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

MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL

PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00705

ID: 8JZ3

X

WINONA, MN

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

1. MEDICARE/MEDICAID PROVIDER NO.

(L1)

2.STATE VENDOR OR MEDICAID NO.

(L2)

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

11. .LTC PERIOD OF CERTIFICATION

From

To (b) :

(a) :

12.Total Facility Beds (L18)

13.Total Certified Beds (L17)

10.THE FACILITY IS CERTIFIED AS:

A. In Compliance With

1. Acceptable POC

B. Not in Compliance with Program

Program Requirements

Compliance Based On:

Requirements and/or Applied Waivers:

And/Or Approved Waivers Of The Following Requirements:

2. Technical Personnel

3. 24 Hour RN

4. 7-Day RN (Rural SNF)

5. Life Safety Code

6. Scope of Services Limit

7. Medical Director

8. Patient Room Size

9. Beds/Room

* Code: (L12)

14. LTC CERTIFIED BED BREAKDOWN

18 SNF

(L37)

18/19 SNF

(L38)

19 SNF

(L39)

ICF

(L42)

IID

(L43)

15. FACILITY MEETS

1861 (e) (1) or 1861 (j) (1): (L15)

A

493543800

7

09/30

71

71

71

12/07/2015

SAUER HEALTH CARE245102

02

1635 WEST SERVICE DRIVE

55987

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

29. INTERMEDIARY/CARRIER NO.

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

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

18. STATE SURVEY AGENCY APPROVAL Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL

RIGHTS ACT:

1. Statement of Financial Solvency (HCFA-2572)

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

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

2. Facility is not Eligible(L21)

22. ORIGINAL DATE

OF PARTICIPATION

23. LTC AGREEMENT

BEGINNING DATE

24. LTC AGREEMENT

ENDING DATE

(L24) (L41) (L25)

27. ALTERNATIVE SANCTIONS25. LTC EXTENSION DATE:

(L27)

A. Suspension of Admissions:

(L44)

B. Rescind Suspension Date:

(L45)

26. TERMINATION ACTION: (L30)

VOLUNTARY

01-Merger, Closure

02-Dissatisfaction W/ Reimbursement

03-Risk of Involuntary Termination

04-Other Reason for Withdrawal

INVOLUNTARY

05-Fail to Meet Health/Safety

06-Fail to Meet Agreement

OTHER

07-Provider Status Change

28. TERMINATION DATE:

(L28) (L31)

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

(L32) (L33)

30. REMARKS

00-Active

01/19/1967

00

03001

12/08/2015 12/9/2015

21.

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

CMS Certification Number (CCN): 245102

December 8, 2015

Ms. Sara Blair, Administrator

Sauer Health Care

1635 West Service Drive

Winona, MN 55987

Dear Ms. Blair:

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

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

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

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

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

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

recertified for participation in the Medicare and Medicaid program.

Effective November 24, 2015 the above facility is certified for or recommended for:

71 Skilled Nursing Facility/Nursing Facility Beds

Your facility’s Medicare approved area consists of all 71 skilled nursing facility beds.

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

certification status.

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

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

Please contact me if you have any questions.

Sincerely,

Kamala Fiske-Downing, Program Specialist

Licensing and Certification Program

Health Regulation Division

Minnesota Department of Health

[email protected]

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

Protecting, Maintaining and Improving the Health of Minnesotans

_____________________________________________________________________________________________________________

Minnesota Department of Health - Health Regulation Division •

General Information: 651-201-5000 • Toll-free: 888-345-0823

http://www.health.state.mn.usAn equal opportunity employer

Electronically delivered

December 8, 2015


Sauer Health Care


Winona, MN 55987

RE: Project Number S5102025

Dear Ms. Blair:

On October 27, 2015, we informed you that we would recommend enforcement remedies based on the

deficiencies cited by this Department for a standard survey, completed on October 15, 2015. This survey found

the most serious deficiencies to be a pattern of deficiencies that constituted no actual harm with potential for

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

On December 7, 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 October 15, 2015. We

presumed, based on your plan of correction, that your facility had corrected these deficiencies as of November

24, 2015. Based on our PCR, we have determined that your facility has corrected the deficiencies issued

pursuant to our standard survey, completed on October 15, 2015, effective November 24, 2015 and therefore

remedies outlined in our letter to you dated October 27, 2015, will not be imposed.

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

with the President of your facility's Governing Body.

Feel free to contact me if you have questions.

Sincerely,





[email protected]

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


_____________________________________________________________________________________________________________

Minnesota Department of Health • Health Regulation Division



Form ApprovedOMB NO. 0938-0390Centers for Medicare & Medicaid Services

Department of Health and Human Services

Post-Certification Revisit ReportPublic 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 (0938-0390), Washington, D.C. 20503.

Street Address, City, State, Zip Code

B. Wing

(Y1) (Y3) Date of RevisitA. Building

245102

Name of Facility

(Y2) Multiple ConstructionProvider / Supplier / CLIA / Identification Number

SAUER HEALTH CARE 1635 WEST SERVICE DRIVEWINONA, MN 55987

12/7/2015

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 Date(Y5)Item(Y4)

ID Prefix

Correction Completed11/24/2015 F0166

Reg. # 483.10(f)(2) 0166LSC

ID Prefix


Reg. # 483.13(c)(1)(ii)-(iii), (c)(2) - ( 0225LSC

ID Prefix


Reg. # 483.13(c) 0226LSC

ID Prefix


Reg. # 483.15(a) 0241LSC

ID Prefix


Reg. # 483.15(h)(7) 0258LSC

ID Prefix


Reg. # 483.20(d), 483.20(k)(1) 0279LSC

ID Prefix


Reg. # 483.20(k)(3)(ii) 0282LSC

ID Prefix


Reg. # 483.25(e)(2) 0318LSC

ID Prefix


Reg. # 483.25(h) 0323LSC

ID Prefix


Reg. # 483.25(l) 0329LSC

ID Prefix


Reg. # 483.30(e) 0356LSC

ID Prefix


Reg. # 483.60(c) 0428LSC

ID Prefix


Reg. # 483.65 0441LSC

ID Prefix

Correction Completed

Reg. # ZZZZLSC

ID Prefix

Correction Completed

Reg. # ZZZZLSC

Reviewed By

State Agency

Reviewed By

Reviewed By

Reviewed By Date:

Date:

CMS RO

Signature of Surveyor:

Signature of Surveyor: Date:

Date:

Followup to Survey Completed on: Check for any Uncorrected Deficiencies. Was a Summary ofUncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NO10/15/2015

Form CMS - 2567B (9-92) Page 1 of 1 8JZ312Event ID:

GPN/kfd 12/8/2015 10160 12/7/2015

245102 SAUER HEALTH CARE

D

Type of Survey (select all that apply):

D

Extent of Survey (Select all that apply):

3.25Total Clerical/Data Entry Hours...............................................................

0.25Total Supervisory Review Hours ...............................................................

Was Statement of Deficiencies given to the provider on-site at completion of the survey? .....

10160 0.25 0.00 0.00 0.00 0.00 0.25

FORM HCFA-670 (12-91)

1.

2.

3.

5.

6.

7.

8.

9.

10.

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVEDHEALTH CARE FINANCING ADMINSTRATION OMB No. 0938-0391

SURVEY TEAM COMPOSITION AND WORKLOAD REPORT

Public reporting burden 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 Office of

Financial Management, HCFA, P.O. Box 26684, Baltimore, MD 21207; or to the Office of Management and Budget,

Paperwork Reduction Project(0838-0583), Washington, D.C. 20503.

Provider/Supplier Number Provider/Supplier Name

SURVEY TEAM AND WORKLOAD DATA

Please enter the workload information for each surveyor. Use the surveyor's information number.

4.

Pre-Survey On-Site On-Site On-Site Travel Off-Site Report

Preparation

Hours

(D)

Hours Hours Hours Hours Preparation

12am-8am 8am-6pm 6pm-12am Hours

(E) (F) (G) (H) (I)

First Last

Date DateArrived Departed

Surveyor Id Number

(A) (B) (C)

Team Leader

A Complaint Investigation E Initial Certification I Recertification

B Dumping Investigation F Inspection of Care J Sanction/Hearing

C Federal Monitoring G Validation K State License

D Follow-up Visit H Life safety Code L Chow

A Routine/Standard (all providers/suppliers)

B Extended Survey (HHA or long term care facility)

C Partial Extended Survey (HHA)

D Other Survey

12-7-15 12-7-15

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESMEDICARE/MEDICAID CERTIFICATION AND TRANSMITTALPART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00705

ID: 8JZ3

X

WINONA, MN

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

1. MEDICARE/MEDICAID PROVIDER NO.

(L1)

2.STATE VENDOR OR MEDICAID NO.

(L2)

3. NAME AND ADDRESS OF FACILITY(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

11. .LTC PERIOD OF CERTIFICATION

From

To (b) :

(a) :

12.Total Facility Beds (L18)

13.Total Certified Beds (L17)

10.THE FACILITY IS CERTIFIED AS:

A. In Compliance With

1. Acceptable POC

B. Not in Compliance with Program

Program Requirements Compliance Based On:

Requirements and/or Applied Waivers:

And/Or Approved Waivers Of The Following Requirements:

2. Technical Personnel

3. 24 Hour RN4. 7-Day RN (Rural SNF)

5. Life Safety Code

6. Scope of Services Limit

7. Medical Director

8. Patient Room Size

9. Beds/Room

* Code: (L12)

14. LTC CERTIFIED BED BREAKDOWN

18 SNF

(L37)

18/19 SNF

(L38)

19 SNF

(L39)

ICF

(L42)

IID

(L43)

15. FACILITY MEETS

1861 (e) (1) or 1861 (j) (1): (L15)

B*

493543800

2

09/30

71

71

71

10/15/2015

SAUER HEALTH CARE245102

02

1635 WEST SERVICE DRIVE

55987

0 Unaccredited2 AOA

1 TJC3 Other

06 PRTF

22 CLIA

29. INTERMEDIARY/CARRIER NO.

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

DETERMINATION APPROVAL

17. SURVEYOR SIGNATURE Date :

(L19)

18. STATE SURVEY AGENCY APPROVAL Date:

(L20)

19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVILRIGHTS ACT:

1. Statement of Financial Solvency (HCFA-2572)2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)3. Both of the Above : 1. Facility is Eligible to Participate

2. Facility is not Eligible(L21)

22. ORIGINAL DATE

OF PARTICIPATION

23. LTC AGREEMENT

BEGINNING DATE

24. LTC AGREEMENT

ENDING DATE

(L24) (L41) (L25)

27. ALTERNATIVE SANCTIONS25. LTC EXTENSION DATE:

(L27)

A. Suspension of Admissions:

(L44)

B. Rescind Suspension Date:

(L45)

26. TERMINATION ACTION: (L30)

VOLUNTARY

01-Merger, Closure

02-Dissatisfaction W/ Reimbursement

03-Risk of Involuntary Termination

04-Other Reason for Withdrawal

INVOLUNTARY

05-Fail to Meet Health/Safety

06-Fail to Meet Agreement

OTHER

07-Provider Status Change

28. TERMINATION DATE:

(L28) (L31)

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

(L32) (L33)

30. REMARKS

00-Active

01/19/1967

00

03001

11/12/2015 12/08/2015

21.

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

Carol Bode, HFE NE II Kamala Fiske-Downing, Enforcement Specialist

Electronically delivered

October 27, 2015


Sauer Health Care


Winona, Minnesota 55987

RE: Project Number S5102025

Dear Ms. Blair:

On October 15, 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 a pattern of

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

immediate jeopardy (Level E), 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



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


18 Wood Lake Drive Southeast

Rochester, Minnesota [email protected]

Telephone: (507) 206-2731 Fax: (507) 206-2711

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 December 5, 2015, the Department of Health will

impose the following remedy:

• State Monitoring. (42 CFR 488.422)

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;

- 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;

Sauer Health Care

October 27, 2015

Page 2

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

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

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

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

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

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

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

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

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

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

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

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

and your ePoC submission.

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

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

corrective action has occurred.

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

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

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

488.417 (a));

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

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

and/or Medicaid agreement.

PRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF 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.

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

Sauer Health Care

October 27, 2015

Page 3

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 January 15, 2016 (three months after

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

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

1919(h)(2)(C) and Federal regulations at 42 CFR Section 488.417(b). This mandatory denial of

payments will be based on the failure to comply with deficiencies originally contained in the Statement

of Deficiencies, upon the identification of new deficiencies at the time of the revisit, or if deficiencies

have been issued as the result of a complaint visit or other survey conducted after the original statement

of deficiencies was issued. This mandatory denial of payment is in addition to any remedies that may

still be in effect as of this date.

Sauer Health Care

October 27, 2015

Page 4

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

Services that your provider agreement be terminated by April 15, 2016 (six months after the

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

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

regulations at 42 CFR Sections 488.412 and 488.456.

INFORMAL DISPUTE RESOLUTION

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

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

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

Nursing Home Informal Dispute Process



P.O. Box 64900

St. Paul, Minnesota 55164-0900

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

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

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

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

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

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

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

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

specified for compliance or the imposition of remedies.

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

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

Gary L. Schroeder – Interim Fire Safety Supervisor

Minnesota State Fire Marshal Division

445 Minnesota Street, Suite 145

St. Paul, MN 55101-5145

[email protected]

Office/Cell: 507-361-6204

Fax: 507-282-7899

Sauer Health Care

October 27, 2015

Page 5

Feel free to contact me if you have questions.

Sincerely,



Health Regulation DivisionMinnesota Department of Health

[email protected]: (651) 201-4112

Fax: (651) 215-9697

Sauer Health Care

October 27, 2015

Page 6

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 11/12/2015FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

245102 10/15/2015STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1635 WEST SERVICE DRIVESAUER HEALTH CARE

WINONA, MN 55987

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5)COMPLETION

DATE

IDPREFIX

TAG

(X4) IDPREFIX

TAG

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

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

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

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

F 166

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483.10(f)(2) RIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES

A resident has the right to prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

This REQUIREMENT is not met as evidenced by:

F 166 11/24/15

Based on observation, interview, and document review, the facility failed to ensure an unresolved grievance was acted on for 1 of 1 resident (R11) reviewed who had voiced concerns with the facility staff.

Findings include:

R11 was interviewed on 10/13/15 at 12:37 p.m., R11 raised his voice, had angry facial expressions and stated nursing assistant (NA)-G told him the key to his motorized scooter needed to be locked up in the nurses station until an

In response to the above stated citation Sauer Health Care has taken the following action:¿ Grievance was noted and filed by Social Service Director on 10/15/2015.¿ The keys to the scooter belonging to R11 were returned to R11 on 10/15/2015.¿ Occupational Therapy evaluation for scooter safety was completed on 10/19/2015 with findings of R11 being safe to utilize the motorized scooter inside the facility if/when needed but recommended no use outside until further

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

11/06/2015Electronically Signed

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

FORM CMS-2567(02-99) Previous Versions Obsolete 8JZ311Event ID: Facility ID: 00705 If continuation sheet Page 1 of 43

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F 166 Continued From page 1 F 166

assessment could be completed by occupational therapy to determine if he was safe to use the scooter and stated she took his key. R11 stated I told NA-G if they said not to ride the scooter, I would not ride it. "I hope they are satisfied." R11 stated another NA (NA-H) had rode his scooter down the hall and R11 stated, "I'm sure she [NA-H] did not have a license to drive it any more than I did." R11 stated he has talked to several people about his concern with his scooter and the keys being taken from him. R11 stated, "I tried to talk to them and nobody would even listen to me, they act just like I am a nobody." R11 stated he wished they would just let him keep the key in here in his room, he again stated he was upset that NA-H took the scooter for a ride and NA-G took the key from him and had the key locked up. R11 stated, "I had said I wouldn't ride it until I had the ok."

R11's admission record revealed R11 was admitted on 5/29/15 with diagnoses of dementia without behavioral disturbance. The significant change Minnesota Data Assessment (MDS) dated 9/3/15, indicated R11 did not display behavior problems and had a brief interview for mental status score of a 13 which indicated intact cognition.

R11's progress note dated 10/10/15 included, "Resident upset about having a scooter in his room but no key until he is evaluated by OT [occupational therapy] next week for scooter safety. This was explained to the resident, and he was told we could address this with OT [occupational therapy] on Monday. He was angry about this but said 'ok' and went back to his room until supper." R11's progress note dated 10/11/15 included,

work on safety training was completed. ¿ Direct education was completed with staff members involved in the event that led to grievance. ¿ A paper grievance form has been created for residents, family and/or visitors to utilize. ¿ Grievance policy updated to reflect that a grievance form was created. ¿ Social Service Director has visited with resident two times since event and R11 denied any concerns. ¿ R11 continues to ambulate freely within the facility with plans to utilize the scooter only for outings. ¿ Follow up meetings with R11 completed by the Social Services Director indicate ongoing satisfaction with current plan of care. ¿ Occupational Therapy advanced R11 to being able to utilize the scooter both inside and outside of the facility but recommend that R11 has someone along if planning to leave the facility grounds. ¿ Social Service Director will ask residents and families about grievances or concerns at care conferences for the next 3 months starting immediately. All concerns/grievances will be addressed by following the grievance policy. *communication to family and residents will occur through monthly newsletter and review at resident council. Information re: grievance process will communicated at the November resident council and in the December newsletter. Concerns/grievances will continue to be asked about and addressed at monthly resident council.


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"This writer entered [R11's] room to check his blood sugar before breakfast. He raised his voice and shook his fists at me saying, 'I'm not doing anything until you give me my [curse word] key back! Get it right now." Asked him to lower his voice and attempted to explain that he will need OT [occupational therapy] eval [evaluation] prior to being able to operate it independently in the facility. R11 yelled, '[curse word] you, you [curse word], get out!' Sig. [significant] other came to visit around 0830, and was able to get R11 to agree to taking his meds [medications] and having blood sugar checked. R11 has had 2 subsequent outbursts yelling at staff, demanding his key back. It is currently locked in the nurse's cart until OT [occupational therapy] can eval [evaluation]." On 10/14/15 at 2:06 p.m., R11's keys to the motorized scooter were observed to be locked in the medication cart.

On 10/14/2015 7:00 p.m., licensed social worker (LSW)-A stated she was unaware of R11's concerns related to the motorized scooter key being removed from his room over the weekend. LSW-A stated she would have expected staff to inform her R11's was upset about his scooter, so she could follow up on the concern. LSW-A stated nursing would not have needed to take the key and lock the key up until the assessment was completed if the resident was alert, orientated and able to make their own decision. LSW-A stated R11 was his own decision maker and if R11 stated he would not drive the motorized scooter until he was assessed, the staff would have no reason to take away the keys until there was a problem and then reassess at that time. LSW-A verified this was a resident right, dignity and grievance concern. LSW-A stated the facility

¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before November 24, 2015.Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of the Social Service Director, The Director of Nursing and the Facility Administrator.


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did not utilize written grievance forms. LSW-A stated normally if a resident or family member was that upset they will either tell the nursing staff or come directly to social service to voice concerns. LSW-A stated when a resident, family member or staff member informed her of a concern she completed a narrative word document regarding the concern and stated she documented a progress note in the medical record. LSW-A stated the investigation of the concern was completed and kept in a separate document from the medical record in her office. LSW-A stated there was no formal grievance process at the facility where residents or family members could write a written concern to the facility. LSW-A stated staff communicated concerns to her through a face to face process, email or leaving a voice message.

On 10/15/2015 at 9:08 a.m., LSW-A stated the key was currently in residents room in the motorized scooter and unsure when the key was returned to R11. LSW-A stated she should have been made aware of R11's concerns over the weekend so she could have followed up with him on Monday. LSW-A stated if she would have been made aware, she would have talked to him on Monday and diffused a lot of this concern. LSW-A stated there was no documentation in R11's medical record to indicate he was not safe to have the key to the motorized scooter in his room.

On 10/15/2015 1:14 p.m. the administrator stated she would have expected staff to notify the social worker of R11's concerns regarding the keys to his scooter being removed from his room. The administrator stated she would consider the concern made by R11 to be a grievance.


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On 10/15/2015 at 2:38 p.m., LSW-A stated the keys were returned to R11's room yesterday on 10/14/15 after the completion of the assessment for safe use of the scooter by occupational therapy which indicated R11 was safe to drive the scooter.

The Grievance Policy dated 2/4/14, included at any time any time comments, suggestions or complaints by the residents and/or their representatives shall be directed to: the administrator, director of social services, director of nursing, nurse manager or other department managers, if indicated.

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483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property;

and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities.

The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the

F 225 11/24/15


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State survey and certification agency).

The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.

The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to ensure allegations of abuse, were reported to the state agency immediately for 1 of 3 resident (R48) allegations reviewed. Also failed to secure licensure status and previous work history to ermine if any concerns with abuse/neglect had occurred for 5 of 5 employees (Registered nurse (RN)-D; Licensed practical nurse (LPN)-A; nursing assistant (NA)-D, E & F) who worked at the facility and had direct contact with residents.

Findings include:

LACK OF REPORTING ALLEGATIONS OF ABUSE IMMEDIATELY TO THE DESIGNATED STATE AGENCY:

R48 had reported to staff concerning allegation of abuse by night staff on 7/25/15 however, this

In response to the above stated citation Sauer Health Care has taken the following action:¿ R48 is not currently a resident at the facility so no changes to progress notes or care plan are being made.¿ Ongoing visits with R48 prior to discharge indicated satisfaction with follow up from report and confirmed that R48 was safe and felt safe in the facility.

¿ Review of details of event from 7/25/15 show that the Facility Administrator was immediately aware of the report, a thorough investigation was immediately started and completed and the safety of all residents was maintained throughout the entire process. Staff members identified in the report were removed from the schedule as of the date


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allegation had not been reported to the designated state agency until 7/27/15 two days later.

R48 had diagnoses of coronary artery disease, heart failure and arthritis. The significant change Minimum Data Set (MDS) dated 9/17/15, identified R48 has cognitively intact and required extensive assistance with all activities of daily living (ADLs). R48 had no behavior.

The facility submitted an Incident Report to the state agency (Office of Health Facility Complaints-OHFC), on 7/27/15 indicated, on 7/25/15, "[R48] voiced concern of night aides CNA [certified nursing aides] staff members [CNA name] and [CNA name]. Resident stated both CNA's do not provide the care that she requests and are 'verbally nasty' to her. When staff asked resident for more details, resident stated 'I don't want any trouble... I'm scared it's going to make it worse for me'. DON [director of nursing] and HR [human resource] director immediately initiated investigation and [name] and[name] were placed on administrative leave until investigation is concluded. Don and HR director interviewed other residents who confirmed and voiced their own concerns for the care [name] and [name] provide to them. Other resident's stated both aides do not assist with taking them to the bathroom and report feeling intimidated by CNA's....." The facility policy indicated reports must be made to the SA immediately.

An interview on 10/14/2015, at 5:41 p.m. with the administrator and the licensed social worker (LSW)-D regarding the report of R48's reporting alleged abuse. The administrator stated she became aware of the incident on 7/24/15, at

of the report.¿ Staff member who failed to report the event in a timely fashion to the State Agency is aware of the policy. ¿ No changes are needed to the facility ¿Abuse Prohibition Plan¿ dated 6/20/12 and potential hires will continue to be screened for potential abuse allegations including OIG checks, background checks, license verification, employment verifications, and reference checks.* Social Services Director will audit all VA reports monthly for the next 3 months to insure that staff are investigating and reporting allegations of abuse to the State Agency immediately. This will be monitored for 3 months. ¿ A new form was created for reference documentation. If the reference does not respond or is not qualified (related to the employee or has had no professional relationship with the potential new hire) that will be noted on the form.¿ The employment verification form was updated and Human Resources Representative will write on the form if there is no response from the previous employer. ¿ All five employees who were audited during the visit have updated information on their pre-employment checklists including verification of licensure, certification and registration. Expiration dates are noted on the checklist until the fax form for the Minnesota Department of Health is received. Licensure, certification and registration were noted to be current for all five employees and have been printed and added to their personnel files.


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R48's care conference. The administrator said she was filling in for the LSW that week. The administrator said, it was reported that staff had been "rough" and "verbally assault" to R48. She said she immediately began to investigate the allegation and didn't think about reporting the incident to the SA. When the LSW returned on Monday, she said she noticed the report to the SA had not been completed so she filed the report with the SA on 7/27/14.

LACK OF THOROUGH PRE-HIRE WORK HISTORY, CURRENT LICENSURE AND LISTED ON NURSING ASSISTANT REGISTRY BEFORE WORKING DIRECTLY WITH RESIDENTS:

During the abuse prohibition investigated, and review of human resources files was completed. An interview 10/15/15, at 12:32 p.m. revealed the following:-licensed practical nurse (LPN)-A's license to practice expired 7/31/15. There was no documentation of reference check being completed before hire date.- Nursing assistant (NA)-D had no documentation of NA certification being verification and no reference check being completed before hire date.- NA-E had no documentation of NA certification verification and no reference check being completed before hire date.- Registered nurse (RN)-D had no documentation of reference check being completed before hire date.- NA-F had no reference checks being completed before hire date.

Human resources director (HR)-F stated her normal process is to check for licenses and call

¿ Licensure, certification and registration will be monitored by the Staffing, Training and Development Coordinator (a newly hired position) moving forward. Tasks will be assigned through outlook which will send an alert one month before licensure, certification or registration is set to expire. Coordinator will notify the employee that a new licensure, certification or registration is needed by the expiration date or the employee will be removed from the schedule.* HR Director will monitor this plan by doing a random audit of 10 staff every month for 3 months to ensure that all licenses and certifications are up to date and information is in their personnel file. ¿ Sauer Health Care has been and will continue using CareProfiler, which has applicants complete a Work style Questionnaire along with their application to assess a potential employee¿s empathy, self-awareness, tolerance for stress, work ethic and more. Candidates who do not meet a certain established threshold are not considered for positions. These thresholds are set by CareProfiler and used in multiple Long Term Care facilities regionally and nationally. ¿ Upon hire and annually all staff will be educated on Vulnerable Adult Reporting and facility policy, including Abuse Prohibition. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th,


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references before an employee's hire date and before the license expires. HR-F said they call a potential hires previous employers for references. The facility does not document the conversation.

A facility policy entitled vulnerable adult policy dated 1/28/15, read, "Each resident has the right to be free from abuse, ...." under procedure section "Sauer Health Care will report ALL cases of known or suspected maltreatment of vulnerable adults to the MN Department of Health-Office of Health Facilities Complaint and appropriate Common Entry Point (CEP). All VA reports need to be reported immediately to MDH-office of health facility complaints and CEP (Common Entry Point at county)." "All VA reports made must be reported to the administrator immediately."

A facility policy entitled registry verification procedure-nursing dated 2/4/15 read, "RN and LPN positions must be filled by someone who has a current license. All CNA positions must be filled by someone who has taken and passed the CNA program. All these employees must also be registered with the Minnesota board of nursing prior to hire."

A facility policy entitled abuse prohibition dated 6/20/12, read, "Screening of potential hires: including obtaining information from previous employers, and checking with the appropriate licensing boards and registries."

A review of the nurses progress noted revealed no documentation regarding this allegation of abuse for towards R48.

2015 and all staff will confirm receipt of training on or before November 24, 2015.Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of the Social Service Director, the Human Resource Director, The Director of Nursing and the Administrator.

F 226 483.13(c) DEVELOP/IMPLMENT F 226 11/24/15


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SS=D ABUSE/NEGLECT, ETC POLICIES

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to implement abuse prohibition policies and procedures to ensure 1 of 3 residents (R48) with complaints of abuse received thorough investigations into each allegation, residents were protected during the investigations and the allegations were immediately reported to the administrator and state agency (SA).

Findings include:

A facility policy entitled vulnerable adult policy dated 1/28/15, indicated "Each resident has the right to be free from abuse, ...." under procedure section "Sauer Health Care will report ALL cases of known or suspected maltreatment of vulnerable adults to the MN Department of Health-Office of Health Facilities Complaint and appropriate Common Entry Point (CEP). All VA reports need to be reported immediately to MDH-office of health facility complaints and CEP (Common Entry Point at county). "Another point is "All VA reports made must be reported to the administrator immediately."

The facility submitted an Incident Report to the state agency (Office of Health Facility

In response to the above stated citation Sauer Health Care has taken the following action:¿ R48 has since expired so no changes to progress notes or care plan are being made.¿ Ongoing visits with R48 prior to discharge indicated satisfaction with follow up from report and confirmed that R48 was safe and felt safe in the facility. ¿ No changes are needed to the facility ¿Abuse Prohibition Plan¿ dated 6/20/12.¿ Review of details of event from 7/25/15 show that the Facility Administrator was immediately aware of the report, a thorough investigation was immediately started and completed and the safety of all residents was maintained throughout the entire process. Staff members identified in the report were removed from the schedule as of the date of the report.¿ Staff member who failed to report the event in a timely fashion to the State Agency is aware of the policy. *Social Services Director will audit all VA reports monthly for the next 3 months to insure that staff are investigating and


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Complaints-OHFC), on 7/27/15 indicated, on 7/25/15, "[R48] voiced concern of night aides CNA [certified nursing aides] staff members [CNA name] and [CNA name]. Resident stated both CNA's do not provide the care that she requests and are 'verbally nasty' to her. When staff asked resident for more details, resident stated 'I don't want any trouble... I'm scared it's going to make it worse for me'. DON [director of nursing] and HR [human resource] director immediately initiated investigation and [name] and[name] were placed on administrative leave until investigation is concluded. Don and HR director interviewed other residents who confirmed and voiced their own concerns for the care [name] and [name] provide to them. Other resident's stated both aides do not assist with taking them to the bathroom and report feeling intimidated by CNA's....." The facility policy indicated reports must be made to the SA immediately.

An interview on 10/14/2015, at 5:41 p.m. with the administrator and the licensed social worker (LSW)-D regarding the report of R48's reporting alleged abuse. The administrator stated she became aware of the incident on 7/24/15, at R48's care conference. The administrator said she was filling in for the LSW that week. The administrator said, it was reported that staff had been "rough" and "verbally assault" to R48. She said she immediately began to investigate the allegation and didn't think about reporting the incident to the SA. When the LSW returned on Monday, she said she noticed the report to the SA had not been completed so she filed the report with the SA on 7/27/14.

reporting allegations of abuse to the State Agency immediately. This will be monitored for 3 months. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before November 24, 2015.Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of the Social Service Director and the Administrator.

F 241

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483.15(a) DIGNITY AND RESPECT OF INDIVIDUALITY

F 241 11/24/15


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The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to promote respect and dignity for 1 of 1 resident (R11) when staff removed the key to R11's motorized scooter from his room prior to completion of an occupational therapy assessment for safe use of a motorized scooter.

Findings include:

R11 was interviewed on 10/13/15 at 12:37 p.m., R11 raised his voice, had angry facial expressions and stated nursing assistant (NA)-G told him the key to his motorized scooter needed to be locked up in the nurses station until an assessment could be completed by occupational therapy to determine if he was safe to use the scooter. R11 said she just took the key and would not listen to him explain his point of view. R11 stated I told NA-G if they said not to ride the scooter, I would not ride it. "I hope they are satisfied" R11 said in a angry tone in regards to the staff taking his scooter key. R11 then said NA-H rode his scooter down the hall the other day and "I'm sure she [NA-H] did not have a license to drive it any more than I did." R11 stated he has talked to several people about his concern with his scooter and the keys being taken from him. R11 stated, "I tried to talk to them [staff] and nobody would even listen to me, they act just like

In response to the above stated citation Sauer Health Care has taken the following action:¿ The keys to the scooter belonging to R11 were returned to R11 on 10/15/2015.¿ Occupational Therapy evaluation for scooter safety was completed on 10/19/2015 with findings of R11 being safe to utilize the motorized scooter inside the facility if/when needed but recommended no use outside until further work on safety training was completed. ¿ Direct education was completed with staff members involved in the event that led to grievance. ¿ R11 continues to ambulate freely within the facility with plans to utilize the scooter only for outings. ¿ Follow up meetings with R11 completed by the Social Services Director indicate ongoing satisfaction with current plan of care. ¿ Occupational Therapy advanced R11 to being able to utilize the scooter both inside and outside of the facility but recommend that R11 has someone along if planning to leave the facility grounds. ¿ Electric wheelchair policy was updated to reflect residents are able to keep the keys and scooter in their


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I am a nobody." R11 stated he wished they would have let him keep the key in his room, and he again stated he was upset that NA-H took the scooter for a ride and then NA-G took the key from him and he was not given a choice in the matter. R11 stated, "I had said I wouldn't ride it until I had the ok."

R11's admission record revealed R11 was admitted on 5/29/15 with diagnoses of dementia without behavioral disturbance. The significant change Minnesota Data Assessment (MDS) dated 9-3-15, indicated R11 did not display behavior problems and had a brief interview for mental status score of a 13 which indicated intact cognition.

R11's progress note dated 10/10/15 included, "Resident upset about having a scooter in his room but no key until he is evaluated by OT [occupational therapy] next week for scooter safety. This was explained to the resident, and he was told we could address this with OT [occupational therapy] on Monday. He was angry about this but said 'ok' and went back to his room until supper." R11's progress note dated 10/11/15 included, "This writer entered [R11's] room to check his blood sugar before breakfast. He raised his voice and shook his fists at me saying, 'I'm not doing anything until you give me my [curse word] key back! Get it right now." Asked him to lower his voice and attempted to explain that he will need OT [occupational therapy] eval [evaluation] prior to being able to operate it independently in the facility. R11 yelled, '[curse word] you, you [curse word], get out!' Sig. [significant] other came to visit around 0830, and was able to get R11 to agree to taking his meds [medications] and

possession prior to assessment by OT, unless the interdisciplinary team deemed it was not safe and documented in medical chart. ¿ Social Service Director will ask residents and families about grievances or concerns at care conferences for the next 3 months starting immediately. All concerns/grievances will be addressed by following the grievance policy. *communication to family and residents will occur through monthly newsletter and review at resident council. Information re: grievance process will communicated at the November resident council and in the December newsletter. Concerns/grievances will continues to be asked about and addressed at monthly resident council. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before November 24, 2015.Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of the Social Service Director, The Director of Nursing and the Facility Administrator.


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having blood sugar checked. R11 has had 2 subsequent outbursts yelling at staff, demanding his key back. It is currently locked in the nurse's cart until OT [occupational therapy] can eval [evaluate]." On 10/14/15 at 2:06 p.m., R11's keys to the motorized scooter were observed to be locked in the medication cart.

On 10/14/2015 7:00 p.m., licensed social worker (LSW)-A stated she was unaware of R11's concerns related to the motorized scooter key being removed from his room over the weekend. LSW-A stated she would have expected staff to inform her R11's was upset about his scooter, so she could follow up on the concern. LSW-A stated nursing would not have needed to take the key and lock the key up until the assessment was completed if the resident was alert, orientated and able to make their own decision. LSW-A stated R11 was his own decision maker and if R11 stated he would not drive the motorized scooter until he was assessed, the staff would have no reason to take away the keys until there was a problem and then reassess at that time. LSW-A verified this was a resident right, dignity and grievance concern.

On 10/15/2015 at 9:08 a.m., LSW-A stated the key was currently in residents room in the motorized scooter and unsure when the key was returned to R11. LSW-A stated there was no documentation in R11's medical record to indicate he was not safe to have the key to the motorized scooter in his room.

On 10/15/2015 at 2:38 p.m., LSW-A stated the keys were returned to R11's room yesterday on 10/14/15 after the completion of the assessment


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for safe use of the scooter by occupational therapy which indicated R11 was safe to drive the scooter.

A policy was requested for treating residents with respect and dignity and was not provided.

F 258

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483.15(h)(7) MAINTENANCE OF COMFORTABLE SOUND LEVELS

The facility must provide for the maintenance of comfortable sound levels.


F 258 11/24/15

Based on observation, interview and the facility failed to ensure comfortable sound levels on the night shift on the west wing. This had the potential to effect all 27 resident residing on the west wing at the time of the time of the survey.

Findings Include:

R82 was interviewed on 10/13/15 at 10:55 a.m., R82 stated I wake up when the when the staff are talking so loud in the mornings and making excessive noise, the staff slams drawers shut on the carts and slam the doors to the rooms. It is a noise factory here. "They can hear them all the way over at St. Anne's (another skilled nursing facility in Winona)".

R11 was interviewed on 10/13/15 at 12:44 p.m. stated there is noise over there, referring to the nurses station. R11 stated they (the staff) slam the doors constantly.

In response to the above stated citation Sauer Health Care has taken the following action:¿ Social Service Director completed follow up visits with R11 & R82 to ask about noise and ongoing visits will take place with residents to ensure noise levels are being maintained at a desirable level.¿ Notices have been posted at both nursing stations reminding staff of the need to maintain a quiet environment and to keep the doors to the nurse¿s stations closed as often as possible but, especially when conversation or activity are taking place. ¿ A ¿Yacker Tracker¿ has been purchased and will be installed to alert and make staff aware of volume levels.¿ Social Service Director will be asking about noise levels at all resident care conferences for the next three months and following up on any reported


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During an observation on the night shift on 10/15/15 at 5:05 a.m. nursing assistant (NA)-G verified the call light system at the west nurses station could be heard outside of the resident rooms close to the nurses station and could be heard inside R11's room. NA-G also verified she heard staff closing the door loudly to room 149 at this time.

During an interview with NA-G on 10/15/2015 at 5:41 a.m. in a common area of the facility, NA-G verified she could hear a male and female staff member talking in the hallway that were not in view of the surveyor and staff member.

On 10/15/2015 at 5:44 a.m., two staff members were observed to be talking loudly in the west nurses station. The doors to the nurses' station were open and a staff member was observed to be shutting the drawers on the medication cart loudly.

On 10/15/2015 6:30 a.m., registered nurse (RN)- E verified she could hear a nurse speaking loudly approximately fifty feet down the hallway from where we were seated completing an interview and could also hear this same nurse speaking loudly approximately thirty feet from where we were sitting as the nurse entered the nurses station.

On 10/15/2015 6:32 a.m., RN-E verified she could hear a nursing assistant talking in the hallway approximately eighty feet from where we were completing an interview. RN-E verified she could hear doors being shut loudly at this time.

On 10/15/2015 6:44 a.m., RN-E verified she could hear a nurse talking loudly in the hallway

concerns.¿ Social Services Director will ask about noise level at the November, December and January Resident Council meetings. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before November 24, 2015Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of the Environmental Services Director, The Director of Nursing and the Facility Administrator.


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approximately seventy feet from where we were completing an interview. RN-E asked surveyor if she could please address the noise concerns with the nurse at this time for the sake of the residents who were still attempting to sleep.

On 10/15/2015 at 6:50 a.m. RN-E verified she could hear the nurse talking loudly she entered the nurses station approximately thirty feet from where we were sitting completing an interview. RN-E verified this concern occurred after she had spoken to this nurse regarding noise level concerns and this staff member being observed to be talking loudly in the hallways and nurses station.

On 10/15/2015 at 6:52 a.m. RN-E stated she was unaware of any specific concerns residents on the west hallway had regarding noise during the night shift. RN-E verified she heard doors being shut loudly and observed staff talking loudly in the hallways and nurses station. RN-E verified the noise being made by the staff in the west nurses station and in the hallways could disturb residents that were sleeping.

On 10/15/2015 3:04 p.m. the adminstrator and licensed social worker stated they were unaware of any resident concerns regarding noise on the night shift and stated there had been no grievances filed related to noise concerns. The adminstrator stated the facility did not have a policy and procedure related to comfortable sound levels.

F 279

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483.20(d), 483.20(k)(1) DEVELOP COMPREHENSIVE CARE PLANS

A facility must use the results of the assessment

F 279 11/24/15


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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 §483.25; and any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

This REQUIREMENT is not met as evidenced by: Based on interview, and document review, the facility failed to develop a plan of care that included monitoring for side effects of an anti-coagulant medication (Coumadin) for 1 of 5 residents (R62) reviewed for unnecessary medications.

Findings include:

R62's physician order dated 10/13/15, identified an order for Coumadin two milligrams (mg) Monday Thursday and Friday and three mg all other days. R62's Admission Record, dated 10/15/15, included diagnoses of atrial fibrillation.

Document review of R62's current

In response to the above stated citation Sauer Health Care has taken the following action:¿ R62 care plan for Coumadin administration was modified to include monitoring for side effects of an anti-coagulant medication¿ The facility identified nine other residents who currently use anticoagulant therapy. The care plans for these residents were audited to ensure that they included monitoring for side effects of an anti-coagulant medication. ¿ Audits will be completed to ensure adherence to this plan.*DON or designee will review care plans


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comprehensive care plan undated indicated bruises easily due to Coumadin administration and has routine labs drawn requiring venipuncture. Interventions included: an incident report will be deferred for bruising related to documented venipuncture sites and each venipuncture site will be reflected in the progress notes.

However, R62's care plan had not addressed risk factors and interventions for bruising and bleeding associated with the use of Coumadin in order to alert care givers the need to report excessive bleeding timely to the nurse.

During interview on 10/15/15, at 2:06 p.m., registered nurse (RN)-A verified R62's current care plan failed to include risk factors and interventions for excessive bleeding.

During interview on 10/15/15, at 2:46 p.m., director of nursing (DON) verified R62's current care plan failed to include risk factors and interventions for excessive bleeding and when to notify the nurse. In addition, the DON stated she would expect R62's care plan to include the information.

The facility policy Care Plans Comprehensive, dated 3/3/14, indicated Goal: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy interpretation and implementation 3. Each resident's comprehensive care plan is designed to: a. incorporate identified problem areas; b. incorporate risk factors associated with identified problems; i. reflect currently recognized

of all residents on Coumadin each month for 3 months to ensure that care plans include monitoring for side effects of an anti-coagulant medication. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before November 24, 2015.Compliance for adherence to this plan will be the responsibility of the RN unit managers, the MDS Coordinator and other licensed staff who complete any section of the comprehensive care plan with overall compliance being the responsibility of the Director of Nursing Services and The Facility Administrator.


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standards of practice for problem areas and conditions.

F 282

SS=D

483.20(k)(3)(ii) SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.


F 282 11/24/15

Based on interview and document review, the facility failed to ensure medication monitoring labs were completed according to the care plan for 1 of 5 (R54) resident reviewed for unnecessary medications. Findings include: R54 was admitted to the facility on 10/4/13 with diagnoses that included atrial fibrillation, hyperlipidemia, and history of a stroke according to the facility's admission record. R54's physician orders provided by the facility on 10/16/15 included Digoxin (heart medication) 0.25 milligrams (mg) by mouth one time a day and Pravastatin (cholesterol medication) 40 mg by mouth at bed time. The physician's orders also included CBC (complete blood count), CMP (comprehensive metabolic panel), and liver panel every three months. Orders further directed staff to obtain a digoxin level every six months. R54's electronic care plan provided by the facility on 10/15/15 identified diagnosis of dyslipidemia and atrial fibrillation. The care plan directed staff to monitor for the effectiveness of the cholesterol lowering medication. The care plan informed staff a liver profile would be helpful in diagnosing

In response to the above stated citation Sauer Health Care has taken the following action:¿ R54 had a blood draw completed on 10/15/2015 with tests run for CBC (complete blood count), CMP (comprehensive metabolic panel), liver panel and a digoxin level.¿ All labs found to be within normal limits and MD was made aware. ¿ R54 was added to the lab binder to have ongoing tests run for CBC (complete blood count), CMP (comprehensive metabolic panel), and liver panel every three months and a digoxin level every six months.¿ An audit of all current resident hard chart medication orders was completed to ensure that any lab orders had been properly transcribed and processed into the lab binder. ¿ Audits will be completed to ensure adherence to this plan. *DON or designee will audit 10 resident charts each month for 3 months to ensure


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adverse side effects and lipid profiles would determine effectiveness of the medication. The care plan further instructed staff to monitor and report digoxin levels to the physician. It was not evident in the medical record medication monitoring labs had been performed within the last year. During an interview on 10/15/15, the director of nursing confirmed labs had not been obtained and indicated they should have been completed. Facility policy Laboratory and Diagnostic Services dated 3/24/14 included "The physician or designated provider will identify and order diagnostic and lab testing on diagnostic and monitoring needs. The staff will process test requisitions, arrange for tests and clarification will be sought for urgency of test."

that all ordered lab work has been properly transcribed and processed into the lab binder. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before November 24, 2015.

Compliance for adherence to this plan will be the responsibility of the RN unit managers and other licensed staff who complete order processing with overall compliance being the responsibility of the Director of Nursing Services and The Facility Administrator.

F 318

SS=D

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

Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.


F 318 11/24/15

Based on observation, interview, and record review, the facility failed to ensure range of motion services had been provided for 1 of 3 residents (R36) who had an identified limitation for the right upper extremity.

In response to the above stated citation Sauer Health Care has taken the following action:¿ An order was received for R36 to have an evaluation completed by physical and occupational therapy to assess need


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Findings include:R36 was observed on 10/15/15 at 8:35 a.m. using left hand to eat breakfast. At 9:53 a.m. R36 lifted right upper extremity to shoulder height.

Review of R36's quarterly Minimum Data Set (MDS) assessment dated 7/9/15, included a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment.

R36's care plan dated 9/1/15, indicated will be able to grab utensils and cups and will be able to ambulate daily for distances of 300 feet. Staff to assist to ambulate daily for distances up to 300 feet and staff to assistance with all meals, requires staff cuing and assist with placing items in hands to keep on task. Provide finger foods as able as has difficulty using utensils.

Review of R36's nurse progress note dated 9/1/15, and documented by registered nurse (RN)-C, indicated active range of motion (AROM) and passive range of motion (PROM) programs were discontinued at this time due to lack of participation possibly related to progression of dementia. R36's eating and swallowing program will remain in place as requires assistance with meals. R36's ambulation program will remain in place as participates but has not reached goal.

During interview on 10/13/15, at 1:26 p.m., RN-A indicated R36 had a right shoulder contracture and was not receiving range of motion services.

During interview on 10/15/2015, at 7:56 a.m., nursing assistant (NA)-C verified R36 was not receiving AROM or PROM restorative services. NA-C stated she did not know why R36 had been

for services and make recommendations as appropriate. ¿ R36 was evaluated by rehab (OT & PT) Physical Therapy is ongoing 3 times each week. Occupational Therapy was not felt to be appropriate. ¿ Restorative Program Coordinator collected data on all current residents who trigger for limited ROM.¿ Consultation meeting to take place with rehab staff and the restorative program coordinator to determine appropriateness of evaluations for those who were identified to have limitations and are not currently on programs.¿ A request for orders to have rehab staff complete an evaluation and treat as indicated will made for those felt to be appropriate.¿ Directives for carryover restorative services will then be received from rehab staff for those felt to be appropriate. ¿ Residents determined to not be appropriate for traditional rehab services and not willing or able to complete restorative programming will have the risks and benefits of this reviewed with them or their responsible party. ¿ This will be the ongoing plan for management of the restorative program. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before December 5, 2015.

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removed from restorative services for AROM and PROM, but may be due to R36 refused too many times. During interview on 10/15/15, at 9:38 a.m., RN-C verified R36 had been discontinued for active and passive range of motion restorative services for upper and lower extremities. In addition, RN-C stated R36's range of motion services had been discontinued due to R36's dementia had progressed and R36 refusing to participate became more frequent. During interview on 10/15/15, at 12:43 p.m., RN-C verified she had not requested a therapy referral or discussed the risk and benefits when R36's AROM and PROM for upper and lower extremities had been discontinued.

During interview on 10/15/2015, at 2:54 p.m., director of nursing (DON) stated she would expect to see an evaluation from the therapy department when a resident is refusing active and passive range of motion services and the services would be discontinued. The DON verified risk and benefits had not been discussed when R36's AROM and PROM had been discontinued.

The facility policy Restorative/Functional Maintenance Programming, undated, indicated it is the policy of this facility that each resident is given the appropriate treatment and services to improve or maintain his or her ability, as indicated by the completion of a comprehensive assessment to achieve and maintain the highest practicable outcome(s). Procedure: any reported decline in resident condition will be reviewed by the RN to determine the need for change in

be the responsibility of the Restorative Program Coordinator with overall compliance being the responsibility of the Director of Nursing Services and The Facility Administrator.


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programming or a referral to traditional rehab services and all restorative/functional maintenance programs are provided with input from the resident and/or responsible party.

F 323

SS=D

483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.


F 323 11/24/15

Based on observation, interview and document review, the facility failed to ensure a hazardous chemical was secured in 1 of 1 shower/tub room on the west center hallway observed during the initial tour.

Findings include:LACK OF SECURED CHEMICALS FROM CONFUSED RESIDENTS ACCESS:

During the initial tour on 10/13/15 at 9:08 a.m. registered nurse (RN)-E verified the door to the shower/tub room on west wing was open. RN-E verified a spray bottle of Oasis 146 multi-quat sanitizer was hanging on the shower curtain rod with approximately 1/5 of the bottle full. RN-E stated the shower/tub room should be locked when not in use and verified the hazardous chemical should have been locked up as the bottle indicated the chemical was hazardous to

In response to the above stated citation Sauer Health Care has taken the following action:¿ The door to the shower room on the west unit was immediately pulled closed on 10/13/2015. The door has an automatic lock so room was then secure.¿ All chemicals kept in the shower rooms were audited for proper labeling and placement inside the room.¿ Signs were placed on the shower room doors to remind staff that those doors are to be kept closed at all times. ¿ Event from 7/29/15 was reviewed. Social Service Director met with R3 and confirmed that she was unharmed and not afraid of R26.¿ Messaging was sent to all staff related to the need to be aware of this event and to monitor R26.


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humans, was to be kept out of reach of children, and may cause eye irritants. RN-E verified unlocked chemicals was a safety concern for cognitively impaired residents who could access the chemical.

The safety data sheets for oasis 146 multi-quat sanitizer included hazard statements: Harmful if swallowed, causes severe skin burns and eye damage.

The west center nursing assistant sheet revealed one resident living on the west center hallway that was able to ambulate with no assistive device with supervision and wandered through out the area. This resident was observed during the survey process to walk independently in the west center hallway passing the tub/shower room.

On 10/15/2015 1:51 p.m. the administrator stated the shower/tub room on west door should have been shut when not in use and stated the door locked automatically when closed. The administrator stated the Oasis 146 multi-quat sanitizer spray should have been kept in the soiled utility room locked up and verified it was a potential accident hazard and resident safety concern to keep the chemical in the tub room unlocked.

A policy and procedure requested for storage of hazardous chemicals and requested and not provided.

LACK OF SUPERVISION IN DINING ROOM AND THOROUGH FOLLOW-UP AFTER RESIDENT TO RESIDENT ALTERCATION:

R3 had diagnoses of depression, cerebral palsy

¿ Efforts were in place prior to this reported event to secure new placement for R26 and a more appropriate setting was found with transfer completed prior to the State Survey.¿ R3 continues to reside in the facility with no ongoing concerns noted. ¿ Sauer Staff Members are present in the Dining Room during all resident meal times and activities. ¿ Vulnerable adult policy updated to reflect resident to resident altercations. ¿ Audits will be completed to ensure adherence to this plan. ¿ Education planned for 11/11/15 to include proper documentation requirements and investigation of resident to resident altercations. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before December 5, 2015.

Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of The Environmental Services Director, The Social Service Director, The Director of Nursing Services and the Facility Administrator.


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and osteoporosis according to the admission form. The significant change Minimum Data Set (MDS) dated 8/27/15, identified R3 was cognitively intact and required extensive assistance with all activities of daily living (ADLs). R3 had no behavior and expressed no feelings of depression, or signs of negative thoughts.

R26 had diagnoses of depression, dementia, psychotic disorder and anemia. The quarterly Minimum Data Set (MDS) dated 7/30/15, identified R26 was cognitively impaired and required extensive assistance with all activities of daily living (ADLs). R26 had no physical behavior towards others and minimal verbal behaviors toward others. The facility was unable to assess R26's mood.

Incident report for R3 , "Description of Incident: Brought to east nursing station by kitchen staff. Resident was grabbed by another resident [R26] and this other resident also threw a knife and fork at her. Resident stated 'She was trying to eat food off the table from the other people. First she threw the fork and then the knife. She grabbed my arm. I didn't want to tell because I am afraid that my sister will think that I am causing trouble.'Immediate Action Taken: Resident assessed for injury. Does have red area on lower left forearm. Measures 12 cm x 1.5. No bruising noted at this time. Ensured resident that she would not get in trouble for telling when someone else hurts her."

R3's care plan dated 5/26/15, does not address the incident on 7/29/15 nor any actions to decrease the event from happening again. R26's care plan dated 4/15/15, indicated R26 has a diagnosis of dementia. It included a goal to display no physical aggression with other


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residents. There was no update to the care plan following the incident in the dining room on 9/29/15 nor any interventions to ensure it does not reoccur.

An interview on 10/14/2015, at 7:42 p.m. with the certified dietary manager (CDM)-H who said there was an issue with a woman taking a fork off of the table and throwing the fork. It was about two weeks ago. I didn't hear why she did it or any further information about it.

An interview on 10/14/2015, at 8:48 p.m. the administrator said she was aware of the incident which happened on 9/29/15. She said R3 was brought to the nursing station by dietary because she was grabbed by R26, she said R26 was eating food off of someone else's plate. R3 told her not to eat off of other people's plates. R26 grabbed R3's forearm and left a red mark. R26 then threw a knife and a fork. There was no bruising on R3 from incident. She was not sure why an incident report was not completed on R26. A thorough investigation had not been completed nor interventions care planned to address this behavior in the future.

The administrator said registered nurse manager did a communication with staff to watch for escalating behaviors to keep R3 and other residents safe.

During an interview on 10/15/2015, at 10 a.m. registered nurse (RN)-A, also the nurse manager said an email was sent out but that is all that was done in regards to a questions about follow-up on investigation and interventions for R3. The email dated 10/2/15 indicated "...As you all know, she [R26] does have behavioral outbursts and has


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been known to become physically aggressive with other residents from time to time Last week there was an incident in the dining room where she threw silverware at another resident [R3], and scratched her arm....".

An interview on 10/15/2015, at 10:10 a.m. with activities director (AD)-A and activities staff (AS)-B said R26 didn't like to do activities and sometimes was disruptive. AD-A was not made aware of the situation in the dining room, therefore, she did not change any activity plan in response to the event.

An interview on 10/15/2015, at 8:34 a.m. Licensed social worker (LSW)-D said we talked about it and we didn't seek medical attention for the incident and R3 was not afraid of R26 so we did not report the event. That is our criteria. LSW went on to say "I wasn't there so I don't know if it was intentional." We didn't report it because it did meet our criteria. Our intervention was to push harder to find another facility for R26 to live.

During an interview on 10/15/2015, at 9:29 a.m. the director of nursing (DON) said she is aware of the issue. DON said our interventions were for the charge nurse to be more alert of where R26 is currently located.

During an interview with R3 on 10/15/2015, at 9:33 a.m. R3 said, "She [R26] was in one of her moods again. She [R26] flung the knife toward the window and I was sitting by the window. She [R26] flung the fork at the staff. She [R26]was sitting behind me, she wheeled herself up to me and grabbed me by the arm. She [R26] flung my knife at me. They


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[facility staff]did not move her or me to another table or anything else."

A facility policy was requested and not provided on resident to resident altercations and supervision of residents with unwanted behaviors.

F 329

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483.25(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 11/24/15

Based on interview and document review the In response to the above stated citation


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facility failed to complete a comprehensive sleep assessment to determine the need for sleep aids ordered for insomnia for 2 of 5 residents (R11 & R30) reviewed for unnecessary medications.

Findings include:

R11's admission record revealed R11 was admitted on 5/29/15 with diagnoses of dementia without behavioral disturbance and insomnia. The significant change Minnesota Data Assessment (MDS) dated 9-3-15, indicated R11 did not display behavior problems or difficulty sleeping according, feeling tired or having little energy.

R11 currently received Tylenol PM (acetaminophen-pain medication and diphenhydramine-an antihistamine medication) Extra Strength Tablet 500-25 milligrams (MG) for insomnia. The current physician's orders reflected a start date for Tylenol PM Extra Strength as 6/4/15 and the resident had received the medication daily since 6/5/15 according to the medication administration record.

R11's medical record lacked a comprehensive sleep assessments and analysis of sleep monitoring to initiate and continue the use of Tylenol PM Extra Strength.

R11's physician order progress note dated 6/4/15 included, "...R11 has been requesting Tylenol PM at bedtime. R11 states that he would take it at bedtime previously and would sleep well. Family confirmed. New order as follows: Tylenol PM 1 tab [tablet] at bedtime for Insomnia. Will continue to monitor sleep pattern as he has been getting 2-7hrs [hours] of sleep at night prior."

Sauer Health Care has taken the following action:¿ Care plan for R30 was updated to include non-pharmacological interventions for sleep. ¿ An analysis of sleep monitoring was completed for R11 & R30.¿ The facility¿s current assessment for sleep was modified to be more comprehensive.¿ A sleep assessment was completed for R11 & R30.¿ This new sleep assessment tool will be used for all residents during their MDS review period. ¿ A structured progress note will now be created as follow up to the monthly Psych Drug Meetings. ¿ The Consultant Pharmacist will be provided with a current census listing of all residents on the date the monthly review is to be completed. ¿ Citation reviewed with Consultant Pharmacist.¿ The monthly Consultant Pharmacist report will be audited by the DON monthly upon receipt to ensure all residents have been reviewed and all suggested follow up has been completed. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before December 5, 2015.

Compliance for adherence to this plan will be the responsibility of the Consultant


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On 10/15/2015 at 8:56 a.m., registered nurse (RN)-E stated sleep monitoring was completed by the night nurse for the first 30 days after a sleep medication was initiated. RN-E stated sleep was documented on a daily basis through the sleep monitor task in the electric medical record. RN-E verified a comprehensive sleep assessment had not been completed for R11 since admission to the facility. RN-E stated a comprehensive sleep assessment should have been completed thirty days after admission to the facility on a sleep medication, thirty days after the initiation of a sleep medication and on a quarterly basis.

On 10/15/2015 at 12:21 p.m., the director of nursing (DON) stated quarterly as a part of the comprehensive nursing assessment a couple of questions were answered regarding sleep for a resident. The DON stated at this time comprehensive sleep assessments were are not being completed. The DON stated she did not think the facility had a policy or procedure for monitoring sleep and completing sleep assessments, but would look. A policy and procedure was not provided.

R30 was admitted to the facility on 2/6/15 according the facility's admission record.

R30's physician orders provided by the facility on 10/16/15 included Trazodone 50 milligrams (mg) by mouth every night for sleep. The original order date for the Trazodone was 3/11/15.

R30's significant change Minimum Data Set (MDS) dated 8/13/15 indicated no cognitiveimpairment with a Brief interview for Mental Status score of 15. The MDS also indicated no

Pharmacist, RN unit managers, and other licensed staff who complete any section of the comprehensive nursing assessment with overall compliance being the responsibility of the Director of Nursing Services and the Facility Administrator.


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sleep disturbances and used sleep medications during the assessment period. A quarterly MDS dated 5/11/15 also indicated no sleep disturbances.

R30's care plan did not include non-pharmacological interventions for sleep.

A facility assessment dated 8/7/15 identified the use of sleep aide medication and indicated"Resident has an MD [medical doctor] order to not wake her between the hours of 2200 [10:00 p.m.] and 0700 [7:00 a.m.]. She does not c/o [complain of] insomnia during the night."

The medical record lacked evidence of a comprehensive sleep assessment and analysis of sleep monitoring to initiate and continue the use of Trazodone. R30's medical record lacked evidence the Consulting pharmacist identified the lack of a comprehensive sleep assessment and analysis of sleep monitoring to justify the initiation and ongoing use for the Trazodone.

On 10/15/2015 at 12:21 p.m., the director of nursing (DON) stated quarterly as a part of the comprehensive nursing assessment a couple of questions were answered regarding sleep for a resident. The DON stated at this time comprehensive sleep assessments were are not being completed. The DON stated she did not think the facility had a policy or procedure for monitoring sleep and completing sleep assessments, but would look. A policy and procedure was not provided.

F 356

SS=C

483.30(e) POSTED NURSE STAFFING INFORMATION

F 356 11/24/15


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The facility must post the following information on a daily basis:o Facility name.o The current date.o The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: - Registered nurses. - Licensed practical nurses or licensed vocational nurses (as defined under State law). - Certified nurse aides.o Resident census.

The facility must post the nurse staffing data specified above on a daily basis at the beginning of each shift. Data must be posted as follows:o Clear and readable format.o In a prominent place readily accessible to residents and visitors.

The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to post the required information for facility daily census on the daily nurse staff posting and had the potential to affect 61 residents residing in the facility, staff, and visitors.

In response to the above stated citation Sauer Health Care has taken the following action:¿ The census information was immediately added to the staffing information posting on 10/13/2015.


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Findings include:

During the initial tour of the facility on 10/13/15, at 9:09 a.m. the facility staff posting dated 10/13/15 was posted on a clip board on the east wing. The document displayed the facility name, staff type, number of staff, shift time, number of staff members, and total hours worked. However, there was no posted information regarding the facility census for the current day, 10/13/15.

On 10/13/15, at 9:22 a.m. human resource assistant (HRA)-A stated she was responsible for posting the nurse staff posting at the end of her work day and verified the facility census was not completed on the nurse staff posting dated 10/13/15. HRA-A stated the nurses that work the day shift were responsible to complete the facility census on the nurse staff posting at the beginning of their shift.

A facility Nurse Staffing Information- Posted policy dated 1/15/13, identified the resident census to be posted on a daily basis at the beginning of each shift.

¿ The current policy ¿Nurse Staffing Information ¿ Posted¿ was reviewed and felt to be appropriate. This policy will be reviewed during staff education planned for November 11, 2015.¿ Audits will be completed to ensure adherence to this plan. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before December 5, 2015.

Compliance for adherence to this plan will be the responsibility of the Nursing Staffing Coordinator and the licensed staff with overall compliance being the responsibility of The Director of Nursing Services and the Facility Administrator.

F 428

SS=D

483.60(c) DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON

The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

The pharmacist must report any irregularities to the attending physician, and the director of nursing, and these reports must be acted upon.

F 428 11/24/15


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This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to ensure the consultant pharmacist reported irregularities regarding lab work was completed as ordered by physician to determine if medication was affective and/or at toxic levels for 1 of 5 residents (R54) and failed to identify the lack of a comprehensive sleep assessment before the use of an hypnotic medication sleep medication was started for 2 of 5 residents (R30 & R11) reviewed for unnecessary medications.Findings include:

LACK OF MEDICATION MONITORING THROUGH PHYSICIAN ORDERED LABORATORY: R54 was admitted to the facility on 10/4/13 with diagnoses that included atrial fibrillation, hyperlipidemia, and history of a stroke according to the facility ' s admission record. R54's physician orders provided by the facility on 10/16/15 included Digoxin (heart medication) 0.25 milligrams (mg) by mouth one time a day and Pravastatin (cholesterol medication) 40 mg by mouth at bed time. The physician's orders also included CBC (complete blood count), CMP (comprehensive metabolic panel), and liver panel every three months. The orders further directed staff to obtain a digoxin level every six months. It was not evident in the medical record any of the labs ordered by the physician had been performed in the last year. It was not evident in the medical record the pharmacist had identified the lack of lab monitoring.

In response to the above stated citation Sauer Health Care has taken the following action:¿ R54 had a blood draw completed on 10/15/2015 with tests run for CBC (complete blood count), CMP (comprehensive metabolic panel), liver panel and a digoxin level.¿ All labs found to be within normal limits and MD was made aware. ¿ R54 was added to the lab binder to have ongoing tests run for CBC (complete blood count), CMP (comprehensive metabolic panel), and liver panel every three months and a digoxin level every six months.¿ An audit of all current resident hard chart medication orders was completed to ensure that any lab orders had been properly transcribed and processed into the lab binder. ¿ The Consultant Pharmacist will be provided with a current census listing of all residents on the date the monthly review is to be completed. ¿ Citation reviewed with Consultant Pharmacist.¿ The monthly Consultant Pharmacist report will be audited by the DON monthly upon receipt to ensure all residents have been reviewed and all suggested follow up has been completed. ¿ Care plan for R30 was updated to include non-pharmacological interventions


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During an interview on 10/15/15, the director of nursing confirmed labs had not been obtained and indicated they should have been completed.Facility policy Laboratory and Diagnostic Services dated 3/24/14 included "The physician or designated provider will identify and order diagnostic and lab testing on diagnostic and monitoring needs. The staff will process test requisitions, arrange for tests and clarification will be sought for urgency of test." LACK OF COMPREHENSIVE SLEEP ASSESSMENT TO DETERMINE IF MEDICATION IS NEEDED: R30 was admitted to the facility on 2/6/15 according the facility's admission record.

R30's physician orders provided by the facility on 10/16/15 included Trazodone 50 milligrams (mg) by mouth every night for sleep. The original order date for the Trazodone was 3/11/15.

R30's significant change Minimum Data Set (MDS) dated 8/13/15 indicated no cognitiveimpairment with a Brief interview for Mental Status score of 15. The MDS also indicated nosleep disturbances and used sleep medications during the assessment period. A quarterly MDS dated 5/11/15 also indicated no sleep disturbances.

R30's care plan did not include non-pharmacological interventions for sleep.

A facility assessment dated 8/7/15 identified the use of sleep aide medication and indicated"Resident has an MD [medical doctor] order to not wake her between the hours of 2200 [10:00 p.m.] and 0700 [7:00 a.m.]. She does not c/o [complain of] insomnia during the night."

for sleep. ¿ An analysis of sleep monitoring was completed for R11 & R30.¿ The facility¿s current assessment for sleep was modified to be more comprehensive.¿ A sleep assessment was completed for R11 & R30.¿ This new sleep assessment tool will be used for all residents during their MDS review period. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before December 5, 2015.

Compliance for adherence to this plan will be the responsibility of the Consultant Pharmacist, RN unit managers, and other licensed staff who complete any section of the comprehensive nursing assessment with overall compliance being the responsibility of the Director of Nursing Services and the Facility Administrator.


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The medical record lacked evidence of a comprehensive sleep assessment and analysis of sleep monitoring to initiate and continue the use of Trazodone. R30's medical record lacked evidence the Consulting pharmacist identified the lack of a comprehensive sleep assessment and analysis of sleep monitoring to justify the initiation and ongoing use for the Trazodone.

On 10/15/15 at 6:11 p.m., the consultant pharmacist (CP)-A stated any time a sleep medication was used he expected a comprehensive sleep assessment to be completed for the resident prescribed the medication. R11's pharmacy monthly regimen reviews revealed the consulting pharmacist did not identify the lack of a comprehensive sleep assessment and analysis of sleep monitoring to justify the initiation and ongoing use for the Tylenol PM Extra Strength (acetaminophen-pain medication and diphenhydramine-an antihistamine medication). R11's admission record revealed R11 was admitted on 5/29/15 with diagnoses of dementia without behavioral disturbance and insomnia. The significant change Minnesota Data Assessment (MDS) dated 9-3-15, indicated R11 did not display behavior problems or difficulty sleeping according, feeling tired or having little energy.

R11 currently received Tylenol PM Extra Strength Tablet 500-25 milligrams (MG) for insomnia. The current physician's orders reflected a start date for Tylenol PM Extra Strength as 6/4/15 and the resident had received the medication daily since 6/5/15 according to the medication administration


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record.

R11's medical record lacked comprehensive sleep assessments and analysis of sleep monitoring to initiate and continue the use of Tylenol PM Extra Strength and none were provided when requested of staff.

R11's physician order progress note dated 6-4-15 included, "...R11 has been requesting Tylenol PM at bedtime. R11 states that he would take it at bedtime previously and would sleep well. Family confirmed. New order as follows: Tylenol PM 1 tab [tablet] at bedtime for Insomnia. Will continue to monitor sleep pattern as he has been getting 2-7 hrs [hours] of sleep at night prior."

On 10/15/2015 at 8:56 a.m., registered nurse (RN)-E stated sleep monitoring was completed by the night nurse for the first 30 days after a sleep medication was initiated. RN-E stated sleep was documented on a daily basis through the sleep monitor task in the electric medical record. RN-E verified a comprehensive sleep assessment had not been completed for R11 since admission to the facility. RN-E stated a comprehensive sleep assessment should be completed thirty days after admission to the facility on a sleep medication, thirty days after the initiation of a sleep medication and on quarterly basis.

On 10/15/2015 at 12:21 p.m., the director of nursing (DON) stated quarterly as a part of the comprehensive nursing assessment a couple of questions were answered regarding sleep for a resident. The DON stated at this time comprehensive sleep assessments were are not being completed. The DON stated she did not think the facility had a policy or procedure for


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monitoring sleep and completing sleep assessments, but would look. A policy and procedure was not provided.

On 10/15/15 at 6:11 p.m., the consultant pharmacist (CP)-A stated any time a sleep medication was used he expected a comprehensive sleep assessment to be completed for the resident prescribed the medication.

F 441

SS=E

483.65 INFECTION CONTROL, PREVENT SPREAD, LINENS

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.

F 441 11/24/15


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(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.

This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to ensure the use of blood borne dieses disinfectant was used for multi-use glucometers for 1 of 2 residents (R11) observed for blood glucose monitoring. In addition, the facility failed to contain dirty linens to prevent spread of infection and to maintain a sanitary laundry chute to prevent the spread of infection through the laundry.

Findings Include:

R11 had used a multiuse glucometer as observed on 10/14/15, at 4:41 p.m., registered nurse (RN)-B after checking R11's blood sugar had removed gloves and cleaned the entire outside of the glucometer with an alcohol wipe. RN-B had had no gloves on when cleaning the glucometer and failed to wash hands after cleaning the glucometer.

During interview on 10/14/15, at 4:57 p.m., RN-B verified the glucometer was a multi resident use glucometer. RN-B verified she had used an alcohol wipe to clean the glucometer, had no

In response to the above stated citation Sauer Health Care has taken the following action:¿ DON immediately met directly with staff member who was reported to have failed to ensure the use of blood borne disease disinfectant for cleaning of a multi-use glucometer and verbal education was provided. ¿ The policy titled, ¿Blood Sugar Monitoring¿ dated 2/2/2009 has been updated to ¿Blood Glucose Monitoring, Obtaining a Finger Stick Glucose Level¿ and includes directives for cleaning multi-use glucometers. ¿ The facility policy titled ¿Linen Handling¿ was reviewed and felt to be appropriate. This policy will be reviewed during staff education planned for 11/1115.¿ Review of the ¿Linen Handling¿ policy shows that the CNA observed during the report to have been following proper facility protocol. ¿ The laundry chute was cleaned on


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gloves on when cleaning the glucometer and had not washed hands after cleaning the glucometer.

During interview on 10/15/15, at 10:28 a.m., director of nursing stated she expected staff to put gloves on before cleaning the glucometer and wash hands when done cleaning the glucometer.

During interview on 10/15/15, at 12:20 p.m., director of nursing verified cleaning the glucometer with an alcohol pad was not an effective sanitization for blood borne pathogens.

The facility policy Handwashing/Hand Hygiene, dated 1/17/11, indicated this facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: s. After handling soiled equipment or utensils.

Food and Drug Agency along with Centers for Disease Control (FDA/CDC) guidance as follows: " The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device.

A policy for sanitizing the multi-use glucometer

10/15/2015.¿ The Environmental Services Director has reviewed and revised the schedule for cleaning the linen chute with an increase of occurrence from previous schedule and a record of this will now be maintained by The Environmental Services Director. ¿ Maintenance slips will be completed as a request for cleaning of the linen chute at times between scheduled cleaning as needed. ¿ Audits will be completed to ensure adherence to this plan. ¿ Citation and Plan of Correction will be reviewed at Quality Assurance Meeting on November 19, 2015. ¿ Education will be provided to staff at an in-service training on November 11th, 2015 and all staff will confirm receipt of training on or before December 5, 2015.

Compliance for adherence to this plan will be the responsibility of all Sauer Health Care staff with overall compliance being the responsibility of The Environmental Services Director, The Director of Nursing Services and the Facility Administrator


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between resident use was requested but none provided. LACK OF INFECTION CONTROL PROCEDURES TO REDUCE AND/OR PREVENT THE SPREAD OF INFECTION:

On 10/15/15 at 7:38 a.m. nursing assistant (NA)-A was observed throwing unbagged soiled laundry down the laundry chute. At 10:18 a.m. NA-A stated he normally uses a bag for the laundry but because he had a lot of laundry he didn't.

On 10/15/15 at 1:39 p.m. the laundry chute was observed to have dried brown debris on the top back and left sides of the device, dried white debris in several spots towards the top back, and dried liquid on the sides.

On 10/15/15 at 1:41 p.m. the director of nursing (DON) observed the chute and said it was gross.

On 10/15/15 at 1:43 p.m. the director of environmental services stated, "I would say no" when asked if the laundry chute was clean. The director of environmental services added housekeeping cleaned the chute the last Sunday of the month but did not keep a record of the cleaning.

Facility policy Linen Handling dated 3/24/14 reads, "Dirty/soiled linen is: 1. Laundry that is soiled with blood or bloody fluids that can drip or flake off shall be placed in a plastic bag, prior to leaving the room, then into a regular laundry bag and put down the laundry chute. 2. All other linens will be placed in soiled linen cart. In the event a cart is not nearby, items will be bagged and put down chute...5. Soiled linen cart laundry


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bags shall not be filled to more than three-fourths of their capacity...7. Minimal handling of soiled linen is advised. 8. Soiled linen is placed in a covered linen storage receptacle. Linen that is grossly contaminated with blood or other bodily fluids should be rinsed and bagged prior to sending down the chute."


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