Protectng, Mantanng and mprovng the Health ofmnnesotans August 13, 2012 Ms. Carol Glbertson, Admnstrator MN Veterans Home Slver Bay 45 Banks Boulevard Slver Bay, Mnnesota 55614 Re: Enclosed Renspecton Results - Project Number SL0038 l 020 Dear Ms. Glbertson: On June 25, 2012 survey staff of the Mnnesota Department ofhealth, Lcensng and Certfcaton Program completed a renspecton ofyour faclty to determne correcton oforders found on the survey completed on May 10, 2012, wth orders receved by you on May 18, 2012. At ths tme these correcton orders were found corrected and are lsted on the attached Revst Report Form. Please note, t s your responsblty to share the nformaton contaned n ths letter and the results of ths vst wth the Presdent ofyour facltys Governng Body. Feel free to contact me wth any questons related to ths letter. Sncerely, N,wUw tfu.~ 4VW-, Ncole Steege, Program Specalst Lcensng and Certfcaton Program Dvson of Complance Montorng Mnnesota Department of Health Telephone: (651) 201-4124 Fax: (651) 215-9697 Enclosure( s) cc: Lcensng and Certfcaton Fle General lnfonna1on: (651) 201-5000 TDDTTY: (651) 201-5797 Mnnesota Relay Servce: (800) 627-3529 www.health.statc.mn. us For drectons to any of the MDH locatons, call (651) 201-5000 + An Equal Opportunty Employer
AH Form Approved 6/8/2012 State Form: Revst Report (Y1) Provder Suppler CLA dentfcaton Number (Y2) Multple Constructon A. Buldng B.Wng (Y3) Date of Revst 6/25/2012 Name of Faclty Street Address, Cty, State, Zp Code MN VETERANS HOME SLVER BAY SLVER BAY, MN 55614 Ths report s completed by a State surveyor to showthose defcences prevously reported that have been corrected and the date such correctve acton was accomplshed. Each defcency should be fully dentfed usng ether the regulaton or provson number and the dentfcaton prefx code prevously shown on the State Survey Report (prefx codes shown to the left of each requrement on the survey report fonn). (Y4) tem (YS) Date (Y4) tem (VS) Date (Y4) tem (Y5) Date Correcton D Prefx 20565 06/08/2012 MN Rule 4658.0405 Subp. Correcton D Prefx 20905 06/08/2012 MN Rule 4658.0525 Subp., Correcton D Prefx 20570 06/08/2012 Reg. # MN Rule 4658.0405 Subp., D Prefx Correcton Correcton D Prefx 20830 06/08/2012 MN Rule 4658.0520 Subp. D Prefx,t";. (<.. Correcton D Prefx Correcton D Prefx Correcton D Prefx Correcton.., D Prefx Correcton D Prefoc Correcton D Prefx Correcton Reg. # Reg. #.. JD Prefx Correcton D Prefx Correcton D Prefx Correcton.. Reg. #. _,. -- Revewed By ~tate Agency --- Revewed By frt),-jj) Revewed By - Revewed By CMS RO Followup to Survey on: 5/10/2012 Date: _Ml3JJ1- Date: -- Sgnature of Surveyor: Sgnature of Surveyor: 2qy35 Check for any Uncorrected Defcences. was a Summary of Uncorrected Defcences (CMS-2567) Sent to the Faclty? STATE FORM: REVST REPORT (5/99) Page 1 of 1 Event D: 81W512 D tr/2 l,_-- Date: YES NO....
/;).1 Protectng, Mantanng and mprovng the Health ofmnnesotans Certfed Mal# 70 l O l 060 0002 3051 1029 May 15, 2012 Ms. Carol Glbertson, Admnstrator MN Veterans Home Slver Bay 45 Banks Boulevard Slver Bay, Mnnesota 55614 - Re: Enclosed State Nursng Home Lcensng Orders - Project Number SL0038 l 020 Dear Ms. Glbertson: The above faclty was surveyed on May 7, 2012 through May 10, 2012 for the purpose ofassessng complance wth Mnnesota Department of Health Nursng Home RuJes. At the tme ofthe survey, the survey team from the Mnnesota Department ofhealth, Complance Montorng Dvson, noted one or more volatons ofthese rules that are ssued n accordance wth Mnnesota Stat. secton 144.653 and/or Mnnesota Stat. Secton l 44A.10. f, upon renspecton, t s found that the defcency or defcences cted heren are not corrected, a cvl fne for each defcency not corrected shall be assessed n accordance wth a schedule offnes promulgated by rule ofthe Mnnesota Department ofhealth. To assst n complyng wth the correcton order(s), a "suggested method ofcorrecton" has been added. Ths provson s beng suggested as one method that you can follow to correct the cted defcency. Please remember that ths provson s only a suggeston and you are not requred to follow t. Falure to fojlow the suggested method wll not result n the ssuance ofa penalty assessment. You are remnded, however, that regardless ofthe method used, correcton ofthe defcency wthn the establshed tme frame s requred. The "suggested method ofcorrecton" s for your nformaton and assstance only. The State lcensng orders are delneated on the attached Mnnesota Department ofhealth order form (attached). The Mnnesota Department ofhealth s documentng the State Lcensng Correcton Orders usng federal software. Tag numbers have been assgned to Mnnesota state statutes/rules for Nursng Homes. The assgned tag number appears n the far left column enttled "D Prefx Tag." The state statute/rule number and the correspondng text of the state statute/rule out ofcomplance s lsted n the "Summary Statement ofdefcences" column and replaces the "To Comply" porton ofthe correcton order. Ths column also ncludes the fndngs that are n volaton ofthe state statute after the statement, "Ths Rule s not met as evdenced by." Followng the surveyors fndngs are the Suggested Method of Correcton and the Tme Perod For Correcton. General lnfonnaton: (651) 201-5000 * TDDfTY: (651) 201-5797 Mnnesota Relay Servce: (800) 627-3529 www.health.statc.nm.us For drectons to any of the MDH locatons, call (651 ) 201-5000 An Equal Opportunty Employer
MN Veterans Home Slver Bay May 15, 2012 Page 2 PLEASE DSREGARD THE HEADNG OF THE FOURTH COLUMN WHCH STATES, "PROVDERS PLAN OF CORRECTON." THS APPLES TO FEDERAL DEFCENCES ONLY. THS WLL APPEAR ON EACH PAGE. THERE S NO REQUREMENT TO SUBMT A PLAN OF CORRECTON FOR VOLATONS OF MNNESOTA STATE STATUTES/RULES. When all orders are corrected, the order fonn should be sgned and returned to ths offce at Mnnesota Department of Health, 320 West Second St, Room 703, Duluth, Mnnesota 55802-1402. We urge you to revew these orders carefully, tem by tem, and f you fnd that any of the orders are not n accordance wth your understandng at the tme ofthe ext conference followng the survey, you should mmedately contact me. You may request a hearng on any assessments that may result from non-complance wth these orders provded that a wrtten request s made to the Department wthn 15 days of recept ofa notce of assessment for non-complance. Please note t s your responsblty to share the nfonnaton contaned n ths letter and the results of ths vst wth the Presdent ofyour facltys Governng Body. Please feel free to cal1 me wth any questons. Sncerely, Pat Halverson, Unt Supervsor Lcensng and Certfcaton Program Dvson of Complance Montorng Telephone: (218) 723-463 7 Fax: (218) 723-23 59 Enclosure(s) cc: Orgnal - Faclty Lcensng and Certfcaton Fle SL003 81020S 12.rtf
/ ~1Y)lf : Mnnesota De artment of Health RECEVED PRNTED: 05/15/2012 FORM APPROVEO STATEMENT OF DEFCENCES (X1) PROVDER/SUPPLER/CUA (X3) DATE SURVEY. (X2) MULTPLE construcma 22 2012 AND PLAN OF CORRECTON DENTFCATON NUMBER: NAME OF PROVDER OR SUPPLER A. BULDNG B. WNG M_N_o_ru-t,~-nH-e_altll 05/10/2012 STREET ADDRESS. CTY, STATE. ZP CODE MN VETERANS HOME SLVER BAY SLVER BAY, MN 55614.:. (X4) D SUMMARY STATEMENT OF DEFCENCES D PROVDERS PLAN OF CORRECTON (X5) PREFX (EACH DEFCENCY MUST BE PRECEDED BY FULL PREFX (EACH CORRECTVE ACTON SHOULD BE COMPLETE CROSS-REFERENCED DATE REGULATORY OR DENTFYNG NFORMATON) TO THE APPROPRATE DEFCENCY) 2 000 ntal Comments 2 000 ***** A TENTON****** NH LCENSNG CORRECTON ORDER n accordance wth Mnnesota Statute, secton 144A.10, ths correcton order has been ssued pursuant to a survey. f, upon renspecton, t s found that the defcency or defcences cted heren are not corrected, a fne for each volaton not corrected shall be assessed n accordance wth a schedule of fnes promulgated by rule of the Mnnesota Department of Health.... :....: Determnaton of whether a volaton has been corrected requres complance wth all requrements of the rule provded at the tag number and MN Rule number ndcated below. When a rule contans several tems, falure to comply wth any of the tems wll be consdered lack of complance. Lack of complance upon re-nspecton wth any tem of mult-part rule wll result n the assessment of a fne even f the tem that was volated durng the ntal nspecton was corrected. You may request a hearng on any assessments that may result from non-complance wth these orders provded that a wrtten request s made to the Department wthn 15 days of recept of a notce of assessment for non-complance. NTAL COMMENTS: On Sn/12 through 5/10/12, surveyors of ths Departments staff, vsted the above provder and the fo!lowng correcton orders are ssued. When correctons are completed, please sgn and date, make a copy of these orders and return the orgnal to the Mnnesota Department of Health, Dvson of Complance Montorng, Lcensng and PPLER REPRESENTATVES SGNATURE 6 99 81W511 lol~
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES (X1) PROVDER/SUPPLER/CLA (X2) MULTPLE CONSTRUCTON AND PLAN OF CORRECTON DENTFCATON NUMBER: NAME OF PROVDER OR SUPPLER MN VETERANS HOME SLVER BAY (X4} D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR DENTFYNG NFORMATON) PRNTED: 05/15/201 2 (XJ} DATE SURVEY A. BULDNG 8. WNG 05/10/2012.. STREET ADDRESS. CTY, STATE, ZP CODE SLVER BAY, MN 55614 D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (X5) COMPLETE. DATE 2 ooo Contnued From page 1 Certfcaton Program; 320 West 2nd Street, Duluth, MN 55802. 2 565 MN Rule 4658.0405 Subp. 3 Comprehensve Plan of Care; Use 2 000 2 565 Subp. 3. Use. A comprehensve plan of care must be used by all personnel nvolved n the care of the resdent..:: ~..,,... Ths MN Requrement s not met as evdenced by: Based on ntervew and document revew, the faclty faled to provde repostonng as drected by the plan of care for 1 of 5 resdents (R2) n the sample revewed for repostonng needs. Fndngs nclude: R2 was not repostoned every two hours as drected by the care plan. R2 went for two (2) hours and twenty-sx (26) mnutes wthout repostonng on 5/7/12.,.. -. -- R2s dagnoses ncluded a spnal cord njury, dabetes melltus and plega (paralyss). The skn assessment dated 3/19/12, ndcated R2 had no pressure ulcers, the Braden score (a tool used to predct the potental for skn breakdown) dated 3/19/12, ndcated R2 was at moderate rsk for skn breakdown. The admsson mnmum data set (MOS) dated 3/25/12, ndcated R2 was cogntvely ntact, requred physcal assstance wth most actvtes of daly lvng (AOLs) and was ncontnent of bowel. The care area assessment (CAA) summary dated 3/28/12, ndcated R2 was at rsk for skn breakdown related to bowel ncontnence, requred two staff for bed moblty Mnnesota Department of Health STATE FORM 6899 81W511 f contnuaton sheet 2 of 11.
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES AND PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER (X1) PROVDER/SUPPLER/CLA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULDNG B. WNG STREET ADDRESS, CTY, STATE, ZP CODE MN VETERANS HOME SLVER BAY SLVER BAY, MN 55614 P~NTED: 05/15/2012 (X3} DATE SURVEY 05/10/2012 (X4) JD PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR DENTFYNG NFORMATON) PROVDERS PLAN OF CORRECTON (XS),o PREFX (EACH CORRECTVE ACTON SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRATE DATE DEFCENCY) 2 565 Contnued From page 2 and a mechancal lft for transfers. The care plan for R2s skn dated 3/28/12, dentfed R2 was at rsk for skn breakdown due to loss of moblty and bowel ncontnence. The care plan drected, Turn and reposton resdent q2h (every two hours} and pm (as needed)... " Durng contnuous observatons on 5/7/12, from 5:08 p.m. untl 7:31 p.m., R2 was not repostoned (two (2) hours and twenty-sx (26) mnutes). On 5/10/12, at 9:51 a.m. the drector of nursng confrmed R2 should have been repostoned every two hours as drected by the care plan. 2 565!... -.!.,..... :. SUGGESTED METHOD OF CORRECTON: The 1 drector of nursng or her desgnee could develop, polces and procedures to ensure resdents are repostoned as drected by the care plan. The drector of nursng or her desgnee could educate all approprate staff members on the processes. The drector of nursng or her desgnee could develop montorng systems to ensure ongong complance. TME PEROD FOR CORRECTON: Twenty-One (21) Days 2 570 MN Rule 4658.0405 Subp. 4 Comprehensve Plan of Care; Revson 2 570 Subp. 4. Revson. A comprehensve plan of care must be revewed and revsed by an nterdscplnary team that ncludes the attendng physcan, a regstered nurse wth responsblty for the resdent, and other approprate staff n dscplnes as determned by the resdents needs, and, to the extent practcable, wth the partcpaton of the resdent, the resdents legal Mnnesota Department of Health STATE FORM 81W511 f contnuaton sheet 3 of 11.
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES (Xl) PROVDER/SUPPLER/CUA (X2) MULTPLE CONSTRUCTON AND PLAN OF CORRECTON DENTFCATON NUMBER: NAME OF PROVDER OR SUPPLER MN VETERANS HOME SLVER BAY (X4)1D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR DENTFYNG NFORMATON) PRNTED: 05/15/2012 (X3) DATE SURVEY A. BULDNG B. WNG 05/10/2012.. STREET ADDRESS, CTY, STATE, ZP CODE SLVER BAY, MN 55614 D PREFX! PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD SE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (X5) COMPLETE l DATE 2 570 Contnued From page 3 guardan or chosen representatve at least quarterly and wthn seven days of the revson of the comprehensve resdent assessment requred by part 4658.0400, subpart 3, tem B. 2 570 Ths MN Requrement s not met as evdenced by: Based on observaton, ntervew and document revew, the faclty faled to revse the care plan for 1 of 1 resdents {R11) revewed for wheelchar postonng. Fndngs nclude:..., 1: R11 s care plan was not revsed to nclude the use of a lateral bolster to correct a rght sded lean. R11 s dagnoses ncluded Parknsons and dementa wth Lewy Bodes. The admsson mnmum data set (MDS) dated 1/10/12, ndcated R11 had moderately mpared cognton and requred physcal assstance wth all actvtes of -- daly lvng (AOLs). The care area assessment.! (CAA) summary dated 1/16/12, ndcated R11. had a communcaton mparment and dd not ; make hs needs known, requred two staff assstance for bed moblty and a mechancal lft for transfers. A Daly Note/Bllng Sheet (a form. used by the therapy department) dated 1/19/12, ndcated R11 had "poor posture and trunk stablzaton." A rehabltaton progress note dated 2/8/12, ndcated R11 was provded wth rock-n-go wheelchar for "postonng and comfort." The note ndcated R11 would beneft from a wheelchar that allowed for greater pelvc tlt and promoted uprght posture and to prevent hp flexon contractures. The Physcal Therapy Dscharge Summary dated 317/12, ndcated, "Addtonal Comments... leanng n w/c (wheelchar), poor trunk and pelvs algnment and j!,.!.. Mnnesota Department of Health STATE FORM 6899 81W511 f contnuaton sheet 4 of 11
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES (X1) PROVDER/SUPPLER/CUA (X2) MULTPLE CONSTRUCTON AND PLAN OF CORRECTON DENTFCATON NUMBER: A. BULDNG 8. WNG~~~~~~~~~ NAME OF PROVDER OR SUPPLER STREET ADDRESS, CTY, STATE, ZP CODE MN VETERANS HOME SLVER BAY SLVER BAY, MN 55614 PRNTED: 05/15/2012 (XJ) DATE SURVEY 05/10/2012 (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR DENTFYNG NFORMATON) D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (X5) COMPLETE DATE 2 570 Contnued From page 4 actvaton." The quarterly MOS dated 4/11/12, ndcated R1 1 had declned n cognton wth long and short-term memory problems, but contnued to requre physcal assstance wth all AOLs. The care plan for moblty dated 4/17/12. dentfed R11 used the wheelchar as the prmary mode of moblty and for staff to assst wth locomoton of the wheelchar. The care plan dentfed R11 utlzed a rock-n-go wheelchar and drected detals of R11 s programs for moblty. The care plan dd not address correct algnment or poston correcton needs whle n the wheelchar. 2 570 l...... ~......... - Durng observatons on 5/9/12. at 9:49 a.m. the regstered nurse (RN-C) confrmed R11 requred the use of the bolster to correct body algnment n the wheelchar. RN-C stated the care plan dd not address the use of the bolster. On 5/10112, at 10:01 a.m. the drector of nursng (DON) confrmed the care plan should have been revsed to nclude the use of the bolster and confrmed R11s wheelchar poston should have been corrected by staff wth the bolster appled to the rock-n-go wheelchar. SUGGESTED METHOD OF CORRECTON: The drector of nursng or her desgnee could develop polces and procedures to ensure resdents mantan proper body algnment whle n the wheelchar. The drector of nursng or her desgnee could educate all approprate staff members on the processes. The drector of nursng or her desgnee could develop montorng systems to ensure ongong complance. Mnnesota Department of Health STATE FORM 889, 81W511 f contnuaton sheet 5 of 11..
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES AND PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER MN VETERANS HOME SLVER BAY (X1) PROVDER/SUPPLER/CUA DENTFtCATON NUMBER: SLVER BAY, MN 55614 (X2) MULTPLE CONSTRUCTON A. BULDNG B. WNG STREET ADDRESS, CTY, STATE, ZP CODE PRNTED: 05/15/2012 (X3) DATE SURVEY 05/10/2012. (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULA TORY OR DENTFYNG NFORMATON) D PREFX PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (X5) COMPLETE DATE 2 570 Contnued From page 5 2 570 TME PEROD FOR CORRECTON: Twenty-One (21) Days 2 830 MN Rule 4658.0520 Subp. 1 Adequate and Proper Nursng Care; General 2 830 Subpart 1. Care n general. A resdent must receve nursng care and treatment, personal and custodal care, and supervson based on ndvdual needs and preferences as dentfed n the comprehensve resdent assessment and plan of care as descrbed n parts 4658.0400 and 4658.0405. A nursng home resdent must be out of bed as much as possble unless there s a wrtten order from the attendng physcan that the resdent must reman n bed or the resdent 1 prefers to reman n bed. \ 1 : ( Ths MN Requrement s not met as evdenced by: Based on observaton, ntervew and document revew, the faclty faled to ensure proper seatng algnment for 1 of 1 resdents (R11) n the sample revewed for wheelchar postonng. Fndngs nclude: R11 was observed to lean to the rght whle n the rock and go wheelchar throughout observatons on 5/7/12. R11s dagnoses ncluded Parknsons and dementa wth Lewy Bodes. The admsson mnmum data set (MDS) dated 1/10/12, ndcated 1 R11 had moderately mpared cognton and requred physcal assstance wth all actvtes of daly lvng (AOLs). The care area assessment Mnnesota Department of Health STATE FORM 6B99 81W511 f contnuaton sheet ~ of 11!! : :.
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES AND PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER 2 830 Contnued From page 6 (X1} PROVDER/SUPPLER/CUA DENTFCATON NUMBER: (CAA) summary dated 1/16/12, ndcated R11 had a communcaton mparment and dd not make hs needs known, requred two staff assstance for bed moblty and a mechancal lft for transfers. A Daly Note/Bllng Sheet (a form used by the therapy department) dated 1/19/12, ndcated R 11 had "poor posture and trunk stablzaton." A rehabltaton progress note dated 2/8/12, ndcated R11 was provded wth rock-n-go wheelchar for "postonng and comfort." The note ndcated R11 would beneft from a wheelchar that allowed for greater pelvc tlt and promoted uprght posture and to prevent hp flexon contractures. The Physcal Therapy Dscharge Summary dated 3/7/12, ndcated, "Addtonal Comments... leanng n w/c (wheelchar), poor trunk and pelvs algnment and actvaton." The quarterly MOS dated 4/11/12, ndcated R11 had declned n cognton wth long and short-term memory problems, but contnued to requre physcal assstance wth all AOLs. The care plan for moblty dated 4/17/12, dentfed R11 used the wheelchar as ther prmary mode of moblty and for staff to assst wth locomoton of the wheelchar. The care plan dentfed R11 utlzed a rock-n-go wheelchar and drected detals of R11 s programs for moblty. The care plan dd not address correct algnment or poston correcton needs whle n the wheelchar. (X2) MULTPLE CONSTRUCTON A. BULDNG B. WNG STREET ADDRESS, CTY, STATE, ZP CODE PRNTED: 05/15/2012 (X3) DATE SURVEY 05/10/2012 MN VETERANS HOME SLVER BAY SLVER BAY, MN 55614 (X4)1D SUMMARY STATEMENT OF DEFCENCES PROVDERS PLAN OF CORRECTON (X5) PREFX (EACH DEFCENCY MUST BE PRECEDED BY FULL D (EACH CORRECTVE ACTON SHOULD BE COMPLETE REGULATORY OR DENTFYNG NFORMATON) PREFX DATE! CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 2 830..,,. : : /., ; On 5f7/12, at 6:30 p.m. R11 was observed be seated n the TV area, leanng to the rght n the rock-n-go wheelchar. From 6:30 p.m. untl 7:14 p.m. R11 was observed to lean to the rght whle n the wheelchar wth the rght armrest frmly aganst hs rght axlla (arm pt). Multple staff Mnnesota Department of Health STATE FORM 6899 81W511 - f contnuaton sheet 7 of 11
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES ANO PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER MN VETERANS HOME SLVER BAY (X1) PROVDER/SUPPLER/CUA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULDNG 6. WNG STREET ADDRESS, CTY, STATE. ZP CODE SLVER BAY, MN 55614 PRNTED: 05/15/20 2 (X3) DATE SURVEY 05/10/2012...., (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR DENTFYNG NFORMATON} D PREFX. PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY} (XS) COMPLETE DATE 2 830 Contnued From page 7 from the unt were observed to walk past and be near R 11 wthout provdng assstance wth correctng the lean. At 7:14 p.m. the human servces techncan (HST-A) confrmed R11 should have had hs postonng algnment corrected. On 5/9/12, at 7: 10 am, R11 was observed to have a blue lateral bolster appled to the wheelchar. R11 s rght elbow was observed to be aganst the bolster. The regstered nurse (RN-8) stated R11 frequently requred poston correctons whle n the wheelchar and confrmed the bolster should be appled to the wheelchar. RN-B stated R11 was "a leaner to the rght." Throughout observatons of R11 on 5/9/12, R11 was observed to mantan proper body algnment whle n the wheelchar. At 9:49 a.m. a regstered nurse (RN-C) confrmed R11 requred the use of the bolster and confrmed the care plan dd not address the use of the bolster and dd not drect correcton of body algnment whle n the wheelchar. RN-C was unclear when the use of the bolster began. On 5/10/12, at 10/01 a.m. the drector of nursng (DON) confrmed the care plan should have been revsed to nclude the use of the bolster and confrmed R 11 s wheelchar poston should have been corrected by staff and the bolster appled to the rock-n-go wheelchar. SUGGESTED METHOD OF CORRECTON: The drector of nursng or her desgnee could develop polces and procedures to ensure resdents mantan proper body agnment whle n the wheelchar. The drector of nursng or her desgnee could educate all approprate staff members on the processes. The drector of nursng or her 2 830 j.. j 1,, 1. f ~~1 } ;~. :... ~ :. Mmnesota Department of Health.. STATE FORM 6699 BW511 f contnuaton sheet aof 11 l l!!......
Mnnesota Deoartment of Health STATEMENT OF DEFCENCES (X1) PROVDERSUPPLERCLA (X2) MULTPLE CONSTRUCTON AND PLAN OF CORRECTON DENTFCATON NUMBER: NAME OF PROVlDER OR SUPPLER PRNTED: 05/15/2012 (X3) DATE SURVEY A. BULDNG B. WNG 05/10/2012 STREET ADDRESS, CTY, STATE, ZP CODE MN VETERANS HOME SLVER BAY SLVER BAY, MN 55614 SUMMARY STATEMENT OF DEFCENCES D PROVlDERS PLAN OF CORRECTON (XS) (X4) D (EACH CORRECTN E ACTON SHOULD BE COMPLETE PREFX (EACH DEFCENCY MUST BE PRECEDED BY FULL PREFX REGULATORY OR DENTFYNG NFORMATON) 2 830 Contnued From page 8 desgnee could develop montorng systems to ensure ongong complance. TME PEROD FOR CORRECTON: Twenty-One (21) Days CROSS-REFERENCED TO THE APPROPRATE, DATE DEFCENCY} j 2 830 2 905 MN Rule 4658.0525 Subp. 4 Rehab - Postonng Subp. 4. Postonng. Resdents must be postoned n good body algnment. The poston of resdents unable to change ther own poston must be changed at least every two hours, ncludng perods of tme after the resdent has been put to bed for the nght, unless the physcan has documented that repostonng every two hours durng ths tme perod s unnecessary or the physcan has ordered a dfferent nterval. 2 905.........:...... Ths MN Requrement s not met as evdenced by: Based on observaton, ntervew and record revew, the faclty faled to provde tmely repostonng assstance for 1 of 4 (R2) resdents revewed for ther repostonng needs. Fndngs nclude: R2 was not provded repostonng for two (2} hours and twenty-sx (26) mnutes durng contnuous observatons on 5/7/12. R2s dagnoses ncluded a spnal cord njury, dabetes melltus and plega (paralyss). The skn assessment dated 3/19/12, ndcated R2 had no pressure ulcers, the Braden score (a tool used to predct the potental for skn breakdown) dated 3/19/12, ndcated R2 was at moderate rsk for skn breakdown. The admsson mnmum data set (MOS) dated 3/25/12, ndcated R2 was cogntvely ntact, requred physcal assstance ). : :.) Mnnesota Department of Heatth STATE FORM 6899 81W511 fconttnuaton sheet 9 of 11
Mnnesota Department of Health PRNTED: 05(15/2012 STATEMENT OF DEFCENCES ANO PLAN OF CORRECTON NAME OF PROVDER OR SUPPLER MN VETERANS HOME SLVER BAY (X4} D PREFX (Xl) PROVJDER/SUPPLERJCLA DENTFCATON NUMBER: SUMMARY STATEMENT OF DEFCENCES (EACH DEFCENCY MUST BE PRECEDED BY FULL REGULATORY OR DENTFYNG NFORMATON) (X2) MULTPLE CONSTRUCTON A. BULDNG B. WNG STREET ADDRESS, CTY, STATE, ZP CODE SLVER BAY, MN 55614,o PREFX 1 (X:3) DATE SURVEY PROVDERS PLAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) 05/10/2012 j,. (X5) COMPLETE DATE 2 905 Contnued From page 9 wth most actvtes of daly lvng (AOLs) and was ncontnent of bowel. The care area assessment (CM) summary dated 3/28/12, ndcated R2 was at rsk for skn breakdown related to bowel ncontnence. requred two staff for bed moblty, and requred a mechancal lft for transfers. 2 905,. The care plan for R2s skn dated 3/28/12, dentfed R2 was at rsk for skn breakdown due to loss of moblty and bowel ncontnence. The care plan drected, Turn and reposton resdent q2h (every two hours) and prn (as needed)... ".. :. On 5/7/12, R2 went from 5:08 p.m. untl 7:31 p.m. wthout repostonng. At 5:08 p.m. R2 was observed to be up n the wheelchar n ther room as staff left the room. R2 moved hmself to the dnng room n a motorzed wheelchar. From 5:08 p.m. untl 6:31 p.m. R2 remaned at the dnng room table for the supper meal. At 6:31 p.m. R2 transported hmself to h1s room and read the newspaper untl 6:47 p.m. At 6:47 p.m. R2 transported hmself to the TV sttng area and then back to hs room. At 6:55 p.m. R2s call lght was actvated. At 7:02 p.m. a human servce techncan (HST-A) answered the lght and then mmedately left the room at 7:03 p.m. R2 was unmoved from hs wheelchar and watchng TV. R2 stated he had actvated the call lght accdentally. From 7:03 p.m. to 7:19 p.m. R2 remaned n hs room watchng TV. At 7:19 p.m. NA-A was notfed R2 had gone past 2 hours for 1 repostonng. NA-A confrmed R2 requred every two hour repostonng and stated he had been last repostoned at 5:05 p.m. and was checked for ncontnence, "but not repostoned" at 6:50 p.m. At 7:31 p.m. R2 was transferred to the bed. R2s coccyx was covered wth a duoderm dressng and there was a darkened area on the bottom of the rght heel. NA-A confrmed the... ".... Mnnesota Department of Health STATE FORM ~99 BW511 f contnuaton sheet ~ Oof 11 : " " ; ",.....
Mnnesota Department of Health STATEMENT OF DEFCENCES AND PlAN OF CORRECTON NAME OF PROVDER OR SUPPLER MN Vf;:TERANS HOME SLVER BAY (Xl) PROVDER/SUPPLER/CUA DENTFCATON NUMBER: (X2) MULTPLE CONSTRUCTON A. BULDNG B. WNG STREET ADDRESS, CTY, STATE. ZP CODE SLVER BAY, MN 55614 PRNTED: 05/15/2.012 (X3) DATE SURVEY 05/10/2012. (X4) D PREFX SUMMARY STATEMENT OF DEFCENCES {EACH DEFCENCY MUST BE PRECEDED BY FULL REGUlATORY OR DENTFYNG NFORMATON) D PREFX PROVDERS PlAN OF CORRECTON (EACH CORRECTVE ACTON SHOULD BE CROSS-REFERENCED TO THE APPROPRATE DEFCENCY) (XS) COMPLETE "DATE 2 905 Contnued From page 1 O areas were not new. At 7:38 p.m. the regstered nurse (RN-A) confrmed R2 had a hstory of pressure ulcers and should have been repostoned every two hours. On 5/10/12, at 9:51 a.m. the drector of nursng confrmed R2 should have been repostoned every two hours. SUGGESTED METHOD OF CORRECTON: The drector of nursng or her desgnee could develop polces and procedures to ensure resdents are repostoned as assessed and drected by the care plan. The drector of nursng or her desgnee could educate all approprate staff members on the processes. The drector of nursng or her, desgnee could develop montorng systems to ensure ongong complance. JME PEROD FOR CORRECTON: Twenty-One (21) Days 2 905 : t 1. t "... ~.... Mnnesota Department of Health STATE FORM G599 81W511 f contnuaton sheet 11 of 11 :