MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY

Transcription

1 CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: GRIK Facility ID: MEDICARE/MEDICAID PROVIDER NO. (L1) 2.STATE VENDOR OR MEDICAID NO. (L2) EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 04/01/ DATE OF SURVEY (L34) 8. ACCREDITATION STATUS: (L10) 0 Unaccredited 2 AOA /10/ TJC 3 Other 3. NAME AND ADDRESS OF FACILITY (L3) (L4) (L5) LA CRESCENT, MN (L6) 7. PROVIDER/SUPPLIER CATEGORY 02 (L7) 01 Hospital 02 SNF/NF/Dual 03 SNF/NF/Distinct 04 SNF 05 HHA 06 PRTF 07 X-Ray 08 OPT/SP 09 ESRD 10 NF 11 ICF/IID 12 RHC 13 PTIP 14 CORF 15 ASC 16 HOSPICE CLIA 4. TYPE OF ACTION: (L8) 1. Initial 3. Termination 5. Validation 7. On-Site Visit 7 8. Full Survey After Complaint 2. Recertification 4. CHOW 6. Complaint 9. Other FISCAL YEAR ENDING DATE: 12/31 (L35) 11..LTC PERIOD OF CERTIFICATION From (a) : To (b) : 12.Total Facility Beds 13.Total Certified Beds (L18) (L17) 10.THE FACILITY IS CERTIFIED AS: A. In Compliance With Program Requirements Compliance Based On: 1. Acceptable POC B. Not in Compliance with Program Requirements and/or Applied Waivers: And/Or Approved Waivers Of The Following Requirements: x 2. Technical Personnel Hour RN 4. 7-Day RN (Rural SNF) 5. Life Safety Code A, 5 * Code: (L12) 6. Scope of Services Limit 7. Medical Director 8. Patient Room Size 9. Beds/Room 14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS 18 SNF (L37) 18/19 SNF 45 (L38) 19 SNF (L39) ICF (L42) IID (L43) 1861 (e) (1) or 1861 (j) (1): (L15) 16. Post certification revisit (PCR) of Health and Life Safety Code Surveys completed on August 8, Refer to CMS form 2567B. Documentation supporting the facility's request for a continuing waiver involving K67 has been forwarded. Approval of the waiver request has been approved. 17. SURVEYOR SIGNATURE Date : Gary Nederhoff, Unit Supervisor PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY (L19) 18. STATE SURVEY AGENCY APPROVAL Date: 08/10/2015 Kamala Fiske-Downing, Enforcement Specialist 08/13/2015 (L20) 19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL RIGHTS ACT: X 1. Facility is Eligible to Participate 2. Facility is not Eligible (L21) Statement of Financial Solvency (HCFA-2572) 2. Ownership/Control Interest Disclosure Stmt (HCFA-1513) 3. Both of the Above : 22. ORIGINAL DATE OF PARTICIPATION 23. LTC AGREEMENT BEGINNING DATE 24. LTC AGREEMENT ENDING DATE 07/01/1986 (L24) (L41) (L25) 25. LTC EXTENSION DATE: 27. ALTERNATIVE SANCTIONS A. Suspension of Admissions: (L44) (L27) B. Rescind Suspension Date: (L45) 26. TERMINATION ACTION: (L30) VOLUNTARY 01-Merger, Closure 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 00-Active 28. TERMINATION DATE: 29. INTERMEDIARY/CARRIER NO. 30. REMARKS (L28) (L31) 31. RO RECEIPT OF CMS DETERMINATION OF APPROVAL DATE 08/12/2015 (L32) (L33) DETERMINATION APPROVAL FORM CMS-1539 (7-84) (Destroy Prior Editions)

2 Protecting, Maintaining and Improving the Health of Minnesotans CMS Certification Number (CCN): August 13, 2015 Ms. Jana Cates, Administrator Golden Livingcenter - La Crescent 101 South Hill Street La Crescent, Minnesota Dear Ms. Cates: 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 August 4, 2015 the above facility is certified for: 45 Skilled Nursing Facility/Nursing Facility Beds Your facility s Medicare approved area consists of all 45 skilled nursing facility beds. We have recommended CMS approve the waivers that you requested for the following Life Safety Code Requirements: K67. 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. Minnesota Department of Health - Health Regulation Division General Information: Toll-free: An equal opportunity employer

3 Golden Livingcenter - La Crescent August 13, 2015 Page 2 Please contact me if you have any questions. Sincerely, Kamala Fiske-Downing, Program Specialist Licensing and Certification Program Health Regulation Division Minnesota Department of Health Kamala.Fiske-Downing@state.mn.us Telephone: (651) Fax: (651)

4 Electronically delivered August 13, 2015 Protecting, Maintaining and Improving the Health of Minnesotans Ms. Jana Cates, Administrator Golden Livingcenter - La Crescent 101 South Hill Street La Crescent, Minnesota RE: Project Number S Dear. Cates: On July 2, 2015, we informed you that we would recommend enforcement remedies based on the deficiencies cited by this Department for a standard survey, completed on June 25, 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 August 10, 2015, the Minnesota Department of Health completed a Post Certification Revisit (PCR) by review of your plan of correction to verify that your facility had achieved and maintained compliance with federal certification deficiencies issued pursuant to a standard survey, completed on June 25, We presumed, based on your plan of correction, that your facility had corrected these deficiencies as of August 4, Based on our PCR, we have determined that your facility has corrected the deficiencies issued pursuant to our standard survey, completed on June 25, 2015, effective August 4, 2015 and therefore remedies outlined in our letter to you dated July 2, 2015, will not be imposed. Your request for a continuing waiver involving the deficiency cited under K67 at the time of the June 25, 2015 standard survey has been forwarded to CMS for their review and determination. Your facility's compliance is based on pending CMS approval of your request for waiver. 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, Program Specialist Licensing and Certification Program Health Regulation Division Minnesota Department of Health Kamala.Fiske-Downing@state.mn.us Telephone: (651) Fax: (651) Minnesota Department of Health Health Regulation Division General Information: Toll-free: An equal opportunity employer

5 Department of Health and Human Services Centers for Medicare & Medicaid Services Post-Certification Revisit Report Form Approved OMB NO Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project ( ), Washington, D.C (Y1) Provider / Supplier / CLIA / Identification Number Name of Facility (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 8/10/2015 This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date ID Prefix F0279 Correction Completed 08/04/2015 ID Prefix F0329 Correction Completed 08/04/2015 ID Prefix F0371 Correction Completed 08/04/2015 Reg. # (d), (k)(1) 0279 LSC Reg. # (l) 0329 LSC Reg. # (i) 0371 LSC ID Prefix F0431 Correction Completed 08/04/2015 ID Prefix F0441 Correction Completed 08/04/2015 ID Prefix Correction Completed Reg. # (b), (d), (e) 0431 LSC Reg. # LSC Reg. # LSC ZZZZ ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ ID Prefix Correction Completed ID Prefix Correction Completed ID Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reviewed By State Agency Reviewed By CMS RO Reviewed By GPN/kfd Reviewed By Followup to Survey Completed on: 6/25/2015 Date: Date: Signature of Surveyor: 08/12/ Signature of Surveyor: Date: Date: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NO Form CMS B (9-92) Page 1 of 1 Event ID: GRIK12 08/10/2015

6 CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: GRIK Facility ID: MEDICARE/MEDICAID PROVIDER NO. (L1) 2.STATE VENDOR OR MEDICAID NO. (L2) EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 04/01/ DATE OF SURVEY (L34) 8. ACCREDITATION STATUS: (L10) 0 Unaccredited 2 AOA TJC 3 Other 3. NAME AND ADDRESS OF FACILITY (L3) (L4) (L5) LA CRESCENT, MN (L6) 7. PROVIDER/SUPPLIER CATEGORY 02 (L7) 01 Hospital 02 SNF/NF/Dual 03 SNF/NF/Distinct 04 SNF 05 HHA 06 PRTF 07 X-Ray 08 OPT/SP 09 ESRD 10 NF 11 ICF/IID 12 RHC 13 PTIP 14 CORF 15 ASC 16 HOSPICE CLIA 4. TYPE OF ACTION: (L8) 1. Initial 3. Termination 5. Validation 7. On-Site Visit 2 8. Full Survey After Complaint 2. Recertification 4. CHOW 6. Complaint 9. Other FISCAL YEAR ENDING DATE: 12/31 (L35) 11..LTC PERIOD OF CERTIFICATION From (a) : To (b) : 12.Total Facility Beds 13.Total Certified Beds (L18) (L17) 10.THE FACILITY IS CERTIFIED AS: A. In Compliance With Program Requirements Compliance Based On: 1. Acceptable POC X B. Not in Compliance with Program Requirements and/or Applied Waivers: And/Or Approved Waivers Of The Following Requirements: x 2. Technical Personnel Hour RN 4. 7-Day RN (Rural SNF) 5. Life Safety Code B, 5 * Code: (L12) 6. Scope of Services Limit 7. Medical Director 8. Patient Room Size 9. Beds/Room 14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS 18 SNF 18/19 SNF 19 SNF ICF IID 1861 (e) (1) or 1861 (j) (1): (L15) 45 (L37) (L38) (L39) (L42) (L43) 16. Documentation supporting the facility s request for a continuing waiver involving LSC K67 is being recommended and forwarded to CMS for approval. 17. SURVEYOR SIGNATURE Date : Lisa Carey (Krebs), HFE NE II PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY (L19) 18. STATE SURVEY AGENCY APPROVAL Date: 07/20/2015 Kamala Fiske-Downing, Enforcement Specialist 08/12/2015 (L20) 19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL RIGHTS ACT: X 1. Facility is Eligible to Participate 2. Facility is not Eligible (L21) Statement of Financial Solvency (HCFA-2572) 2. Ownership/Control Interest Disclosure Stmt (HCFA-1513) 3. Both of the Above : 22. ORIGINAL DATE OF PARTICIPATION 23. LTC AGREEMENT BEGINNING DATE 24. LTC AGREEMENT ENDING DATE 07/01/1986 (L24) (L41) (L25) 25. LTC EXTENSION DATE: 27. ALTERNATIVE SANCTIONS A. Suspension of Admissions: (L44) (L27) B. Rescind Suspension Date: (L45) 26. TERMINATION ACTION: (L30) VOLUNTARY 01-Merger, Closure 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 00-Active 28. TERMINATION DATE: 29. INTERMEDIARY/CARRIER NO. 30. REMARKS (L28) (L31) 31. RO RECEIPT OF CMS DETERMINATION OF APPROVAL DATE 08/12/2015 (L32) (L33) DETERMINATION APPROVAL FORM CMS-1539 (7-84) (Destroy Prior Editions)

7 Protecting, Maintaining and Improving the Health of Minnesotans Electronically delivered July 2, 2015 Ms. Jana Cates, Administrator Golden Livingcenter - La Crescent 101 South Hill Street La Crescent, Minnesota RE: Project Number S Dear Ms. Cates: On June 25, 2015, 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. A copy of the Statement of Deficiencies (CMS-2567) is enclosed. Please 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 Services determine that termination or any other remedy is warranted, it will provide you with a separate formal notification of that determination. This letter provides important information regarding your response to these deficiencies and addresses the following issues: Opportunity to Correct - the facility is allowed an opportunity to correct identified deficiencies before remedies are imposed; Electronic Plan of Correction - when a plan of correction will be due and the information to be contained in that document; Remedies - 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 at the time of a revisit; Minnesota Department of Health Health Regulation Division General Information: Toll-free: An equal opportunity employer

8 Golden Livingcenter - La Crescent July 2, 2015 Page 2 Potential Consequences - the consequences of not attaining substantial compliance 3 and 6 months after the survey date; and Informal Dispute Resolution - your right to request an informal reconsideration to dispute the 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 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: Gary Nederhoff, Unit Supervisor Minnesota Department of Health 18 Wood Lake Drive Southeast Rochester, Minnesota gary.nederhoff@state.mn.us Telephone: (507) Fax: (507) OPPORTUNITY TO CORRECT - 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 August 4, 2015, the Department of Health will impose the following remedy: State Monitoring. (42 CFR ) In addition, the Department of Health is recommending to the CMS Region V Office that if your facility has not achieved substantial compliance by August 4, 2015, the following remedy will be imposed: Per instance civil money penalties. (42 CFR through ) ELECTRONIC PLAN OF CORRECTION (epoc) An epoc for the deficiencies must be submitted within ten 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;

9 Golden Livingcenter - La Crescent July 2, 2015 Page 3 - 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 (a)); Per day civil money penalty (42 CFR through ). 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 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.

10 Golden Livingcenter - La Crescent July 2, 2015 Page 4 VERIFICATION 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 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 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 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 LAST DAY OF THE SURVEY If substantial compliance with the regulations is not verified by September 25, 2015 (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 (b). This mandatory denial of payments will be based on the failure to comply with deficiencies originally contained in the Statement of Deficiencies, upon the identification of new deficiencies at the time of the revisit, or if deficiencies have been issued as the result of a complaint visit or other survey conducted after the original statement

11 Golden Livingcenter - La Crescent July 2, 2015 Page 5 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 December 25, 2015 (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 and INFORMAL DISPUTE RESOLUTION In accordance with 42 CFR , 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 Minnesota Department of Health Health Regulation Division P.O. Box St. Paul, Minnesota 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: 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: 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. Patrick Sheehan, Supervisor Health Care Fire Inspections State Fire Marshal Division pat.sheehan@state.mn.us Telephone: (651) Fax: (651)

12 Golden Livingcenter - La Crescent July 2, 2015 Page 6 Feel free to contact me if you have questions. Sincerely, Kamala Fiske-Downing, Program Specialist Licensing and Certification Program Division of Compliance Monitoring Minnesota Department of Health Kamala.Fiske-Downing@state.mn.us Telephone: (651) Fax: (651)

13 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 000 INITIAL COMMENTS F 000 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. F 279 SS=D 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 (d), (k)(1) DEVELOP COMPREHENSIVE CARE PLANS F 279 8/4/15 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe 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 ; and any services that would otherwise be required under but are not provided due to the resident's exercise of rights under , including the right to refuse treatment under (b)(4). LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 07/10/2015 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 Event ID: GRIK11 Facility ID: If continuation sheet Page 1 of 18

14 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 279 Continued From page 1 F 279 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to develop a comprehensive dialysis plan of care for 1 of 1 resident (R43) reviewed for dialysis. Findings include: R43 was observed on 6/23/15, at 2:00 p.m. R43 was noted to have a right upper subclavian central line dialysis access site and a healed left antecubital arteriovenous fistula site with a fading incisional scar. R43 stated, "The fistula doesn't work that's why I have the one on my chest." R43 was admitted to the facility on 5/20/15 according to the admission record with diagnoses that included but was not limited to end stage renal failure that required dialysis and diabetes type I. R43's admission Minimum Data Set (MDS) dated 5/27/15 acknowledged impaired renal function diagnoses and R43 had dialysis. The MDS assessment also indicated R43 had received diuretics daily during the assessment period. Care Area Assessment (CAA's) were triggered based off of the MDS assessment information that required a plan of care. The CAA's triggered as a result of the MDS assessment included dehydration/fluid maintenance. The CAA summary worksheet indicated dehydration/fluid maintenance was addressed in the care plan on 6/2/15. R43's physician orders provided by the facility on 6/23/15 included, Furosemide (diuretic) 40 milligrams (mg) by mouth twice a day. Physician orders did not include a dietary fluid restriction. R43's care plan provided by the facility on 6/23/15 FORM CMS-2567(02-99) Previous Versions Obsolete 1. The comprehensive care plan for R43 has been reviewed and revised to reflect resident's current care needs. 2. All comprehensive care plans for residents with hemodialysis have been reviewed and updated as necessary. 3.Licensed nursing staff have been educated on the updated comprehensive care plan and on how to develop comprehensive care plans for residents with hemodialysis. 4. DNS or designee will complete random audits on charts for residents with dialysis for four weeks and then monthly for two months. Results will be communicated to facility QAPI committee. Event ID: GRIK11 Facility ID: If continuation sheet Page 2 of 18

15 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 279 Continued From page 2 F 279 indicated R43 had a physician ordered fluid restriction of 1.5 liter (L) per 24 hours with directions to "measure/record daily I & O [intake and output], per MD [medical doctor] orders." The care plan indicated R43 had a right subclavian renal port (central line used for dialysis) and incorrectly instructed staff to auscultate for bruit and palpate for distal thrill (a bruit or thrill would never be present on a central line). The care plan also indicated the resident had a "fistula site," the care plan did not include location, did not indicate the fistula was thrombosed (clotted, non-functioning), and did not include monitoring care for a thrombosed fistula. During an interview on 6/24/15, at 1:48 p.m. licensed practical nurse (LPN)-B stated R43 had not been on a fluid restriction and intake and output had not been monitored or recorded. LPN-B explained the dialysis port (fistula) had failed and staff had not been checking for bruit or thrill. During an interview on 6/25/15, at 1:54 p.m. off-site dialysis registered nurse (RN) stated left upper extremity fistula failed and the facility needed to monitor the left hand for signs and symptoms of lack of blood flow. During an interview on 6/24/15, at 2:30 p.m. certified dietary manager (CDM)-D stated the hospital discharge summary had not included a physician's order for a dietary fluid restriction. During an interview on 6/24/15, at 4:34 p.m. registered dietician (RD)-C stated R43 was discharged from the hospital without a fluid restriction, and had verified and clarified dietary needs with the dialysis RD on 6/3/15. During a follow-up interview on 6/25/15, at 8:39 a.m. RD-C stated, "The care plan [as it pertains to fluid restriction and monitoring intake and output] is incorrect and should have been updated." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 3 of 18

16 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 279 Continued From page 3 F 279 During an interview on 6/25/15, at 1:36 p.m. director of nursing (DON) verified the care plan was incorrect and needed to be updated. DON stated the facility did not have a care plan policy, however the expectation was to follow the Centers for Medicare and Medicaid Services' (CMS) Resident Assessment Instrument (RAI) manual. F 329 SS=D (l) DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. F 329 8/4/15 This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 4 of 18

17 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 329 Continued From page 4 F 329 by: Based on interview and document review, the facility failed to assess sleep pattern for 1 of 5 residents (R26) reviewed for unnecessary medications; and failed to provide physician justification for continued use of prophylactic antibiotic for 1 of 5 residents (R26) reviewed in the sample for unnecessary medications. Findings include: LACK of SLEEP ASSESSMENT: R26 was admitted to the facility on 9/10/14, according to facility admission record. Document review of physician orders dated 6/1/15 to 6/30/15, revealed R26 had diagnosis of insomnia. The facility identified R26 on the quarterly Minimum Data Set (MDS), an assessment dated 3/4/15, to be cognitively intact, independent with activities of daily living, and received antidepressant, hypnotic, and diuretic medication. Document review of physician orders dated 6/1/15 to 6/30/15, revealed orders for zolpidem (hypnotic medication) 5 milligrams every 24 hours as needed for insomnia related to anxiety, with a start date of 5/21/15. Document review of facility medication administration record dated 6/1/15 to 6/24/15, revealed R26 received zolpidem 18 out of 24 possible evenings. 1. Sleep pattern assessment has been completed for R26. Physician has provided comprehensive justification for prophylactic antibiotic use. 2. All residents receiving a hypnotic medication have potential to be affected. The facility had identified, assessed and monitored sleep pattern. All residents with an order for prophylactic antibiotic have the potential to be affected. The facility has identified and justification for use is present or medication had been discontinued. 3.Licensed nursing staff have been educated on completion of sleep assessment. Education has been provided to physicians on need for comprehensive justification for prophylactic antibiotic use. 4. DNS or designee will complete random audits on residents who have been prescribed hypnotic medication or prophylactic antibiotic weekly for four weeks then monthly for two months. Results will be communicated to QAPI committee. R26's care plan with print date of 6/25/15, directed staff that R26 sometimes had behaviors which included insomnia. Interventions included to administer medication as ordered, avoid situations or people that are upsetting, let physician know if behaviors interfere with daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 5 of 18

18 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 329 Continued From page 5 F 329 living, and make sure not in pain or uncomfortable. There was no evidence of an assessment of sleep patterns to determine cause of insomnia nor was one provided upon request from the facility. During interview on 6/25/15, at 10:30 a.m., assistant director of nursing verified the facility lacked assessment of sleep patterns related to use of zolpidem for insomnia. During interview on 6/25/15, at 12:08 p.m., director of nursing verified lack of sleep pattern assessment and stated she would expect sleep pattern assessment completed for R26. LACK OF JUSTIFICATION FOR PROPHYLACTIC ANTIBIOTIC USE: R26 was admitted to the facility on 9/10/14, with diagnosis that included disorders of urethra and urinary tract, according to facility admission record. The facility identified R26 on the quarterly Minimum Data Set (MDS), an assessment dated 3/4/15, to be cognitively intact, independent with activities of daily living, and received antidepressant, hypnotic, and diuretic medication. Document review of facility care area assessment dated 9/17/14, revealed R26 was incontinent of urine and to proceed to care plan. R26 care plan with print date 6/25/15, directed staff toileting assist of one staff as needed and toilet schedule on request. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 6 of 18

19 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 329 Continued From page 6 F 329 Document review of physician orders dated 6/1/15 to 6/30/15, revealed orders for trimethoprim (an antibiotic) 100 milligrams in the morning with a start date of 9/13/14. Document review of facility medication administration record dated 6/1/15 to 6/25/15, revealed R26 received medication as ordered. Document review of facility clinical pharmacist letter to physician services, dated 1/17/15, revealed "Long-term use of antibiotics without appropriate evaluation for continued need is not recommended." Physician response dated 1/20/15, was recommendation rejected, on urinary tract infection prophylactic. However, this lacked sufficient clinical evidence for continued use of prophylactic use of antibiotic, especially when the resident continued to have UTIs while on antibiotic. Document review of physician progress note dated 9/12/15, revealed R26 was recently discharged from hospital after urosepsis and confusion. The progress note identified start trimethoprim 100 milligrams today and try to decrease hospitalizations for recurrent urinary tract infections and urosepsis Document review of physician limited evaluation dated 9/16/14, revealed R26 had been in facility since 9/10/14, was hospitalized for septic shock from E.Coli, now on trimethoprim 100 milligrams for prophylaxis for urinary tract infection. Impression was Escherichia coli septic shock with bacteremia from urinary source and acute renal failure resolved. Document review of physician progress note FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 7 of 18

20 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 329 Continued From page 7 F 329 dated 11/11/14, revealed the following: saw physician on 11/11/14, urinary frequency, no other symptoms, had to get up at night for past three weeks, urine culture collected on 10/29/14, normal renal function, received trimethoprim prophylaxis, impression included urinary tract infection secondary to enterococcus faecalis. Plan included nitrofurantoin 100 milligrams two times a day for five days and hold trimethoprim during that five days, restart after completed. Document review of physician progress note dated 3/17/15, revealed the following: saw physician on 3/12/15, urine abnormal, placed on macrobid (antibiotic) 100 milligrams two times a day for one week. The progress note identified medications were reviewed, received trimethoprim prophylaxis, has normal renal function, impression included urinary tract infection/urge incontinence. Document review of physician two month follow-up limited evaluation dated 5/12/15, revealed R26 had urinary incontinence at night, urgency, frequency, a little bit of dysuria, recurrent urinary tract infections in the past, briefly discussed use of premarin to decrease risk of urinary tract infections, and currently on trimethoprim. The evaluation identified R26 received Ditropan for urge incontinence, low dose of Lasix, and had frequency in the evening. The plan was for no changes at this point. Document review of facility line listing of resident infections, revealed the following: 9/2014--R26 had been hospitalized for urinary tract infection sepsis and received antibiotic treatment; 11/2014-urine culture positive and received antibiotic treatment; and 3/12/15-urine positive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 8 of 18

21 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 329 Continued From page 8 F 329 and received antibiotic treatment. Although R26 received prophylactic antibiotic from 9/12/14 to present, R26 had two further urinary tract infections after hospitalized 9/2014 for urosepsis. The facility lacked physician comprehensive justification for continued use of antibiotics. F 371 SS=F During interview on 6/25/15, at 123:08 p.m., assistant director of nursing verified the lack of physician justification for prophylactic antibiotic use. During interview at that time, director of nursing verified the facility had no policy related to prophylactic antibiotic use (i) FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY F 371 8/4/15 The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to ensure resident foods stored in 1 of 1 resident snack refrigerators was dated and labeled. This had the potential to affect all 42 residents who resided in the facility. Findings include: 1. All unlabeled food items have been removed from the snack refrigerator. 2. All residents had the potentisl to be affected. The facility implememted policy Storage of Refrigerated Foods for the snack refrigerator. 3. Education has been provided to staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 9 of 18

22 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 371 Continued From page 9 F 371 Observations with dietary aide (DA)-A on 6/24/15, at 9:30 a.m., of the facility (resident food stored) snack refrigerator located near the nurses' station, revealed the following: One large plastic bag with many green grapes, brown in color and soft to touch, undated and without resident name; one small plastic bag of mushrooms, very brown in color, soft with small amount of brown liquid in the bag. DA-A opened and quickly closed the bag exclaiming very foul odor, undated and without resident name; one large plastic bag of sliced summer sausage, undated but with resident name. that all resident food items must be label with resident name and date. 4. Certified dietary manager or designee will complete random audits of snack refrigerator weekly for four weeks and then monthly for two months. Results will be communicated to facility QAPI committee. During interview on 6/24/15, at 9:30 a.m., DA-A verified the refrigerator contained resident snacks. DA-A stated did not know who was responsible for monitoring foods in the snack refrigerator although thought nursing department monitored resident foods brought into the snack refrigerator. During interview on 6/24/15, at 1:12 p.m., certified dietary manager (CDM) stated dietary department monitored foods that dietary placed in the snack refrigerator. CDM stated she assumed nursing monitored foods brought into the snack refrigerator by residents. CDM stated she expected foods to be dated and identified with resident names. During interview on 6/24/15, at 1:20 p.m., administrator stated she thought the activities department monitored foods in the resident snack refrigerator. Document review of facility policy Storage of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 10 of 18

23 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 371 Continued From page 10 F 371 Refrigerated Foods dated 2/12/15, on page 1 read, "The director of dining or designee must ensure that all refrigerated food is properly stored, used or disposed of according to guidelines." and on page 3 read, "Monitor all items daily for expiration dates or "use by" dates and discard all outdated items immediately." F 431 SS=D During interview on 6/24/15, at 3:00 p.m., administrator stated the policy included resident snack refrigerator. Administrator stated she expected staff to follow the policy (b), (d), (e) DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS F 431 8/4/15 The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. 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. 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. The facility must provide separately locked, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 11 of 18

24 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 431 Continued From page 11 F 431 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 remove expired insulin subsequently resulting in the administration of the expired insulin for 1 of 4 residents (R2) receiving insulin. Findings include: R2 was given outdated insulin: During the medication review of the 200 wing medication cart on 6/22/15 at 5:15 p.m. an opened vial of Novolog (insulin, injectable medication for treatment of Diabetes) was noted with the opened date of 5/23/15 which would outdate on 6/20/15 (28 days from the date of being opened). This vial was available for use and the only Novolog available in the medication cart for R2. Registered Nurse (RN)-C verified the opened date of 5/23/ Expired insulin has been removed from the medication cart. 2. All insulin dependent diabetics had the potential to be affected. All remaining insulins in medication cart have been checked for current dates. 3. Licensed staff have been educated on insulin expiration dates. 4. DNS or designee will complete random audits of insulin in medication carts weekly for four weeks and then monthly for two months. Results will be communicated to the facility QAPI committee. On 6/23/15 at 2:33 p.m. the 200 wing medication cart was reviewed. R2's Novolog with the open date of 5/23/15 was noted. The assistant director of nursing (ADON) verified the opened date of 5/23/15 and also verified insulin is good for 28 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 12 of 18

25 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 431 Continued From page 12 F 431 days after opening and should not be used past the 28 days (6/20/15). Review of R2's medication administration record (MAR) indicated on 6/23/15 at 7:30 a.m. R2 received 1 unit of Novolog and at 11:30 a.m. received 2 units of Novolog. Licensed practical nurse (LPN)-A was interviewed on 6/23/15 at 2:33 p.m. LPN-A verified she administered R2 ' s morning Novolog from the Novolog vial with the open date of 5/23/15. LPN-A also verified that once opened insulin is only good for 28 days. The director of nursing (DON) provided copies of a medication expiration dates lists which indicated insulin expires 28 days after opened. This list was found hanging in the medication storage room, on the side of the medication dispensing unit. A review of the facility's Medication Administration-Preparation and General Guidelines policy dated 5/12, section B 12, read, "The expiration date on the packaging/container is checked." F 441 SS=D A review of the facility's Medication Storage in the Facility, Storage of Medications policy dated 5/12, Expiration Dating E. read, "When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated...(see MEDICATIONS WITH SHORTENED EXPIRATION DATES)." Section dated 5/12, read, "Novolog, vials...expire 28 days after opening or removing from refrigerator, whichever comes first." INFECTION CONTROL, PREVENT SPREAD, LINENS F 441 8/4/15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 13 of 18

26 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 441 Continued From page 13 F 441 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 14 of 18

27 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 441 Continued From page 14 F 441 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review the facility failed to maintain a sanitary environment during dressing changes for 2 of 2 residents (R9, R67) observed for dressing changes. Findings include: R9's dressing change to her right heel was observed on 6/24/15 at 1:48 p.m. Registered nurse (RN)-A completed this dressing change. R9 was sitting in her wheelchair in her room. RN-A sat on the floor while she placed her clean supplies for the dressing change directly on the floor. Supplies included one pair of gloves, Mepore [self-adhesive absorbent dressing] in a sealed package, gauze in a sealed package, and a bottle of wound cleanser. RN-A applied the gloves that were directly touching the floor on her hands then proceeded to remove the soiled dressing and place the soiled dressing directly on the floor. RN-A then proceeded without changing soiled gloves to clean the right heel area with gauze and wound cleanser, redressed the area with the new Mepore dressing. Throughout this dressing change RN-A was not observed to change her gloves, leaving the same gloves on her hands from the beginning to the end of the dressing change. 1. The facility maintained sanitary procedures during wound dressing change for R9 and R67. 2.All residents with orders for dressing changes have the potential to be affected. The facility maintained sanitary procudres for wound dressing changes. 3. Licensed nursing staff have been educated on proper sanitary procedures for wound dressing changes. 4. DNS or designee will complete random observations on nurses completing wound dressing changes weekly for four weeks and then monthly for two months. Results will be communicated to the facility QAPI committee. On 6/24/15 at 2:03 p.m. RN-A stated, "I am aware that [referring to putting clean supplies on floor and using soiled gloves to redress the wound] was wrong and I know to do it differently. I was just nervous." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 15 of 18

28 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 441 Continued From page 15 F 441 On 6/24/15 at 2:08 p.m. the director of nursing (DON) was asked her expectations for a dressing change. DON stated, "Have a clean or sterile field to work in. Gloves on to remove soiled dressing first, clean gloves to put any medication and dressing on." The DON verified gloves are not to go on the floor prior to wearing and gloves need to be changed in between dirty dressing and clean dressings. A review of the facility's Dressing Change, Clean, Procedure 330, undated, included the following procedure: 1. Place plastic bag near foot of bed to receive soiled dressing. 2. Create clean field with paper towels or towelette drape. 3. Remove old adhesive with adhesive remover, if necessary, taking care not to get solution into wound. 4. Open dressing pack. 5. Put on first pair of disposable gloves. 6. Remove soiled dressing and discard in plastic bag. 7. Dispose of gloves in plastic bag. 8. Put on second pair of disposable gloves. 9. Pour prescribed solution onto gauze to be used for cleaning, if required. 10. Cleanse wound with prescribed solution. 11. Apply prescribed medication if ordered. 12. Apply dressings and secure with tape. 13. Remove gloves and discard with all unused supplies in plastic bag. 14. Assist resident to comfortable position with call light in reach. R67 had wound care done and licensed nurse placed box of gloves on floor then moved the box of gloves to the residents table without protecting the table from being soiled. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 16 of 18

29 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 441 Continued From page 16 F 441 R67 was admitted to the facility on 6/16/15, with diagnosis that included syncope, diabetes mellitus, and peripheral vascular disease, according to facility admission record. Document review of physician orders dated 6/24/15, revealed orders for dressing change daily, check wound, betadine cleanse to outside wound edges and redress with soft dressing. During observations on 6/25/15, at 10:15 a.m., RN-A completed R67's dressing change in the physical therapy room. R67 was seated in a wheelchair with left leg elevated. RN-A placed a box of non-sterile gloves onto the bare floor and sat on the floor. RN-A placed gloves on both hands, removed the soiled dressing from the left heel, and placed the dressing onto the bare floor. Observation of the dressing revealed no drainage. RN-A removed gloves and placed on the floor along side the soiled dry dressings. RN-A clean gloves applied from the box on the floor. Observations of skin revealed fluid filled left heel blister intact with no drainage. RN-A cleansed the area with a betadine swab, covered with four 2 by 2 dressings, wrapped with kerlix, taped in place, and applied sock to left foot. RN-A removed the box of gloves from the floor and placed on resident's over the bed table which was positioned next to R67. RN-A picked up the soiled dressings from the bare floor and placed in wastebasket. During interview on 6/25/15, at 10:30 a.m., RN-A stated the soiled dressings should have been placed on paper towels. Document review of facility wound evaluation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 17 of 18

30 PRINTED: 08/13/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) B. WING ID STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 441 Continued From page 17 F 441 dated 6/24/15, revealed left heel pressure wound, 4 centimeters by 4 centimeters, suspected deep tissue injury. During interview on 6/25/15, at 12:57 p.m., director of nursing stated the box of gloves and soiled dry dressings on bare floor were "not appropriate." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: GRIK11 Facility ID: If continuation sheet Page 18 of 18

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