

12/31

10/20/2017

COLONIAL MANOR OF BALATON245552

02

HIGHWAY 14 EAST PO BOX 219

56115

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

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

From (a) :

To (b) :

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

Program Requirements

Compliance Based On:

1. Acceptable POC

2. Technical Personnel 6. Scope of Services Limit

3. 24 Hour RN 7. Medical Director

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

5. Life Safety Code 9. Beds/Room12.Total Facility Beds 33 (L18)

13.Total Certified Beds 33 (L17) X B. Not in Compliance with Program

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

14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS

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

33

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

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

29. INTERMEDIARY/CARRIER NO.

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

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

18. STATE SURVEY AGENCY APPROVAL Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL

RIGHTS ACT:

1. Statement of Financial Solvency (HCFA-2572)

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

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

2. Facility is not Eligible(L21)

22. ORIGINAL DATE

OF PARTICIPATION

23. LTC AGREEMENT

BEGINNING DATE

24. LTC AGREEMENT

ENDING DATE

(L24) (L41) (L25)

27. ALTERNATIVE SANCTIONS25. LTC EXTENSION DATE:

(L27)

A. Suspension of Admissions:

(L44)

B. Rescind Suspension Date:

(L45)

26. TERMINATION ACTION: (L30)

VOLUNTARY

01-Merger, Closure

02-Dissatisfaction W/ Reimbursement

03-Risk of Involuntary Termination

04-Other Reason for Withdrawal

INVOLUNTARY

05-Fail to Meet Health/Safety

06-Fail to Meet Agreement

OTHER

07-Provider Status Change

28. TERMINATION DATE:

(L28) (L31)

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

(L32) (L33)

30. REMARKS

00-Active

04/01/1991

00

06201

11/14/2017 12/04/2017

21.

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

Kamala Fiske-Downing, Health Program Representative Wendy Buckholz, HFE NE II

Electronically delivered

November 3, 2017



Highway 14 East P.O. Box 219

Balaton, MN 56115

RE: Project Number S5552029

Dear Mr. Ness:

On October 20, 2017, a standard survey was completed at your facility by the Minnesota Departments

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

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

Medicaid programs.

This survey found the most serious deficiencies in your facility to be 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 attached CMS-2567 whereby corrections are required.

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

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

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

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

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

the following issues:

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

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

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

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

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

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

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

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

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



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

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

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

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

DEPARTMENT CONTACTDEPARTMENT CONTACTDEPARTMENT CONTACTDEPARTMENT CONTACT

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

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

Kathryn Serie, Unit Supervisor

Mankato Survey Team




1400 East Lyon Street, Suite 201

Marshall, Minnesota 56258-2504


Phone: (507) 476-4233

Fax: (507) 344-2723

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 November 29, 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 November 29, 2017 the following remedy will be imposed:

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

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;


November 3, 2017

Page 2

- 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 remedies be imposed:

• Optional denial of payment for new Medicare and Medicaid admissions (42 CFR 488.417 (a));

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

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

and/or Medicaid agreement.

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

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

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

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

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

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

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

acceptable.


November 3, 2017

Page 3

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

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

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

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

your plan of correction.

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

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

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

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

occurred sooner than the latest correction date on the ePoC.

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

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

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

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

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

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

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

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

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

imposed.

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

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

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

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

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

imposition of these remedies.

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

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

If substantial compliance with the regulations is not verified by January 20, 2018 (three months after

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

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

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

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

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


November 3, 2017

Page 4

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 April 20, 2018 (six months after the

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

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

regulations at 42 CFR Sections 488.412 and 488.456.

INFORMAL DISPUTE RESOLUTIONINFORMAL DISPUTE RESOLUTIONINFORMAL DISPUTE RESOLUTIONINFORMAL DISPUTE RESOLUTION

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

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

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

Nursing Home Informal Dispute Process



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.

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

Health Care Fire Inspections

Minnesota Department of Public Safety

State Fire Marshal Division

445 Minnesota Street, Suite 145

St. Paul, Minnesota 55101-5145


November 3, 2017

Page 5


Telephone: (651) 430-3012

Fax: (651) 215-0525

Feel free to contact me if you have questions.

Sincerely,

Kate JohnsTon, Program Specialist





[email protected]

Telephone: (651) 201-3992 Fax: (651) 215-9697



November 3, 2017

Page 6

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 11/14/2017FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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

245552 10/20/2017STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

HIGHWAY 14 EAST PO BOX 219COLONIAL MANOR OF BALATON

BALATON, MN 56115

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

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

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

On October 17, 18, 19 and 20, 2017, a standard survey was completed at your facility by the Minnesota Department of Health to determine if your facility was in compliance with requirements of 42 CFR Part 483, Subpart B, and Requirements for Long Term Care Facilities.

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

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

F 157SS=D

483.10(g)(14) NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

(g)(14) Notification of Changes.

(i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s) when there is-

(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

(B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial

F 157 11/30/17

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

11/13/2017Electronically 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 D6O711Event ID: Facility ID: 00982 If continuation sheet Page 1 of 67

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F 157 Continued From page 1 F 157status in either life-threatening conditions or clinical complications);

(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).

(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.

(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-

(A) A change in room or roommate assignment as specified in §483.10(e)(6); or

(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.

(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to ensure the primary care physician (PCP) was notified of weight loss for 1 of 1 resident (R35) reviewed who experienced significant weight loss.

F1571. Corrective action as it applies to R35. MD informed of weight loss. No change to Plan of Care as resident was discharged on the same date of 10/20/2017.


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F 157 Continued From page 2 F 157

Findings include:

R35's medical record identified an admission date on 8/21/17, for rehabilitation following surgery resulting from a fracture to his right ankle. R35's Brief Interview for Mental Status (BIMS) score was identified as 15/15, indicating no cognitive impairment. The pre-surgical hospital admission physician progress note dated 8/17/17, identified R35's diagnoses included: heart disease, history of lymphoma (cancer in the lymph nodes), and "pre-diabetes". R35's weight at that time was documented as 115.8 kilograms (kg) or 255 pounds (lbs).

Review of R35's physician's orders, signed by the orthopedic surgeon (OS) upon admission indicated: Tylenol and oxycodone as needed for pain, allopurinol daily-gout, aspirin-hearth, carvedilol-heart, losartan-blood pressure, metformin-blood sugar control, nitroglycerin-as needed for chest pain, ranitadine-acid reflux, Crestor-high cholesterol, ticagrelor-heart, trazadone at bedtime and a regular diet.

Review of R35's current medication and treatment record lacked identification that a nutritional supplement was ordered. Review of the weights (#) documented for R35 identified the following dates: (1) 8/28/17, 257.6 lbs.(2) 9/29/17, 236 lbs, (8% weight loss), (3) 10/17/17, 225 lbs. (12% wt. loss), and (4) 10/20/17, re-weighed-223 lbs. (13% severe wt. loss).

When interviewed on 10/19/17, at 2:13 p.m. with the certified dietary manager (CDM) related to R35's weight loss since admission (admission wt. 257# and on 10/17/17, 225#). The CDM stated

2. The facility identifies that all residents have the possibility of weight loss at any given time in their stay.3. The facility will put measures into place at this time (11/9/17) to inform all primary MDs of significant weight changes. From this point on after weekly meeting with dietician the dietician will inform the MD of significant weight loss promptly. Dietician will also inform DON and the RD. Also, all nursing staff that note a weight loss will immediately bring information to the IDT team to be addressed and reported if necessary. Staff were instructed of this on 11/1/2017 and all nursing staff meeting.4. Facility will monitor its performance by the Dietician and the RD monitoring of the medical record for MD notifications monthly. Documentation will be done on a monthly flow log for weight loss for tracking purposes. 5. Completion date, November 30th 2017.


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F 157 Continued From page 3 F 157the registered dietician (RD) visited the facility on 9/20/17, and confirmed the wt. loss identified for R35 had not triggered on the weight variance report in September thus the RD had not been alerted. The CDM verified had only informed the DON of the weight loss noted on 9/29/17, 236 # (8 % weight loss).

When interviewed on 10/19/17, at 3:38 p.m. the MDS coordinator/RN-F indicated she could not find any dictation from any PCP in R35's medical record. It was verified that R35 had not seen the in-house primary care provider (MD-G) who made rounds at the facility. R35 was off-site at an appointment with OS during the time of this facility visit. RN-F agreed there was no PCP who managed R35's overall health since admission, stating "We missed him." Upon further questioning RN-F agreed an orthopedic doctor would not manage R35's diabetes, high blood pressure medication, etc., or overall health needs but rather a PCP.

During observation on 10/20/17, at 9:11 a.m. it was noted R35 appeared tall and thin. When interviewed at this time, R35 stated he experienced weight loss during the first two weeks after admission. R35 admitted he didn't have an appetite, so he didn't he didn't eat very much. The weight loss concerned him since he had a history of lymphoma, expressing he was afraid he had a relapse of cancer. R35 confirmed he never discussed weight loss with the staff and stated he did not experience extra fluid post surgery.

Interview on 10/20/17, at 9:33 a.m. with registered dietician (RD)-H indicated she was unaware of R35's weight loss. R35 was


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F 157 Continued From page 4 F 157re-weighed after her most recent visit (9/20) and learned of the wt. loss but she had not contacted the PCP.

Interview on 10/20/17, at 10:41 a.m. with medical assistant (MA)-I from PCP's office indicated the PCP was out of the office at the moment, but R35's last weights were noted on 8/15/17, at 252 lbs (114.7 kg), and the same weight on 7/21/17 and 4/26/17. In December of 2016, R35 weighed 249 lbs. (113 kg). MA-I indicated that R35 had not experienced weight fluctuations but the PCP would need to be notified of weight loss and this notification had not occurred. MA-I stated lab tests may need to be ordered to verify R35's cancer had not returned and to evaluate the cause of rapid weight loss.

Interview on 10/20/17, at 11:29 a.m. PCP certified medical assistant (CMA)-K indicated the physician had never seen R35 while a resident at the facility and confirmed the weight loss had not been reported. CMA-K stated the physician had seen R35 once for a toenail trimming on 8/14/17, prior to his ankle surgery.

Interview on 10/20/17, at 12:21 p.m. with OS's registered nurse (RN)-C confirmed they do not monitor care for residents other than health issues related to orthopedics; for example, not diabetes or other health issues. It was confirmed they do not take weights post-surgical if the resident cannot stand and were not aware of R35's weight loss as had not been notified.

When interviewed on 10/20/17, at 12:59 p.m. the director of nursing (DON) indicated although the electronic medical record (EMR) has an auto-populated warning when a resident's weight


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F 157 Continued From page 5 F 157drops or increases, to re-weigh the resident, there is no automatic notification sent to the nurse in the EMR. The DON further explained that staff are expected to report any weight changes immediately to nursing. The DON agreed no PCP had been involved with R35's care and no notification had occurred related to the identified weight loss.

Review of the policy dated December 2008, titled, Interdepartmental Notification of Diet (Including Changes and Reports) indicated nursing services shall notify the physician and dietician when nutritional problems such as weight loss has been identified and shall collaborate with the dietician and physician to initiate an appropriate process of clinical review for causes of nutritional problem.

Review of the policy dated May 2011, titled, Weighing and Measuring the Resident indicated weight will be measured upon admission, monthly, as needed and in accordance with MDS 3.0 guidelines during the resident's stay. Reweigh the resident if there is a discrepancy of 2 pounds plus or minus. Report to the nurse supervisor or charge nurse. Significant weight loss is defined as greater than 5% difference in 30 days or greater than 7.5% difference in 90 days. The physician is to be notified if weight loss meets the criteria above.

F 205SS=D

483.15(d)(1)(i)-(iv)(2) NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR

(d) Notice of bed-hold policy and return-

(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility

F 205 11/30/17


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F 205 Continued From page 6 F 205must provide written information to the resident or resident representative that specifies-

(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;

(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;

(iii) The nursing facility’s policies regarding bed-hold periods, which must be consistent with paragraph (c)(5) of this section, permitting a resident to return; and

(iv) The information specified in paragraph (c)(5) of this section.

(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (e)(1) of this section.This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to inform 1 of 1 resident (R18) and/or family member of the bed-hold policy when admitted to the hospital.

Findings include:

When interviewed on 10/17/17, at 7:21 p.m. family member (FM)-A indicated being the responsible party for all financial decisions for R18. FM-A stated that R18 had recently been

F2051. Corrective action as it applies to R 18. Resident family was given bed hold notice as R18 not cognitively intact.2. All residents that the potential to be affected by bed holds not being given at time of transfer. 3. Measure put in place to prevent further occurrence was instruction (meeting on 11/1/2017) to new charge nurses (and reinforced to senior charge


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F 205 Continued From page 7 F 205discharged to the hospital on or about the previous Thursday (10/12/17) and returned from the hospital on 10/16/17. FM-A stated a bed hold notification had not been provided to R18 nor to FM-A. FM-A stated that another family member who lived closer to the facility was present at the time of hospitalization of R18.

Review of the facility's 10/13/17, Bed Hold authorization form for R18 indicated a staff nurse had signed the Bed Hold form; however, no resident/family member signed this form indicating the notice had been provided to the family member and/or resident.

Review of the facility's Admission Agreement policy, section VII Bed hold-Hospital or Therapeutic Leave, indicated if the resident was hospitalized, the facility would hold a bed for the resident for days as determined by Minnesota State law. Arrangements were to be made with the social worker or director of nursing.

nurse staff) of the necessity of a bed hold to be given to resident and/ or resident family with every transfer. Telephone may be used as verbal compliance and signed and dated by nurse reflecting the appropriate party notification with notification information documented in nurses note also. 4. Facility will monitor bed hold notifications being given by the DON or designee after each transfer, for 1 month and then periodically thereafter. Performance of said actions will be monitored by QA for compliance.5. Date of Completion, 11/30/2017

F 242SS=D

483.10(f)(1)-(3) SELF-DETERMINATION - RIGHT TO MAKE CHOICES

(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

(f)(3) The resident has a right to interact with members of the community and participate in

F 242 11/30/17


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F 242 Continued From page 8 F 242community activities both inside and outside the facility.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review the facility failed to identify resident preferences for frequency of bathing for 1 of 2 residents (R24) reviewed for choices.

Findings include:

R24, a 64 yr. old female was admitted on 8/23/17. The hospital discharge summary dated 8/23/17, identified diagnoses including anxiety/depression, diabetes mellitus II, end stage renal disease with hemodialysis and obesity. The Minimum Data Set (MDS) dated identified that R24 required extensive assistance with bathing but is alert and oriented with moderate depression.

During an observation on 10/17/17, at 4:29 p.m. R24 was neatly dressed, free of odor and combed/groomed; however, R24's hair appeared greasy on the top of the hairline and the back of the head. When interviewed on 10/17/17, at 4:29 p.m. R24 reported that more than one bath a week had not been offered as a choice. R24 stated, "I would like another bath. A couple of weeks ago I asked for another bath and they looked at me like I had 4 heads".

During a subsequent observation on 10/19/17, at 9:18 a.m. R24 was sitting in her room completing the breakfast meal. R24 was fully dressed and her hair remained greasy and stringy appearing. Review of the bath schedule indicated R24 was due for her weekly bath on 10/17/17; however, R24 denied having a bath as scheduled due to

F2421. Corrective action as it applies to R24. Discussed resident preference for bathing and was determined that 2 baths a week are requested. Care plan and NAR assignments changed to reflect same.2. All residents have the right to bathe as frequently as they request within reason. The facility will ask on admission their preference for bathing.3. Facility has placed on the Admission Activity Assessment the question of how frequently the resident would like to bathe on 10-23/17. This information will be passed on to Nursing as soon as information is obtained. The Charge nurse will document this on the nursing assistant assignment sheet. The MDS nurses will care plan information. 4. The DON will follow up with all new admits with interview if receiving bathes per preference. The DON will also do a walk-through facility for a visual of the resident cleanliness. Started on 10/23/17 and will be ongoing for 4 months. Data collected will be brought to QA for follow through with compliance.5. Date of completion, 11/30/17


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F 242 Continued From page 9 F 242having possible surgery (10/19/17) and staff wanted to "wait" to provide the bath on Wednesday (10/18/17). It was further learned the surgery was canceled but no shower was provided for R24.

When interviewed on 10/19/17, at 8:10 a.m. the licensed social worker (LSW) indicated she had talked with R24 this week and noted she had greasy hair. LSW stated she had been unaware that R24 would prefer more than one shower a week; adding it was a reasonable request.

When interviewed on 10/19/17, at 12:54 p.m. registered nurse (RN)-MDS coordinator indicated she was unsure how it was decided who receives more than one bath/week. RN/MDS verified the aide charting identified weekly bathing for R24. RN-MDS stated, "I would agree she should have 2 baths a week. It might improve her outlook and make her feel better". RN-MDS further explained the bath schedule and morning (AM) or evening (PM) bath time was determined by the room the resident resides.

During record review the bath note dated 8/31/17, at 1:59 p.m. indicated R24 would like a Tuesday and Thursday PM shower.

F 278SS=D

483.20(g)-(j) ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

(g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status.

(h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

F 278 11/30/17


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(i) Certification(1) A registered nurse must sign and certify that the assessment is completed.

(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

(j) Penalty for Falsification(1) Under Medicare and Medicaid, an individual who willfully and knowingly-

(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or

(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.

(2) Clinical disagreement does not constitute a material and false statement.This REQUIREMENT is not met as evidenced by: Based on interview and document review the facility failed to accurately code the resident status related to range of motion (ROM) on the Minimum Data Set (MDS) assessment for 1 of 1 resident (R10) reviewed with limited range of motion of the right hand.

Findings include:

Review of the face sheet identified R10's original admit date as 5/3/14 and latest readmit date as

F278 1. Corrective action as it applies to R10. R10 was assessed by OT on 10/24/17 for resident status with ROM to right hand. This is a change from when the MDS was first done and will be noted as a change on the next MDS due in December to reflect change in functional limitations.2. Facility will identify other residents that have a functional limitation with range with input from MDS nurses.


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F 278 Continued From page 11 F 2788/24/17. The significant change Minimum Data Set (MDS) reassessment dated 9/6/17, identified that R10 had an arthritis diagnosis. The Brief Interview for Mental Status (BIMS) identified R10 with moderately impaired cognitive skills. The MDS identified no functional limitation in ROM (range of motion) of the upper extremity. The MDS also identified R10 required extensive assistance with bed mobility, bathing, dressing, grooming and eating.

Review of the occupational therapy (OT) plan of care dated 12/3/15, identified reason for referral: a 93 year old female presents with a decline in functional ROM of right hand due to increased flexion contracture of digits. The care giver started noticing a decrease in ROM/mobility approximately a few weeks ago, which resulted in [R10] now requiring significantly more assistance for extension of right hand to complete self feeding tasks and placement of resting hand splint. Documentation identified skilled OT required due to increased flexion contracture of the right hand in order to regain extension of digits and will be provided with appropriate orthotics and splint wear schedule. Documentation also indicated that without skilled intervention [R10] is at further risk for contracture and decreased functional use of right dominant hand. Plan included: AROM (active range of motion) of 4th and 5th digits limited to -90 degrees extension, impacting ability to complete self feeding tasks with moderate assist. Review of the OT therapist progress and discharge summary dated 1/4/16, identified ROM goal not met. The notes identified: demonstrates AROM of right 4th and 5th digits limited to -75 degrees, impacting ability to complete self feeding tasks.

3. The facility MDS nurse will code appropriately, the functional limitations in ROM. If functional limitation is noted and the MDS nurse is not sure of the degree of limitation, the OT will be asked to eval the resident to be sure accurate coding is completed per RAI manual.4. The DON will review documentation on the MDS for accuracy with coding in the future for the resident that have a functional limitation. This will be monthly times 3 to cover a quarter of MDSs.5. Date of Completion, 11/30/17


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F 278 Continued From page 12 F 278During interview on 10/19/17, at 12:36 p.m. registered nurse (RN)- D stated she did not code the right upper extremity as having a functional limitation because "that is the way it was previously coded so that is how I coded it." It was confirmed the MDS had not been coded accurately for R10.

F 279SS=D

483.20(d);483.21(b)(1) DEVELOP COMPREHENSIVE CARE PLANS

483.20(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan.

483.21(b) Comprehensive Care Plans

(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -

(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and

(ii) Any services that would otherwise be required

F 279 11/13/17


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F 279 Continued From page 13 F 279under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).

(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.

(iv)In consultation with the resident and the resident’s representative (s)-

(A) The resident’s goals for admission and desired outcomes.

(B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.

(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review the facility failed to develop a care plan which included safe smoking for 1 of 3 residents (R5) reviewed who smoked.

Findings include:

R5's diagnosis sheet, dated 7/31/17 identified a

F2791. Corrective action for R5 pan was to address a care plan to reflect residents smoking needs. Resident was discharged to hospital on 10/21/17 and did not return. 2. Corrective action as it applies to 2 other residents that smoke, both have a care plan related to smoking. These were


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F 279 Continued From page 14 F 279diagnosis of Multiple Sclerosis. R5's admission Minimum Data Set (MDS) assessment dated 8/11/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS also identified R5 required extensive assistance of one staff for dressing, limited assistance of one staff for grooming, extensive assistance of of one staff for locomotion on and off the unit and extensive assistance of 2 staff for transfers.

R5's smoking assessment dated 8/1/17, indicated R5 smoked in designated areas and did not smoke around oxygen, safely utilized lighter/matches and lit smoking material, used smoking apron and demonstrated safe smoking practices with other residents. The interdisciplinary team recommendation identified R5 was able to smoke independently and agreed to wear apron while smoking.

R5's nursing assistant care sheet dated 10/18/17, indicated staff were to accompany R5 for smoking. The care plan dated 8/17/17, did not address R5's smoking.

During observation on 10/18/17, at 10:17 a.m. nursing assistant (NA) B brought R5 to the outside smoking area. NA-B draped the smoking apron across R5's lap. The smoking apron was not fastened around R5's neck. R5 was unable to light the cigarette lighter and asked NA-B to assist her. NA-B lit the lighter but couldn't light the cigarette. NA-B gave R5 back her lighter and R5 was able to light the cigarette. NA-B gave R5 a doorbell to ring when she was done smoking. R5 appeared weak and did not use her right hand. R5 reached across her body to "ash" her cigarette into an ash can that had been placed on

reviewed and are updated.3. Systemic changes to ensure that smoking care plans are added to each and every resident in facility that smokes by the MDS nurse. 4. The facility plans will be monitored by the DON every quarter or on admission if applicable that a smoking care plan has been made. QA will be updated Quarterly of compliance.5. Date of completion, 11/30/17


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F 279 Continued From page 15 F 279a table beside R5's wheelchair. When R5 finished the cigarette she was attempting to drop it into the ash can. R5 was unable to get her left hand over far enough and dropped the cigarette on the ground between her wheelchair and the table.

During observation on 10/19/17, at 9:30 a.m. R5 was again observed outside smoking. The smoking apron was again draped across R5's lap, not fastened around her neck. R5 again struggled with dropping the cigarette into the ash can.

During observation on 10/20/17, at 10:00 a.m. R5 was again observed outside smoking. Restorative aide (RA)-F draped the smoking apron on R5's chest and lap. R5 pulled the apron down onto her lap (there were no ties for the neck of the apron.) R5 was unable to light her cigarette and needed staff assist. When R5 finished smoking she was able to get the cigarette into the ash can without difficulty. During interview on 10/20/2017, at 11:22 a.m. the director of nursing (DON) stated the care plan should address R5's smoking as it had been assessed but not added to the plan of care.

The policy Smoking revised June 2008 identified The smoking plan is to be included in the resident's care plan and the assessment and care plan is reviewed and updated as needed, but at least quarterly.

F 280SS=D

483.10(c)(2)(i-ii,iv,v)(3),483.21(b)(2) RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

483.10

F 280 11/13/17


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F 280 Continued From page 16 F 280(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:

(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.

(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.

(iv) The right to receive the services and/or items included in the plan of care.

(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must--

(i) Facilitate the inclusion of the resident and/or resident representative.

(ii) Include an assessment of the resident’s strengths and needs.

(iii) Incorporate the resident’s personal and cultural preferences in developing goals of care.

483.21


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F 280 Continued From page 17 F 280(b) Comprehensive Care Plans

(2) A comprehensive care plan must be-

(i) Developed within 7 days after completion of the comprehensive assessment.

(ii) Prepared by an interdisciplinary team, that includes but is not limited to--

(A) The attending physician.

(B) A registered nurse with responsibility for the resident.

(C) A nurse aide with responsibility for the resident.

(D) A member of food and nutrition services staff.

(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan.

(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.

(iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document F280


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F 280 Continued From page 18 F 280review, the facility failed to revise the care plan for 1 of 1 resident (R10) who had a significant change related to a fracture.

Findings include:

Review of the face sheet identified R10's latest readmit date as 8/24/17. Review of the significant change Minimum Data Set (MDS) reassessment dated 9/6/17, identified R10 with diagnosis including "other fracture". The Brief Interview for Mental Status (BIMS) identified moderately impaired cognitive skills and no functional limitation in ROM (range of motion) upper extremity was evident. The MDS also identified R10 needed extensive assistance with, bed mobility, bathing, dressing, grooming and eating.

Review of the hospital discharge summary dated 8/24/17, identified R10 was admitted to the hospital on 8/22/17, with a left femur fracture. Activity/restrictions included bedrest, brace in place at all times and no weight bearing for 6-8 weeks.

Review of the nursing note dated 9/15/17, identified that R10 attempted to get out of bed, stating she was going to get up. Staff assisted R10 out of bed and transferred into a wheelchair. The physician assistant, certified (PA-C) was informed of the incident and the PA agreed with getting the resident out of bed.

It was observed on 10/17, 10/18, 10/19, and 10/20 that R10 was seated in the wheelchair for meals with a brace noted on the left leg.

Review of the care plan dated 9/11/17, identified:

1. Corrective action for R10. Care plan updated with the following: R10 is getting up in wheel chair for meals and eating in the dining room, R10 wears leg brace to left leg, ( off for skin checks only), moves about unit in wheel chair pushed by staff.2. The facility will identify other residents care plans that need to be updated by reviewing current care plans.3. The facility will identify resident care plans that need to be updated with a change of condition through IDT meetings, with care plan adjustments made at the time of resident change of condition. Starting 11/11/17 and ongoing.4. This plan will be monitored by the DON, MDS nurses reviewing care plans weekly and ongoing for 3 months, of residents that have a change in condition warranting care plan changes.Same information will be discussed at QA for followup.5. Date of completion, 11/30/17


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F 280 Continued From page 19 F 280increased dependence in activities of daily living (ADL's) related to fracture. Interventions included: (1) extensive assist for dressing upper body; (2) lower body dressing not occurring related to being bed bound; (3) indwelling Foley catheter; (4) bed bound, locomotion and transferring not occurring due to R10 being bed bound; (5) eats all meals in bed due to bed bound/left femur fracture.

The care plan was not revised to include R10 was getting up in the wheelchair for meals and eating in dining room nor did it identify the use of the brace. The nursing assistant (NA) care sheet dated 10/18/17, identified R10 as being on bed rest and did not include the brace on the left leg.

When interviewed on 10/20/17, at 11:55 a.m. registered nurse (RN)-A verified the care plan had not been revised to identify the use of the brace nor the current activity level which included getting R10 up in the wheelchair for meals.

F 282SS=D

483.21(b)(3)(ii) SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

(b)(3) Comprehensive Care PlansThe services provided or arranged by the facility, as outlined by the comprehensive care plan, must-

(ii) Be provided by qualified persons in accordance with each resident's written plan of care.This REQUIREMENT is not met as evidenced by:

F 282 11/13/17

Based on observation, interview and document review, the facility failed to ensure personal hygiene and grooming needs were provided as identified in the plan of care for 2 of 3 residents

F2821. Corrective action for R5 facial hair was plucked. Smaller water cup found for resident had the ability to lift. Staff placed


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F 282 Continued From page 20 F 282(R5, R28) reviewed who required staff assistance and that hydration needs are provided as directed in the plan of care for 1 of 1 resident (R5) reviewed who required staff assistance with drinking fluids.

Findings include:

R5's diagnosis sheet, dated 7/31/17 identified diagnosis including Multiple Sclerosis, pain in left shoulder and weakness. R5's admission Minimum Data Set (MDS) assessment dated 8/11/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS also identified R5 required limited assistance of one staff for grooming activities and required supervision with set up from staff with eating and extensive assistance of 2 staff with bed mobility.

R5's Care Area Assessment (CAA) for activities of daily living (ADLs) dated 8/7/17, indicated R5 required limited assistance of one person for personal hygiene. R5's CAA for dehydration/fluid maintenance dated 8/10/17, indicated recent decline in activities of daily living, including body control or hand control problems, inability to sit up, etc., recent change in oral intake, fluid intake began to decrease on 8/5/17.

R5's care plan dated 8/17/17, identified potential for fluid volume deficit (dehydration/fluid). Approaches included: (1) provide assistance with fluids, (2) provide fluids consistently throughout the day, (3) fresh water pitcher maintained at bedside, (4) offer fluids with juice/snack cart, (5) offer fluids frequently, (6) assist with fluid intake, (7) keep fluids within reach, (8) record fluid intake with meals, (9) assess oral intake and (9) assess

liquids next to resident within reach. R28 nails were trimmed.2. All dependent residents have the potential to be affected by lack of personal hygiene and grooming and meeting fluid requirements.3. The facility will do audits of nail care and facial hair weekly by charge nurse and reports handed into DON for follow up. This will be ongoing. DON will do random visual audits ongoing to supervise same and report information to QAA if further action is necessary. Hydration concern with ability to reach fluids will be assessed by DON and or Charge Nurse by, visually monitoring of dependent resident ability to give self-hydration. Adaptive equipment will be ordered if necessary.4. The Don will do assessment of information gathered weekly x1 month then monthly x3. This POC will be discussed in great detail at QA for assistance in follow through and moniitoring for compliance.5. Completion date, 11/30/17


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F 282 Continued From page 21 F 282hydration status.

During initial observation on 10/17/17, at 4:41 p.m. R5 had facial hair along her upper lip with one long (1 inch) hair noted on the left side of upper lip.

On 10/20/17, at 9:28 a.m. R5 was noted to have a long hair on lower right chin, a long hair (1 inch) upper lip left side and one long hair in the middle of her chin. When interviewed on 10/20/17, at 9:28 a.m. R5 stated being unaware of facial hair but would prefer to have removed as she did at home.

On 10/20/17, at 9:28 a.m. nursing assistant (NA)-B confirmed R5 had some long facial hairs and indicated they had shavers available to remove facial hair but R5 requested the use of tweezers. After being questioned, NA-B proceeded to assist R5 with facial hair removal.

During interview on 10/20/17, at 11:17 a.m. the director of nursing (DON) verified that shaving should be done weekly and as needed for women and daily for men.

During observation on 10/17/17, at 4:44 p.m. R5 was lying in bed on left side with pillow under back. R5's mouth and lips were very dry. R5 had a difficult time talking due to dry mouth. When asked whether she received the fluids she wanted between meals R5 responded "no". R5 stated "I can't move my left shoulder very well so I can't reach it". She stated she frequently could not reach her fluids.

During observation on 10/18/17, at 1:30 p.m. R5 was observed lying in bed on right side. Mouth


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F 282 Continued From page 22 F 282and lips were very dry. R5 asked for a drink. A cup was on the bedside table but no straw was in the cup. R5 was unable to use right hand due to stiffness. R5 stated her left shoulder is bad and it didn't work. R5 was unable to reach over to get her cup. When the surveyor requested assistance from staff, a straw was brought to the room and they gave the cup to R5. It was noted that R5 had a very difficult time holding the cup.

During observation on 10/19/17, at 10:30 a.m. R5 had a mug of Mountain Dew located on the bedside table. The table was located up against the bed. R5 was unable to reach the mug to get a drink. R5 stated "I can't get it". Mouth and lips remained very dry in appearance.

During observation on 10/20/17, at 8:00 a.m. R5 had a large mug located on the bedside table located next to the bed. When questioned whether she could reach the mug to get a drink, R5 attempted to retrieve the mug but was unable to maneuver the mug to drink. R5 added, "I'm really thirsty". Mouth and lips noted to very dry.

During observation on 10/20/17, at 9:36 a.m. R5 sitting outside. mouth and lips dry with crust noted on lips. R5 stated I have a hard time getting the cup it is too heavy and a lot of times I can't reach it.

During interview on 10/19/17, at 8:36 a.m. certified occupational therapy assistant (COTA) A stated a staff member had asked her about getting a straw for R5. She stated she had looked in a catalogue to see if she could find a straw that would make it easier for R5 to drink. She stated she didn't find one and never heard anymore about it.


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During interview on 10/20/17, at 11:25 p.m. the director of nursing (DON) stated the nursing assistants (NA's) should notice signs of thirst, dry mouth/lips when providing cares for R5. The DON confirmed staff should be offering a drink frequently and obviously R5 needs a different cup and/or glass.

A policy Shaving the Resident revised October 2010, identified procedures used to shave a resident. The policy did not identify how often shaving a resident should be completed.

R28's annual Minimum Data Set (MDS) dated 3/28/17, identified R28 had moderate cognitive impairment and required extensive assistance with grooming cares.

R28's Cumulative diagnoses list dated 3/23/17, revealed the following: congestive heart failure, hypertensive heart disease, chronic kidney disease, glaucoma, macular degeneration, osteoarthritis, and history of falls. Document review identified a hospice referral was dated 10/17/17, subsequent to a decline in condition and a request by family.

R28's care plan updated 10/3/17, identified R28 required extensive assistance to complete personal hygiene due to weakness and cognitive impairment. The care plan identified the following intervention: Grooming: extensive assist of one staff.

It was observed on 10/18/17, at 1:42 p.m. R28 was seated in the recliner chair in her room, dozing. It was noted that R28 had un-trimmed, long fingernails on both hands; several nails had


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F 282 Continued From page 24 F 282a dark colored substance beneath the nails. During a subsequent observation on 10/19/17, at 12:04 p.m. R28 continued to have long fingernails on both hands with a visible dark substance underneath several of the nails. When interviewed on 10/19/17, at 9:36 a.m. registered nurse (RN)-B stated nail care was completed on bath day and anytime staff notice it should be provided. RN-B observed R28's fingernails at 9:36 a.m. and confirmed the nails appeared long, dirty and required trimming. RN-B stated should would have staff provide the necessary nail care.

During a observation on 10/19/17 at 10:36 p.m. therapeutic recreation aide (TR)-A was seated adjacent to R28 who was seated in the recliner. R28 was using a wet washcloth to clean her own nails while visiting with TR-A. TR-A was providing encouragement while R28 attempted the task.

Review of the revised October 2010 policy titled Care of fingernails/toenails, included general guidelines: (1) Nail care includes daily cleaning and regular trimming. (4) Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Steps included (5) Allow the first hand or foot to soak in the warm soapy water for approximately five minutes. Encourage the resident to exercise his or her fingers or toes while they are soaking.

F 312SS=D

483.24(a)(2) ADL CARE PROVIDED FOR DEPENDENT RESIDENTS

(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and

F 312 11/13/17


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F 312 Continued From page 25 F 312personal and oral hygiene.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to provide grooming needs for 2 of 3 residents (R28, R5) reviewed who were dependent upon staff assistance.

Findings include:

R28's annual Minimum Data Set (MDS) dated 3/28/17, identified R28 had moderate cognitive impairment and required extensive assistance with grooming cares.

R28's Cumulative diagnoses list dated 3/23/17, revealed the following: congestive heart failure, hypertensive heart disease, chronic kidney disease, glaucoma, macular degeneration, osteoarthritis, and history of falls. Document review identified a hospice referral was dated 10/17/17, subsequent to a decline in condition and a request by family.

R28's care plan updated 10/3/17, identified R28 required extensive assistance to complete personal hygiene due to weakness and cognitive impairment. The care plan identified the following intervention: Grooming: extensive assist of one staff.

It was observed on 10/18/17, at 1:42 p.m. R28 was seated in the recliner chair in her room, dozing. It was noted that R28 had un-trimmed, long fingernails on both hands; several nails had a dark colored substance beneath the nails. During a subsequent observation on 10/19/17, at 12:04 p.m. R28 continued to have long fingernails on both hands with a visible dark substance

F3121. Corrective action as it applies to R5 long facial hair was plucked. R28 nails were trimmed. See corrective action of F282 as they are the same concerns. 2. All dependent residents have the potential to be affected by lack of personnel hygiene and grooming.3. The facility will do audits of nail care and facial care weekly by charge nurse and reports handed in to DON for follow-up. This will be done for 1 year or until next survey. DON will do random visual audits ongoing to supervise same and report information to QAA quarterly if further action is necessary. Wash clothes will be used after meals for hand hygiene. 4. The Don will do assessment of information gathered weekly x1 month X3 months.5. Completion date, 11/30/17


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F 312 Continued From page 26 F 312underneath several of the nails. When interviewed on 10/19/17, at 9:36 a.m. registered nurse (RN)-B stated nail care was completed on bath day and anytime staff notice it should be provided. RN-B observed R28's fingernails at 9:36 a.m. and confirmed the nails appeared long, dirty and required trimming. RN-B stated should would have staff provide the necessary nail care.

During a observation on 10/19/17 at 10:36 p.m. therapeutic recreation aide (TR)-A was seated adjacent to R28 who was seated in the recliner. R28 was using a wet washcloth to clean her own nails while visiting with TR-A. TR-A was providing encouragement while R28 attempted the task. R28 stated, "If I just had a bowl of water I could clean them good".

Review of the revised October 2010 policy titled Care of fingernails/toenails, included general guidelines: (1) Nail care includes daily cleaning and regular trimming. (4) Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Steps included (5) Allow the first hand or foot to soak in the warm soapy water for approximately five minutes. Encourage the resident to exercise his or her fingers or toes while they are soaking. R5's diagnosis sheet, dated 7/31/17 identified diagnosis including Multiple Sclerosis, pain in left shoulder and weakness. R5's admission Minimum Data Set (MDS) assessment dated 8/11/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS also identified R5 required limited assistance of one staff for grooming activities and required supervision with set up from staff


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F 312 Continued From page 27 F 312with eating and extensive assistance of 2 staff with bed mobility.

R5's Care Area Assessment (CAA) for activities of daily living (ADLs) dated 8/7/17, indicated R5 required limited assistance of one person for personal hygiene. R5's care plan dated 8/17/17, indicated R5 required limited assistance of one staff member for coming hair and cleaning teeth.

During initial observation on 10/17/17, at 4:41 p.m. R5 had facial hair along her upper lip with one long (1 inch) hair noted on the left side of upper lip.

On 10/20/17, at 9:28 a.m. R5 was noted to have a long hair on lower right chin, a long hair (1 inch) upper lip left side and one long hair in the middle of her chin. When interviewed on 10/20/17, at 9:28 a.m. R5 stated being unaware of facial hair but would prefer to have removed as she did at home.

On 10/20/17, at 9:28 a.m. nursing assistant (NA)-B confirmed R5 had some long facial hairs and indicated they had shavers available to remove facial hair but R5 requested the use of tweezers. After being questioned, NA-B proceeded to assist R5 with facial hair removal.

During interview on 10/20/17, at 11:17 a.m. the director of nursing (DON) verified that shaving should be done weekly and as needed for women and daily for men.

A policy Shaving the Resident revised October 2010, identified procedures used to shave a resident. The policy did not identify how often shaving a resident should be completed.


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F 318SS=D

483.25(c)(2)(3) INCREASE/PREVENT DECREASE IN RANGE OF MOTION

(c) Mobility.

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

(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.This REQUIREMENT is not met as evidenced by:

F 318 11/13/17

Based on observation, interview and document review, the facility failed to provide and reassess restorative needs implement a plan of care recommended by the occupational therapist upon discharge from therapy to prevent further decrease in range of motion (ROM) for 1 of 1 resident (R10) reviewed who had limited ROM.

Findings include:

Review of the face sheet identified R10's latest readmit date as 8/24/17. Review of the significant change Minimum Data Set (MDS) reassessment dated 9/6/17, identified R10 with diagnosis including "other fracture". The Brief Interview for Mental Status (BIMS) identified moderately impaired cognitive skills and no functional limitation in ROM (range of motion) upper extremity was evident. The MDS also identified R10 needed extensive assistance with, bed mobility, bathing, dressing, grooming and eating.

F3181. Corrective action as it applies R 10. OT evaluated hand contracture, noting the 5-degree decline. Care Plan: Edema glove on during the day as the resident is not tolerating the cone grip (she removes it once it is placed). Blue resting hand splint in the evening/overnight. ROM 2-3 times a day (prior to placing the edema glove or resting hand splint).Staff to use wah cloth in hand if allows.2. All residents that return from a discharge have the opportunity to be affected with restorative orders not being carried through.3. The MDS nurses or DON will now evaluate all hospital returns to make sure prior orders that are necessary for resident health care are continued if need. Residents will be re-assed to determine health care need by RNs and Therapist if necessary. Any decline in ROM will be reported to Therapist for eval if


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F 318 Continued From page 29 F 318Review of R10's significant change Care Area Assessment (CAA) related to activities of daily living (ADL's)functional status dated 9/6/17, identified R10 to require staff assistance with eating for all meals; so far during the look back period resident is an extensive assist of one person for eating.

Review of the hospital discharge summary dated 8/24/17, identified R10 was admitted to the hospital on 8/22/17, with a left femur fracture. Activity/restrictions included bedrest, brace in place at all times and no weight bearing for 6-8 weeks.

Review of R10's care plan dated 9/15/17, identified R10 had resting hand splint on right hand while in bed, and restorative nursing-upper extremities, 10 reps to joints BID (twice daily).

Review of R10's current nursing assistant care sheet dated 10/18/17, did not identify the resting hand splint nor the restorative interventions identified on the 9/15/17 care plan.

Review of the occupational therapy (OT) plan of care dated 12/3/15, identified reason for referral: a 93 year old female presents with a decline in functional ROM of right hand due to increased flexion contracture of digits. The care giver started noticing a decrease in ROM/mobility approximately a few weeks ago, which resulted in [R10] now requiring significantly more assistance for extension of right hand to complete self feeding tasks and placement of resting hand splint. Documentation identified skilled OT required due to increased flexion contracture of the right hand in order to regain extension of digits and will be provided with appropriate

appropriates. 4. The MDS nurses and DON will evaluate together on every hospital return continuity of care ongoing. Reporting same info to the QA committee quarterly or as needed.5. Completion Date, 11/30/17


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F 318 Continued From page 30 F 318orthotics and splint wear schedule. Documentation also indicated that without skilled intervention [R10] is at further risk for contracture and decreased functional use of right dominant hand. Current level of function was identified as AROM (active range of motion) of 4th and 5th digits limited to -90 degrees extension, impacting ability to complete self feeding tasks with moderate assist.

Review of R10's OT therapist progress and discharge summary dated 1/4/16, identified ROM goal not met. The notes identified: demonstrates AROM of right 4th and 5th digits limited to -75 degrees, impacting ability to complete self feeding tasks. The discharge summary included R10's OT discharge instructions including: use of compression glove for day use and resting hand splint for night use and palm protector used as tolerated throughout day and night.

Review of the physician orders printed 10/18/17, did not identify the use of the hand splint, palm protector nor compression glove for R10. After discussion with surveyor about R10's ROM, a physician order was obtained on 10/20/17, for OT to evaluate and treat for change in ROM.

During observation on 10/17/17, at 7:17 p.m. R10 was observed to have right hand clenched, 3rd and 4th fingers were pressing into the palm of R10's hand. R10 was unable to open her hand. Red indentations were identifiable on R10's palm. No palm protector, splint or glove was in place.

During observation on 10/18/17, at 1:30 p.m. R10 was lying in bed with right hand clenched and 3rd and 4th fingers pressing into palm of hand.


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F 318 Continued From page 31 F 318During observation on 10/19/17, at 6:40 a.m. R10 was in bed, no hand splint evident, fingers were curled and pressing into palm of hand.

During observation on 10/19/17, at 7:45 a.m. nursing assistant (NA)-B was providing morning cares for R10. No hand splint was evident on the hand. While attempting to open and wash the right hand, R10 grabbed at the right hand, stating "oh my God that hurts!" The hand splint was noted lying on the table beside R10's recliner. When questioned NA-B whether R10 utilized the splint, NA-B replied, "I have never seen that on her". When questioned further if NA-B had ever had the splint applied when morning cares were provided, NA-B confirmed she routinely worked the day shift and had never seen the hand splint on R10 during morning cares. Asked if R10 ever had the splint on when she did morning cares, NA-B replied she worked the day shift and had never seen the hand brace on R10 when she did morning cares. NA-B said R10 did not have any devices applied to the right hand that she had been aware.

R10 was resting in bed with her right hand clenched, finger pressing into the palm of her hand on 10/19/2017, at 11:10 a.m. when the surveyor and director of nursing (DON) entered R10's room. The DON attempted to open R10's hand. R10 pulled her hand away and stated "no not now". The DON stated R10 had a finger "thing" the resident was supposed to wear to separate the fingers. The DON indicated she thought R10 was to wear a splint at night. The DON searched throughout the room and indicated she was unable to locate this device.

During observation on 10/19/17, at 11:29 a.m. the


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F 318 Continued From page 32 F 318certified occupational therapy assistant (COTA) measured R10's right hand with the surveyor in the room. When the COTA opened R10's hand to view, a sour odor was noted. At this time indentations were noted on the palm of the hand from R10's fingers pressing into palm. At 12:00 p.m. the COTA completed the measurement of the right hand; the 5th digit measured 75 degrees (unchanged from previous measurement); the 4th digit measured at 60 degrees (10 degrees less than previous measurement); and the 3rd digit measured at 40 degrees. The COTA explained there had been no previous documentation to compare this measurement (3rd digit) which indicated there must not been limitation at that time.

During observation on 10/19/17, at 12:53 p.m. R10 in the dining room and was eating with the use of her left hand, picking up food with her fingers. R10 had a spoon located in the right hand and staff instructed R10 to use her spoon. R10 attempted to scoop food onto the spoon to eat. After several attempts, a very small amount was scooped onto the spoon and into her mouth.

During observation on 10/20/17, at 8:30 a.m. cares were being completed for R10. A splint was not applied. When asked to open her hand, R10 would not respond by opening the hand. The NA was able to partially open the hand (approximately 50% of extension) to complete the cares.

During observation on 10/20/17, at 12:20 p.m. R10 was attempting to feed self. It was noted R10 was unable to scoop the food onto her silverware. Staff then assisted R10 with feeding.


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F 318 Continued From page 33 F 318When interviewed on 10/18/17, at 3:29 p.m. family member (FM)-A stated, "I personally have issues with the fact that nothing is in her hand to protect her palm from breaking down. I will come in and put a rolled washcloth in her hand. She has pain if you try to do anything major with the hand". FM-A stated R10 had "made herself left handed" and R10 was always right handed. FM-A now has to use her left hand instead of her right due to the contracture. FM-A stated she will use her left hand to eat and when offered coffee R10 will hold the cup with her left hand and support it with the right. FM-A stated R10 isn't able to open the right hand very far anymore.

When interviewed on 10/19/17, at 8:32 a.m. COTA-A stated OT had not evaluated R10's right hand since 2015 when the splint was ordered. COTA-A stated OT had worked with R10 in September and October for positioning in wheelchair.

During interview on 10/19/17, at 2:20 p.m. registered nurse (RN)-A stated that on 8/28/17, the edema glove, palm protector and hand splint had all been discontinued and was unsure the reason they were discontinued.

During interview on 10/20/17, at 8:51 a.m. restorative aide (RA)-F stated he provides an upper extremity ROM program for R10. RA-F stated R10's right hand doesn't open very far and attempts to open it until resistance is met and then quits. RA-F stated R10 does grimace sometimes when ROM is first initiated,confirming R10 can only open right hand about half way. RA-F verified no device is applied to R10's hand during the day when he does ROM. RA-F stated ROM is completed 5 days/week unless R10


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F 318 Continued From page 34 F 318refuses.

During interview on 10/20/17, at 11:50 a.m. the DON stated the orders for the hand splint, edema glove and palm protector should not have been discontinued. The DON confirmed she was unsure how that happened. The DON verified R10 required some sort of device in her right hand to protect it and prevent further decline in ROM. She stated you would have thought OT would have noticed her hand when they were working with her for positioning.

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F 323SS=D

483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

(d) Accidents.The facility must ensure that -

(1) The resident environment remains as free from accident hazards as is possible; and

(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

(1) Assess the resident for risk of entrapment from bed rails prior to installation.

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F 323 Continued From page 35 F 323(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

(3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to provide fully functioning protective apron to prevent burns as assessed for safety for 1 of 3 residents (R5) who was reviewed for smoking.

Findings include:

R5's diagnosis sheet, dated 7/31/17, identified a diagnosis of Multiple Sclerosis. R5's admission Minimum Data Set (MDS) assessment, dated 8/11/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS also identified R5 required extensive assistance of one staff for dressing, limited assistance of one staff for grooming, extensive assistance of one staff for locomotion on and off the unit and extensive assistance of 2 staff for transfers.

R5's smoking assessment dated 8/1/17, indicated R5 smoked in designated areas and did not smoke around oxygen, safely utilized lighter/matches and lit smoking material, used smoking apron and demonstrated safe smoking practices with other residents. The interdisciplinary team recommendation identified R5 was able to smoke independently and agreed to wear apron while smoking.

R5's nursing assistant care sheet dated 10/18/17,

F3231. Corrective action as it applies to R5. A new smoking apron was ordered and received.2. All residents that smoke will be assessed if need to use appropriate smoking apron to prevent accidents.3. Smoking aprons will be checked monthly for defaults when used.4. DON will be responsible for checking.5. Completion date, 11/30/17


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F 323 Continued From page 36 F 323indicated staff were to accompany R5 for smoking. The care plan dated 8/17/17, did not address R5's smoking needs/interventions.

During observation on 10/18/17, at 10:17 a.m. nursing assistant (NA)-B brought R5 to the outside smoking area. NA-B draped the smoking apron across R5's lap on top of her small purse. There was a gap between the apron and R5's legs. The smoking apron was not fastened around R5's neck. R5 was unable to light the cigarette lighter and asked NA-B to assist her. NA-B lit the lighter but couldn't light the cigarette. NA-B gave R5 back her lighter and R5 was able to light the cigarette. NA-B gave R5 a doorbell to ring when she was done smoking. R5 appeared weak and did not use her right hand. R5 reached across her body to "ash [remove ash from cigarette]" her cigarette into an ash can that had been placed on a table beside R5's wheelchair. When R5 finished the cigarette she was attempting to drop it into the ash can. R5 was unable to get her left hand over far enough and dropped the cigarette on the ground between her wheelchair and the table. During observation on 10/19/17, at 9:30 a.m. R5 was again observed outside smoking. The smoking apron was again draped across R5's lap on top of her purse, not fastened around her neck. R5 again struggled with dropping the cigarette "ash" into the ash can. During observation on 10/20/17, at 10:00 a.m. R5 was again observed outside smoking. Restorative aide (RA)-F laid the smoking apron on R5's chest and lap. R5 pulled the apron down onto her lap (there were no ties for the neck of the apron.) R5 was unable to light her cigarette and needed staff assist to do so. When R5 finished smoking she was able to get the cigarette into the ash can without difficulty. No


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F 323 Continued From page 37 F 323burn holes were noted in R5's clothing or on her wheelchair. During interview on 10/20/2017, at 11:22 a.m. the director of nursing (DON ) stated she had brought R5 in from smoking earlier and noticed the smoking was on R5's lap. She stated the apron should go all the way up and tie around the residents neck. She stated the neck piece is gone. I need to get a new apron. She stated no one reported the apron was missing the ties. It should have been reported to me. The DON stated that it was a hazard with the apron being placed only across R5's lap. She stated the cigarette could have gotten down in that gap and burned R5.

Review of the facility policy titled Smoking, revised June 2008, indicated Residents are allowed to smoke if an assessment shows that the resident is capable of smoking safely. The safety of the facility and other residents supersedes a residents right to smoke unsafely. The purpose was identified as to provide a process where residents who wish to smoke may be allowed to smoke in designated smoking areas. To provide a mechanism to prevent avoidable accidents related to smoking.

F 325SS=D

483.25(g)(1)(3) MAINTAIN NUTRITION STATUS UNLESS UNAVOIDABLE

(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident-

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(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident’s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to recognize, evaluate and implement interventions when weight was not maintained for 2 of 2 residents (R5, R35) reviewed who experienced significant weight loss.

Findings include:

R35's medical record identified an admission date of 8/21/17, for rehabilitation following surgery resulting from a fracture to his right ankle. R35's Brief Interview for Mental Status (BIMS) score was identified as 15/15, indicating no cognitive impairment. The pre-surgical hospital admission physician progress note dated 8/17/17, identified R35's diagnoses included: heart disease, high cholesterol, high blood pressure, history of lymphoma (cancer in the lymph nodes), and "pre-diabetes". R35's weight at that time was documented as 115.8 kilograms (kg) or 255 pounds (lbs). Lab results for glucose (blood sugar) level was listed as 182 milligrams/deciliter (mg/dl) (normal test value is 74-106).

Review of R35's physician's orders, signed by the orthopedic surgeon (OS) upon admission

POC Tag F325

1. Corrective action cited for R35, no changes were made to plan of care for R35 due to discharge to home from facility this day. R5 corrective action had nutritional supplement added to meet dietary needs on 10/19/17. 2. The facility will identify all residents with a potential for weight loss in the future by Dietician running weight variances weekly. 3. Dietician and DON will meet weekly, starting Monday the 30th of October and discuss weight variances. Appropriate interventions for significant weight loss will be implemented immediately on verified unexplained weight loss. RD will then be notified monthly and assess if interventions appropriate or needing change. Instruction also given to all nursing staff at meeting on 11/1/2017 when charting weights in medical record to report to charge nurse any flags that appear that reflect a percentage of weight loss, to assist in prompt intervention.


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F 325 Continued From page 39 F 325indicated: Tylenol and oxycodone as needed for pain, allopurinol daily-gout, aspirin-hearth, carvedilol-heart, losartan-blood pressure, metformin-blood sugar control, nitroglycerin-as needed for chest pain, ranitadine-acid reflux, Crestor-high cholesterol, ticagrelor-heart, trazadone at bedtime and a regular diet.

Review of R35's current medication and treatment record concurred no nutritional supplement was ordered.Review of the weights (#) documented for R35 identified the following dates: (1) 8/28/17-257.6 lbs.; (2) 9/29/17-236 lbs, (8% weight loss); (3) 10/17/17-225 lbs. (12% wt. loss); and (4) 10/20/17-223 lbs. (13% severe wt. loss).

Review of R35's meal intake records dated 8/21/17-9/20/17, identified the following.:(1) 8/21/17- 8/26/17, only 1 meal per day was recorded as having been eaten 50- 100%;(2) 8/27/17-consumed all 3 meals;(3) 8/28/17-consumed only 2 meals, one of which only half eaten at 50%;(4) 8/29/17-consumed all 3 meals, one of which consumed at 75%;(5) 8/30/17-consumed only breakfast and lunch;(6) 8/31/17 and 9/1/17-consumed only one meal per day, at only 75% of each of those meals;(7) 9/2/17, 9/3/17, 9/4/17, and 9/5/17-consumed only two meals per day;(8) 9/6/17-consumed all 3 meals, one only consumed at 75%; and (9) 9/7/17-only ate 2 meals.(10) On 9/7/17 through 9/20/17, R35 was reviewed by the interdisciplinary team (IDT). It was documented that R35 consumed all 3 meals/day on only 3 days; 5 days were documented that R35 consumed only 2

4. Facility will monitor its performance by Monthly in the first week of the month starting November 6th, 2017, their evaluations of significant weight loss of 5% in 30 days, with RD, Dietician, DON and report the monthly outcomes to QAA. QA will address said concerns with medcical director and others present to maintain compliance.5. Date of Completion. November 30th,2017.


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F 325 Continued From page 40 F 325meals/day and 4 days documentation indicated R35 consumed on 1 meal/day and 1 day did not consume any meal; and(11) From 9/21/17 until 10/20/17, R35 had 19 days where he ate 3 meals per day consuming anywhere from 50-100% of his meals, 5 days where he ate only 2 meals per day, 3 days where he ate only 1 meal per day, and 1 day he ate no meal at all.

On 9/20/17, IDT notes from R35's Care Plan Conference Summary indicated: "No concerns. Weight stable. Good intakes." Those in attendance included the Minimum Data Set (MDS) Coordinator, the certified dietary manager (CDM), activities, registered nurse (RN), Physical therapy (PT), resident and family member. The director of nursing (DON) was not in attendance.

Review of R35's current undated care plan identified: at risk for altered nutrition related to ankle fracture, lymphoma history and high cholesterol. Dietary interventions included to monitor intakes and weights daily, weekly, monthly and as needed. No nursing interventions were noted on the care plan related to R35's altered risk for nutrition.

When interviewed on 10/19/17, at 2:13 p.m. with the certified dietary manager (CDM) related to R35's weight loss since admission (admission wt. 257# and 10/17/17, 225#). CDM indicated R35 was admitted with braces and bandages post surgery and therefore attributed the weight loss to the bandages. The CDM stated the registered dietician (RD) visited the facility on 9/20/17. The CDM confirmed the wt. loss identified for R35 had not triggered on the weight variance report in September thus the RD had not been alerted.


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F 325 Continued From page 41 F 325The RD reviews all resident's weight once per month during the monthly visit. The CDM verified she will call the RD if a "big weight jump" was noticed and stated she had not yet informed the RD of the continued wt. loss identified on 9/29/17, 236 # (8 % weight loss) but only informed the DON. The CDM confirmed she informed the RD today (10/19/17). CDM explained there is no facility policy related when to call the RD but uses her own judgement.

During observation on 10/20/17, at 9:11 a.m. it was noted R35 appeared tall and thin. When interviewed at this time, R35 stated he experienced weight loss during the first two weeks after admission. R35 admitted he didn't have an appetite, so he didn't he didn't eat very much. The weight loss concerned him since he had a history of lymphoma, expressing he was afraid he had a relapse of cancer. R35 confirmed he never discussed weight loss with the staff and stated he did not experience extra fluid post surgery. R35 explained he was going home today and plans to follow up with his PCP for a checkup to determine whether his cancer had returned.

Interview on 10/20/17, at 9:33 a.m. with the registered dietician (RD)-H indicated she was unaware of R35's weight loss and knew that R35 had been re-weighed after her last onsite visit (9/20). RD-H stated the expectation was that once a weight discrepancy is noted, staff should re-weigh and if a true weight loss, she would try to determine the source. RD-H indicated she would question if related to history of edema and discuss with nursing staff whether to initiate a dietary supplement.

Interview on 10/20/17, at 10:41 a.m. with medical


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F 325 Continued From page 42 F 325assistant (MA)-I from the PCP's office indicated the PCP was out of the office at the moment, but R35's last weights were noted on 8/15/17, at 252 lbs (114.7 kg), and the same weight on 7/21/17 and 4/26/17. In December of 2016, R35 weighed 249 lbs. (113 kg). MA-I indicated that R35 had not experienced weight fluctuations in the past but the PCP would need to be notified of weight loss and this did not occur. MA-I stated lab tests may need to be ordered to verify R35's cancer had not returned and to evaluate the cause of rapid weight loss.

Interview on 10/20/17, at 12:21 p.m. with orthopedic surgeon's registered nurse (RN)-C confirmed they do not monitor care for residents other than health issues related to orthopedics; for example, not diabetes or other health issues. It was confirmed they do not take weights post-surgically if the resident cannot stand and were not aware of R35's weight loss.

When interviewed on 10/20/17, at 12:59 p.m. the director of nursing (DON) indicated her expectation related to R35's weight loss would have been to implement at least weekly weights. The DON explained when the nursing assistants (NAs) noticed the weight loss, a re-weigh for R35 should have been completed. Although the electronic medical record (EMR) has an auto-populated warning when a resident's weight drops or increases, to re-weigh the resident, there is no automatic notification sent to the nurse. The DON further explained that staff are expected to report any weight changes immediately to licensed nursing staff. In addition, the CDM should have notified nursing and the RD after the weight change noted on 9/29/17. The DON agreed no PCP had been involved with R35's


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F 325 Continued From page 43 F 325care while at the facility.

Observation on 10/20/17, at 1:09 p.m. R35 was re-weighed by nursing staff and weight of 223 lbs. was documented.


Review of the policy dated May 2011, titled, Weighing and Measuring the Resident indicated weight will be measured upon admission, monthly, as needed and in accordance with MDS 3.0 guidelines during the resident's stay. Reweigh the resident if there is a discrepancy of 2 pounds plus or minus. Report to the nurse supervisor or charge nurse. Significant weight loss is defined as greater than 5% difference in 30 days or greater than 7.5% difference in 90 days. The physician is to be notified if weight loss meets the criteria above.

Review of the policy dated February 2014, titled, Physician Services indicated the resident's attending physician participates in the residents assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident.

R5's Diagnosis sheet dated 7/31/17, identified diagnosis including Multiple Sclerosis (MS), pain


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F 325 Continued From page 44 F 325in left shoulder and weakness. R5's admission Minimum Data Set (MDS) assessment dated 8/11/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS also identified R5 required supervision with set up from staff with eating.

The initial dietary assessment dated 8/9/17, identified R5's weight as 121 lbs (pounds), oral/nutrition intake, food- moderate risk, appetite fair and small portions per request. The 14 day assessment dated 8/15/17, identified R5's weight as 135 lbs, intake 0-50% at all meals and poor oral intakes. The assessment identified eating as a concern due to small eater, intakes have declined since having issues with bowel movements for R5. The Care Area Assessment (CAA) for R5 dated 8/9/17, indicated current eating pattern as 25-50%, unwilling to accept food supplements or eat more than three meals per day.

R5's care plan dated 8/9/17, identified alteration in nutritional status due to MS, constipation, hip fracture, increased need for protein and dietary fiber, inadequate fluid and food intake. Goals included no weight loss, adequate food intake and eat 75-100%. Approaches included provide ordered diet regular, monitor intakes daily, offer food substitutions, determine food likes/dislikes and offer extra snacks.

Review of R5's weekly weights identified were as noted: 8/3/17- 122.2 lb (#), 8/11/17-127# , 8/17/17-123#; 8/23/17-126.4#; 8/29/17-127#; 9/5/17: 127.8#; 9/11/17-127.9 #; 9/21/17: 121; 10/6/17-117.2 lb; 10/10/17-116.8 and 10/17/17-113.2 lbs. (9 lb. wt. loss).


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F 325 Continued From page 45 F 325Review of R5's nurses notes identified the following documentation: (1) 8/19/17, fair appetite; (2) 8/21/17, usual amount eaten 25%, refused meals at least 4 times during the look back period; (3) 8/21/17, nutrition probably inadequate- rarely eats full meal, usually eats 1/2 food offered, eats less than 50%, rarely eats full meal; (4) 8/22/17, fair appetite; (5) 8/23/17, no eating concerns has poor appetite; (6) 8/23/17, no eating concerns has poor appetite; (7) 8/26/17, no eating concerns has poor appetite; (8) 8/27/17, no eating concerns has poor appetite; (9)10/15/17, took only bites of supper and 80 cc of fluid, Stated "I'm just not hungry". Offered something different to eat but refused; (10) 10/16/17, stated she had not been eating well because she cannot reach her food; had not stated this previously, was assisted with eating supper meal and only had four bites.

During observation on 10/19/17, at 9:01 a.m. R5 was up in wheelchair and had eaten yogurt for breakfast but nothing else.

During observation on 10/20/17, at 9:30 a.m. R5 was outside in wheelchair and stated she had a really good drink for breakfast and really liked it.

During interview on 10/18/17, at 10:00 a.m. the CDM stated she was unaware of R5's significant weight loss, indicating "well she is on Boost" (dietary supplement). The CDM stated nursing provides the supplement and the RD will address the weight loss on the 26th of November.

During interview on 10/20/17, at 11:35 a.m. the director of nursing (DON) stated R5 was not receiving any supplement and no interventions related to weight loss had been implemented.


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F 325 Continued From page 46 F 325The DON confirmed that a supplement had not been initiated since admission and they only yesterday (10/19) had R5 been given a supplement. The DON confirmed that when the weight loss was identified for R5, a reweigh conducted and a supplement started. She stated the CDM was supposed to monitor weights weekly and inform nursing of any discrepancies.

F 327SS=D

483.25(g)(2) SUFFICIENT FLUID TO MAINTAIN HYDRATION

(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident’s comprehensive assessment, the facility must ensure that a resident-

(2) Is offered sufficient fluid intake to maintain proper hydration and health.This REQUIREMENT is not met as evidenced by:

F 327 11/13/17

Based on observation, interview and document review the facility failed to offer sufficient fluid intake to maintain hydration for 1 of 1 resident (R5) reviewed for hydration.

Findings include:

R5's Diagnosis sheet dated 7/31/17, identified diagnoses including Multiple Sclerosis, pain in left shoulder and weakness. R5's admission Minimum Data Set (MDS) assessment dated 8/11/17, indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact). The MDS also identified R5 required supervision with set up from staff with eating and extensive

F3271. Resident R5 was given smaller cup for liquids in room on 10/20/17. Encouraged her also to ask for drink with call light also.2. All residents have the potential of not meeting fluid requirements if cannot access fluids easily. 3. Nursing staff was informed on meeting on 11/1/17 of the need to make sure all residents liquids are in reach and accessible to them. If they are in anyway unable to take liquids with current containers, IDT will discuss which options would be best suited for each resident


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F 327 Continued From page 47 F 327assistance of 2 staff with bed mobility.

R5's dietary assessment dated 8/9/17, identified R5's oral/nutrition intake, fluids: high risk as consumes < 1,000 milliliters per day.

R5's CAA for dehydration/fluid maintenance dated 8/10/17, indicated recent decline in activities of daily living, including body control or hand control problems, inability to sit up, etc., recent change in oral intake, fluid intake began to decrease on 8/5/17.

R5's care plan dated 8/17/17, identified potential for fluid volume deficit (dehydration/fluid). Approaches included: (1) provide assistance with fluids, (2) provide fluids consistently throughout the day, (3) fresh water pitcher maintained at bedside, (4) offer fluids with juice/snack cart, (5) offer fluids frequently, (6) assist with fluid intake, (7) keep fluids within reach, (8) record fluid intake with meals, (9) assess oral intake and (9) assess hydration status.

During observation on 10/17/17, at 4:44 p.m. R5 was lying in bed on left side with pillow under back. R5's mouth and lips were very dry. R5 had a difficult time talking due to dry mouth. When asked whether she received the fluids she wanted between meals R5 responded "no". R5 stated "I can't move my left shoulder very well so I can't reach it". She stated she frequently could not reach her fluids.

During observation on 10/18/17, at 1:30 p.m. R5 was observed lying in bed on right side. Mouth and lips were very dry. R5 asked for a drink. A cup was on the bedside table but no straw was in the cup. R5 was unable to use right hand due to

with concerns. Facility will purchase said items. The charge nurse and DON made rounds on 11/11/17 and determined current residents have access to their liquids. The facility will assess current residents with every significant change for ability to access liquids. QA will monitor compliance on going and make surethat foolow through is maintained.. Also inform therapy of need for assessment.4. DON/or designee are responsible for assessing.5. Completion date, 11/30/17


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F 327 Continued From page 48 F 327stiffness. R5 stated her left shoulder is bad and it didn't work. R5 was unable to reach over to get her cup. When the surveyor requested assistance from staff, a straw was brought to the room and they gave the cup to R5. It was noted that R5 had a very difficult time holding the cup.

During observation on 10/19/17, at 10:30 a.m. R5 had a mug of Mountain Dew located on the bedside table. The table was located up against the bed. R5 was unable to reach the mug to get a drink. R5 stated "I can't get it". Mouth and lips remained very dry in appearance.

During observation on 10/20/17, at 8:00 a.m. R5 had a large mug located on the bedside table located next to the bed. When questioned whether she could reach the mug to get a drink, R5 attempted to retrieve the mug but was unable to maneuver the mug to drink. R5 added, "I'm really thirsty". Mouth and lips noted to very dry.

During observation on 10/20/17, at 9:36 a.m. R5 sitting outside. mouth and lips dry with crust noted on lips. R5 stated I have a hard time getting the cup it is too heavy and a lot of times I can't reach it.

During interview on 10/19/17, at 8:36 a.m. certified occupational therapy assistant (COTA) A stated a staff member had asked her about getting a straw for R5. She stated she had looked in a catalogue to see if she could find a straw that would make it easier for R5 to drink. She stated she didn't find one and never heard anymore about it.

During interview on 10/20/17, at 11:25 p.m. the director of nursing (DON) stated the nursing


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F 327 Continued From page 49 F 327assistants (NA's) should notice signs of thirst, dry mouth/lips when providing cares for R5. The DON confirmed staff should be offering a drink frequently and obviously R5 needs a different cup and/or glass.

F 329SS=D

483.45(d)(e)(1)-(2) DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used--

(1) In excessive dose (including duplicate drug therapy); or

(2) For excessive duration; or

(3) Without adequate monitoring; or

(4) Without adequate indications for its use; or

(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

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

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F 329 Continued From page 50 F 329clinical record;

(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;This REQUIREMENT is not met as evidenced by: Based on interview and document review the facility failed to identify specific mood/behavior symptoms related to anxiety and to ensure non-pharmacological interventions were implemented prior to the administration of as needed (PRN) anxiety medications for 1 of 5 residents (R15) reviewed for unnecessary medications.

Findings include:

Review of a form titled, Cumulative diagnosis list dated 10/18/17, identified R15 with the following diagnoses:Alzheimer's disease, dementia with Major depression and psychotic features and anxiety disorder.

Review of the Minimum Data Set (MDS) with assessment reference date of 1/23/17, identified R15 as a 93 year old with a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R15 required extensive staff assistance for all activities of daily living. It also identified R15 received antipsychotic, antidepressant and diuretic medications 7 days a week.

Review of the 8/9/17, care plan for R15 revealed: Major depression with psychosis, insomnia, and

F3291. Corrective action as it applies to R15. Nursing instruction with interventions that are resident specific for anxiety. Care plan updated with these changes on 11/1/17. On 11/8/17 prn Ativan was discontinued.2. All residents using PRN psychotropic medications for anxiety or restlessness have the ability to be affected with not using interventions prior to med use thus possibly getting medication that is not warranted.3. Charge nurses were instructed on 11/1/17 that is the requirement to use and chart prior interventions to using psychotropic medications. Resident specific interventions must be used. All PRN psychotropic med use will be addressed at IDT meeting for necessity of appropriate interventions being used. 4. Monitoring compliance will be done by Charge Nurses, MDS nurses and DON at IDT meetings. Pharmacist will also review nursing action with PRN psychotropics on a monthly basis.The same information will be followed up at Qa with medical director and pharmacist for monitoring follow through.5. Completion date 11/30/17


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F 329 Continued From page 51 F 329anxiety, related to psychotropic medication including antidepressant, antianxiety and antipsychotic medications. R15 continues to experience restlessness, anxiety and difficulties with mood related to lack of understanding. Interventions included: all staff will allow [R15] time to express fears and staff will comfort her with conversation; listen with patience and compassion acknowledging her feelings and fear of abandonment; offer conversation on subjects of interest, provide reassurance, with consistent and calm approach; and report pain indicators.

Physician orders dated 9/13/17 revealed orders for the following medications: (1) Trazadone 75 milligrams (mg) daily (daily) for insomnia and major depressive disorder;(2) Zoloft 15 mg daily for depression;(3) Tylenol 650 mg daily at bedtime for pain;(4) Lasix 40 mg daily for cardiac failure/hypertension;(5) Seroquel 25 mg daily mid-day and Seroquel 50 mg daily at bedtime for psychosis;(6) Depakote extended release 400 mg daily for mood disorder;(7) Aricept 10 mg daily for dementia; and (8) Ativan 0.5 every 6 hours as needed for anxiety

Document review of physician progress note dated 7/12/17, revealed: Continues to have dementia with Major depression and psychotic features, still occasionally will want to leave the building but, for the most part, is doing stable. Is having much less frequency of behaviors related to that. Continue on current doses of Seroquel, Zoloft, trazadone, and Depakote. Could consider, sometime in the future, decreasing the evening Seroquel.


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F 329 Continued From page 52 F 329Documentation review of a form titled: Monthly pharmacy review dated 7/17/17, revealed: ATTENTION NURSING MEDICATION MONITORING. Ativan is PRN (as needed) is commonly utilized for behaviors of crying, and asking to go home, non-pharmacological interventions not always documented. PRN follow up notes, often documented too far past dose administration to draw any correlation to effectiveness (e.g.-6 hours post dose follow up.) Recommendations, alternative strategies for management before the Ativan should be heavily emphasized. Please scrutinize pain control as possible contributor,consider a trial of more intensive pain management if appropriate. Ativan PRN should only be utilized when non pharmacological interventions fail and the symptoms are significantly disturbing to resident or placing her at risk for harm.

In addition to the pharmacy note, was the following handwritten note: Nurses: "Try non-med interventions 1st- Always assess for unmet pain needs that resident may not be able to express, try redirection or involve resident in activity. Take for walk, give snack, 1:1 time, and chart non interventions used and response prior (underlined) to giving PRN Ativan. A copy of this pharmacy review was filed on the first page of the resident chart.

Document review of the care plan dated 8/5/16 updated 7/26/16 revealed: Psychotropic drug use potential for dehydration/fluid monitor intake and output, encourage fluid intake monitor electrolyte results and report to physicianMajor depression with psychosis, insomnia and anxiety, psychotropic medication, antidepressant medication, antianxiety medication, antipsychotic


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F 329 Continued From page 53 F 329medication.

Document review of the interdisciplinary (IDT) notes, reveal that when the PRN Ativan dose was given on 7/20/2017, 8/7/2017, 8/8/2017, 8/11/2017, 10/1/2017 at 1:41 p.m., 10/1/2017 at 10:00 p.m., and 10/12/2017, the staff did not respond with non-pharmacological interventions nor consider a pain medication, before the administration of the Ativan.

When interviewed and reviewed the IDT notes from 7/26/17 through 10/18/17, the registered pharmacist consultant (RPh) revealed that staff had not consistently implemented non-pharmacological interventions prior to the administration of Ativan. The RPh confirmed it was the expectation that staff document non-pharmacological interventions and consider a pain medication such as Tylenol prior to Ativan PRN administration. The IDT notes lacked documentation this was implemented.

When interviewed on 10/18/17, registered nurse (RN)-A confirmed after reviewing the IDT notes that staff were not implementing non-pharmacological interventions prior to PRN Ativan administration and stated, "that documentation is something we really need to work on."

F 385SS=D

483.30(a)(1)(2) RESIDENTS' CARE SUPERVISED BY A PHYSICIAN

§483.30(a) Physician Supervision. The facility must ensure that--

(1) The medical care of each resident is supervised by a physician; and

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(2) Another physician supervises the medical care of residents when their attending physician is unavailable.This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to ensure a primary care physician (PCP) provided supervision of the medical for 1 of 1 resident (R35) reviewed who experienced severe weight loss after admission.

Findings include:

R35's medical record identified an admission date on 8/21/17, for rehabilitation following surgery resulting from a fracture to his right ankle. R35's Brief Interview for Mental Status (BIMS) score was identified as 15/15, indicating no cognitive impairment. The pre-surgical hospital admission physician progress note dated 8/17/17, identified R35's diagnoses included: heart disease, high cholesterol, high blood pressure, history of lymphoma (cancer in the lymph nodes), and "pre-diabetes". R35's weight at that time was documented as 115.8 kilograms (kg) or 255 pounds (lbs).

Review of R35's physician's orders, signed by the orthopedic physician (OS) upon admission indicated: Tylenol and oxycodone as needed for pain, allopurinol daily-gout, aspirin-hearth, carvedilol-heart, losartan-blood pressure, metformin-blood sugar control, nitroglycerin-as needed for chest pain, ranitadine-acid reflux, Crestor-high cholesterol, ticagrelor-heart, trazadone at bedtime and a regular diet.

Review of R35's current medication and

F3851. Corrective action as it applies to R35. R35 was discharged to home on 10/20/17 (the day surveyors in the building) with order written by Orthopedic surgeon on 10/12/17. No Primary MD visit was kept.2. All residents health in the facility have the potential to be affected by facility not scheduling and keeping appointments with Primary MD.3. All current residents chart reviewed for Primary MD visits. The facility will not overlook the need for visits with the Primary MD in the future for completeness of resident s overall health. Charge Nurses in charge of scheduling were informed that a resident has to be seen by a primary in 30 days after admit, and must have a primary care MD in charge of overall health in meeting on 11/1/17. 4. Monitoring to be done by DON or designee.Follow up with QA for ongoing compliance quarterly.5. Completion date 11/30/17


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F 385 Continued From page 55 F 385treatment record concurred no nutritional supplement was ordered.Review of the weights (#) documented for R35 identified the following dates: (1) 8/28/17, 257.6 lbs. (2) 9/29/17, 236 lbs, (8% weight loss), (3) 10/17/17, 225 lbs. (12% wt. loss), and (4) 10/20/17, re-weighed-223 lbs. (13% wt. loss indicating severe).

Review of the 8/18/17 hospital progress note, documented by orthopedic surgeon (OS) indicated the consolidated plan for R35 included follow-up with PCP after resuming his home medications post-operatively.

Review of the Doctor Visit Log for R35 indicated from the time of admission (8/21/17) until 10/20/17, no PCP was documented and/or visited to review R35's overall health and wellness while at the facility. The only physician visit noted was recorded by the orthopedic surgeon who managed only the post-op care of the ankle.

Review of orthopedic surgeon OS progress note dated 9/1/17, there was no follow up regarding R35's overall health. The notes indicated OS-E only provided follow-up for post-operative care related to the resident's ankle surgery.

When interviewed on 10/19/17, at 3:38 p.m. the Minimum Data Set (MDS) coordinator/registered nurse (RN)-F indicated she could not find any dictation from any PCP in R35's medical record. RN-F verified that R35 had not seen the in-house primary care provider (MD-G) who made rounds at the facility because R35 had been off-site at an appointment with OS-E during the time of MD-G rounds. RN-F agreed there had not been a PCP


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F 385 Continued From page 56 F 385managing R35's overall health since admission. RN-F stated the nursing staff thought that since OS-E had been seeing R35 weekly, they assumed he was the attending physician versus R35 having a PCP. RN-F stated, that was good enough. "We missed him." Upon further questioning, RN-F agreed an orthopedic doctor would not manage R35's diabetes, high blood pressure medication, etc., or overall health needs.

Review of the Center for Medicare and Medicaid Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2016, defines who may perform physician certification and recertification on a resident. "An attending physician or a physician on the staff of the skilled nursing home who has knowledge of the case, must certify the need for extended care services in the facility." It was noted the certification and recertification for R35 was signed by the resident's PCP, not the resident's OS-E, on 8/22/17, and again on 9/1/17 via fax that he needed occupational (OT) and physical therapy (PT) in the nursing home to regain his activities of daily living (ADLs) related to his ankle fracture.

During observation and interview on 10/20/17, at 9:11 a.m. R35 revealed going home today and plans to see his PCP for a checkup once he returns home to make sure everything is ok and the cancer has not returned.

Interview on 10/20/17, at 10:41 a.m. with medical assistant (MA)-I from PCP's office indicated the PCP was out of the office at the moment, but R35's last weights were noted on 8/15/17, at 252 lbs (114.7 kg), and the same weight on 7/21/17 and 4/26/17. In December of 2016, R35 weighed


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F 385 Continued From page 57 F 385249 lbs. (113 kg). MA-I indicated that R35 had not experienced weight fluctuations but the PCP would need to be notified of weight loss and this notification did not occur. MA-I stated lab tests may need to be ordered to verify R35's cancer had not returned and to evaluate the cause of rapid weight loss.

Interview on 10/20/17, at 12:21 p.m. with OS's registered nurse (RN)-C confirmed they do not monitor care for residents other than health issues related to orthopedics; for example, not diabetes or other health issues. It was confirmed they do not take weights post-surgical if the resident cannot stand and were not aware of R35's weight loss.

When interviewed on 10/20/17, at 12:59 p.m. the director of nursing (DON) agreed no PCP had been involved with R35's care while at the facility.


Review of the policy dated February 2014, titled, Physician Services indicated the resident's attending physician participates in the residents assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident.


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F 431 Continued From page 58 F 431F 431SS=D

483.45(b)(2)(3)(g)(h) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS

The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--

(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

(g) Labeling of Drugs and Biologicals.Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

(h) Storage of Drugs and Biologicals.

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F 431 Continued From page 59 F 431(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to maintain the security of medications located in the only refrigerator located in 1 of 1 unsecured clean utility room. This had the potential to affect all 27 residents who reside in the facility.

Findings include:

Observation and interview on 10/20/17 at 11:24 a.m. with licensed practical nurse (LPN)- A and the director of nursing (DON) in the clean utility room located near the nurses' station revealed there is no lock on the door to the clean utility room. The medication refrigerator was located in this room. It was noted the key for the medication refrigerator was hung on a hook located on the back of the door. It was noted the door was unlocked so all staff had access to this clean utility room. It was also observed that medications stored in this refrigerator included: insulin pens, influenza and Tubersol vials . When interviewed

F04311. Corrective action as it applies to the refrigerator stored in supply room was moved to the Med room on 10/30/17. It is now under lock from all staff except nursing.2. All residents in the facility that had stored meds in this refrigerator had the risk to have meds tampered with. 3. All medications will be stored in med room from now on.4. Monitoring to be done by DON. Information will be monitored for at QA for compliance.5. Completion date 11/30/17.


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F 431 Continued From page 60 F 431at this time both LPN-A and the DON agreed unlicensed staff have access to these unsecured medications, and potentially visitors.

Review of the facility policy titled, Medication: Storage identified: medications were to be stored in a safe secure manner. Medications requiring refrigeration must be stored in the refrigerator located in the drug room in the nurses station.

F 441SS=E

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

(a) Infection prevention and control program.

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

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F 441 Continued From page 61 F 441communicable 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 least 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 F0441


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F 441 Continued From page 62 F 441review the facility failed to ensure the glucometer used to monitor blood sugar level was disinfected between resident use for 3 of 3 residents (R3, R11, R30) who had blood sugar levels measured with the use of the shared glucometer that was disinfected weekly and failed to implement proper handwashing when providing assistance with meals for 4 of 4 residents (R8, R10, R14, R17) observed during meal observation.

Findings include:

During observation on 10/19/17, at 6:35 a.m. registered nurse (RN)-B was conducting a blood sugar check for R3. After completion of the blood glucose level, RN-B returned the glucometer (Assure Platinum) to the medication cart for storage and placed it in the drawer. RN-B did not clean and/or wipe down the glucometer after use with any disinfectant. At this time, RN-B confirmed this glucometer was not designated for an individual resident but was a shared glucometer. When RN-B was questioned about the cleaning process, RN-B replied that glucometers were cleaned weekly and not immediatly after use.

Document review and interview on 10/20/17 at 11:08 a.m. with LPN- A and the DON confirmed the spare glucometer was used on a weekly schedule for 3 residents (R3, R11, R34). They verified it was cleaned weekly and not between resident use. Review of the manufacturer's instructions of the glucometer indicated it was to be disinfected between resident use.

The manufacturer cleaning and disinfecting guidelines for the Assure Platinum glucometer utilized during the observation identified the

1. Corrective action was taken by assigning glucometers to each resident needing blood sugar monitoring. No glucometer will be designated a spare for multiple residents use. Nursing staff instructed on handwashing before meals and after touching personal items of another resident. Also instructed they are not to touch any food with bare hands.2. All residents have the potential to be affected by not washing hands, touching food and shared glucometers by contamination. 3. All nursing staff instructed during meeting on 11/1/17 about risk of infection with above noted actions.4. Don will monitor staggered meals weekly x 1 month. QA to be informed of same and given information related to compliance for ongoing monitoring.5. Completion date 11/30/17.


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F 441 Continued From page 63 F 441following: (1) clean and disinfect the meter between patient use; (2) cleaning can be completed by using a commercially available EPA-registered disinfectant detergent and/or germicide wipe; (3) use a wipe, remove from container and follow product label instructions to disinfect the meter; (4) take extreme care not to get liquid in the test strip and key code ports of the meter; (5) many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter two wipes must be used.

During observations of the evening meal on 10/17/17 at 6:15 p.m., registered nurse, (RN)-B picked up a hot dog with her bare hands and rearranged it on a bun for R14 and R17, who required assistance with eating. R8, who sat at the same table, was struggling to move her sunglasses out of the way that were placed on the table. RN-B, got up and set aside the R8's sunglasses and then proceeded to help R8 pick up the hot dog and bun without implementing handwashing. At the same meal, the director of nursing (DON) was noted to pick up a hot dog with her bare hands and hand it to R10.

During an observation on 10/19/17, at 9:23 a.m. RN-A was assisting R10 with the meal. RN-A picked up R10's bacon with her bare fingers and fed the bacon strip to R10.

During an interview with RN-A on 10/19/17, at 10:56 a.m. whe the above observations were discussed, RN-A verified all staff require further education related to safe food handling practices in order to minimize risk and/or prevent food borne illness.

F 520 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i) QAA F 520 11/13/17


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F 520 Continued From page 64 F 520SS=F COMMITTEE-MEMBERS/MEET

QUARTERLY/PLANS

(g) Quality assessment and assurance.

(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:

(i) The director of nursing services;

(ii) The Medical Director or his/her designee;

(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and

(g)(2) The quality assessment and assurance committee must :

(i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;

(h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

(i) Sanctions. Good faith attempts by the


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F 520 Continued From page 65 F 520committee to identify and correct quality deficiencies will not be used as a basis for sanctions.This REQUIREMENT is not met as evidenced by: Based on interview and document review the facility failed to ensure the quality assessment and assurance (QAA) committee identified, developed and implemented action plans to meet resident needs and correct quality of care issues. This practice had the potential to affect all 27 residents who reside in the facility.

Findings include:

When interviewed on 10/20/17, at 1:30 p.m. the director of nursing (DON) indicated the QAA committee identified issues to be addressed by listening to resident/family concerns, departmental concerns, quality indicators, recent surveys, satisfaction surveys, visitor survey concerns, any grievances, and the interdisciplinary team (IDT). The QAA team is informal and if unable to fix a problem, input will be requested to devleop action plans. The action plans are taken reviewed at QAA to determine whether resolved and/or concern continues to be addressed. The DON stated, "Most concerns come from resident council. Most are a legit concern. Now the weight issues will be a huge concern." The DON further stated the QAA committee needed to be more observant of what was happening in the facility and indicated, "We should have been aware R24 had a right to have her hair washed. Staff should have been providing care according to the resident's care plans". As management, she agreed herself and the administrator were responsible for overseeing the care provided by staff to residents in the

F520 1. Corrective action as it applies to QAA committee and failure to follow up with concerns related lack of care is the issues of concern will be discussed at next QAA meeting and currently at IDT meetings.2. This has the potential to affect all residents with dependent care needs.3. DON will do visual view of staggered residents care weekly X 1 month and then report to QAA every quarter her findings for follow up.This will be ongoing Will also include administrator at department head meetings held weekly.4. Don in charge of monitoring.All identified care area concerns and needs will be indentified to QA and monitered by same ongoing for compliance.5. Completion date 11/30/17.


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F 520 Continued From page 66 F 520facility.

Evidence was lacking to indicate the QAA committee had oversight of the cares provided by staff and that an effective plan had been developed and implemented to ensure resident needs were met and care provided as planned. See F157, F242, F278, F279, F280, F282, F312. F318, F323, F325, F327, F329, F385, F441 .


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