susanne reuss, unit supervisor alison helm, enforcement ... · 06-fail to meet agreement other...

06/28/2018

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: 00501

ID: NOV9

SAINT PAUL, MN

1. MEDICARE/MEDICAID PROVIDER NO.

(L1)

2.STATE VENDOR OR MEDICAID NO.

(L2)

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION:

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)

009342400

12/31

06/18/2018

LYNGBLOMSTEN CARE CENTER245347

02

1415 ALMOND AVENUE

55108

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

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

From (a) :

To (b) :

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

Program Requirements

Compliance Based On:

1. Acceptable POC

2. Technical Personnel 6. Scope of Services Limit

3. 24 Hour RN 7. Medical Director

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

5. Life Safety Code 9. Beds/Room12.Total Facility Beds 237 (L18)

13.Total Certified Beds 237 (L17) B. Not in Compliance with Program

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

14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS

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

237

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

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

Reduction in the number of certified SNF/NF beds from 237 beds to 225 beds, effective July 1, 2018, in accordance with a change in licensure. Due to 12 beds being placed in layaway

status (in accordance with Minn. Stat. 144A.071, Subd. 4b., as amended by the Minnesota State Licensure) effective July 1, 2018, all 225 facility beds are certified SNF/NF. After this

change they have twelve (12) beds on layaway.

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

X

00-Active

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00

03001

06/27/2018

06/28/2018

21.

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

Susanne Reuss, Unit Supervisor Alison Helm, Enforcement Specialist

7

CMS Certification Number (CCN): 245347

June 18, 2018

Ms. Brenda Johnson, Administrator

Lyngblomsten Care Center

1415 Almond Avenue

Saint Paul, MN 55108

Dear Ms. Johnson:

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

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

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

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

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

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

recertified for participation in the Medicare and Medicaid program.

Effective June 12, 2018 the above facility is certified for:

237 Skilled Nursing Facility/Nursing Facility Beds

Your facility’s Medicare approved area consists of all 237 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,

Alison Helm, Enforcement Specialist

Licensing and Certification

Minnesota Department of Health

P.O. Box 64970

Saint Paul, Minnesota 55164-0970

Phone: 651-201-4206

Email: [email protected]

cc: Licensing and Certification File

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

An equal opportunity employer.

Electronically delivered

June 18, 2018

Ms. Brenda Johnson, Administrator

Lyngblomsten Care Center

1415 Almond Avenue

Saint Paul, MN 55108

RE: Project Number S5347031

Dear Ms. Johnson:

On May 18, 2018, we informed you that we would recommend enforcement remedies based on the

deficiencies cited by this Department for a standard survey, completed on May 3, 2018. 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 June 18, 2018, 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 May 3, 2018.

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

of June 12, 2018. Based on our PCR, we have determined that your facility has corrected the

deficiencies issued pursuant to our standard survey, completed on May 3, 2018, effective June 12,

2018 and therefore remedies outlined in our letter to you dated May 18, 2018, 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,

Alison Helm, Enforcement Specialist

Licensing and Certification

Minnesota Department of Health

P.O. Box 64970

Saint Paul, Minnesota 55164-0970

Phone: 651-201-4206

Email: [email protected]

cc: Licensing and Certification File

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

An equal opportunity employer.

06/08/2018 06/27/2018

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: 00501

ID: NOV9

SAINT PAUL, MN

1. MEDICARE/MEDICAID PROVIDER NO.

(L1)

2.STATE VENDOR OR MEDICAID NO.

(L2)

3. NAME AND ADDRESS OF FACILITY

(L3)

(L4)

(L5) (L6)

4. TYPE OF ACTION: (L8)

1. Initial

3. Termination

5. Validation

8. Full Survey After Complaint

7. On-Site Visit

2. Recertification

4. CHOW

6. Complaint

9. Other

FISCAL YEAR ENDING DATE: (L35)

7. PROVIDER/SUPPLIER CATEGORY (L7)

01 Hospital

02 SNF/NF/Dual

03 SNF/NF/Distinct

04 SNF

05 HHA

07 X-Ray

08 OPT/SP

09 ESRD

10 NF

11 ICF/IID

12 RHC

13 PTIP

14 CORF

15 ASC

16 HOSPICE

5. EFFECTIVE DATE CHANGE OF OWNERSHIP

(L9)

6. DATE OF SURVEY (L34)

8. ACCREDITATION STATUS: (L10)

009342400

2

12/31

05/03/2018

LYNGBLOMSTEN CARE CENTER245347

02

1415 ALMOND AVENUE

55108

0 Unaccredited

2 AOA

1 TJC

3 Other

06 PRTF

22 CLIA

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

From (a) :

To (b) :

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

Program Requirements

Compliance Based On:

1. Acceptable POC

2. Technical Personnel 6. Scope of Services Limit

3. 24 Hour RN 7. Medical Director

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

5. Life Safety Code 9. Beds/Room12.Total Facility Beds 237 (L18)

13.Total Certified Beds 237 (L17) X B. Not in Compliance with Program

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

14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS

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

237

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

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

Reduction in the number of certified SNF/NF beds from 237 beds to 225 beds, effective July 1, 2018, in accordance with a change in licensure. Due to 12 beds being placed in layaway

status (in accordance with Minn. Stat. 144A.071, Subd. 4b., as amended by the Minnesota State Licensure) effective July 1, 2018, all 225 facility beds are certified SNF/NF. After this

change they have twelve (12) beds on layaway.

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

X

00-Active

09/01/1986

00

03001

06/27/2018

21.

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

Glenora Souther, HFE NE II Alison Helm, Enforcement Specialist

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(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 06/08/2018FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

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

245347 05/03/2018

C

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

1415 ALMOND AVENUELYNGBLOMSTEN CARE CENTER

SAINT PAUL, MN 55108

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)

E 000 Initial Comments E 000

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on April 30, 2018 through May 3, 2018 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

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. "A recertification survey was conducted on 4/30/18, through 5/3/18, and a complaint investigation was also completed at the time of the standard survey."

An investigation of complaint, H5347090 was completed. The complaint was not substantiated.

F 554

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Resident Self-Admin Meds-Clinically AppropCFR(s): 483.10(c)(7)

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.This REQUIREMENT is not met as evidenced

F 554 6/12/18

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

06/01/2018Electronically 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 NOV911Event ID: Facility ID: 00501 If continuation sheet Page 1 of 35

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F 554 Continued From page 1 F 554

by: Based on observation, interview, and document review, the facility failed to determine if the practice of self-administration of medications (SAM) was safe for 1 of 1 resident (R120) observed to self-administer a nebulizer (neb-broken into a mist and inhaled through a mask) treatment during a random observation.

Findings include:

R120's care plan dated 12/17/16, identified R120 had a history of a behavior problems related to Alzheimer's dementia and depression diagnosis as evidenced by refusing cares. The care plan directed staff to continue to give medications per orders. R120's care plan lacked documentation R120 was safe to self administer the nebulizer.

On 5/2/18, at 8:38 a.m. to 8:46 a.m., the door to R120 was observed wide open and the nebulizer machine was heard running when standing at the nursing station. Upon entering the room R120 was observed lying in bed and was holding a hand held nebulizer to her mouth.-At 8:46 a.m. the trained medication aide (TMA)-B reviewed the orders and verified R120 did not have an order to SAM. TMA-B stated R120 did not like to be watched and she would set the nebulizer up, start it and then would return to room to turn it off. TMA-B at this time went to room, turned it off and rinsed the device.

On 5/2/18, at 9:06 a.m., registered nurse (RN)-F stated all residents were supposed to be assessed and care plan developed to indicate they were able and safe to self administer medication. RN-F stated the TMA-B had just reported the concern to her. RN-F stated she had

The preparation of the following plan of correction for this deficiency does not constitute and should not be interpreted as an admission nor an agreement by the facility of the truth of the facts alleged on conclusions set forth in the statement of deficiency. The plan of correction prepared for this deficiency was executed solely because it is required by provisions of State and Federal law. Without waiving the foregoing statement, the facility states that:

F554It is the policy of Lyngblomsten to assure that each resident has the right to self-administer medications if the interdisciplinary team has determined that the practice is clinically appropriate. To assure continued compliance the following plan has been implemented:Regarding cited residents:With respect to resident R 120, she was assessed for the ability to safely self-administer medications. It was determined that she is able to safely administer her nebulizer after set up by facility staff. Her care plan was updated to reflect this ability and staff were informed. The staff directly involved in allowing the resident to self-administer her nebulizer was coached immediately following the incident and acknowledged understanding.Actions taken to identify other potential residents having similar occurrences:All other residents with medication self-administration assessments were


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told TMA-B she should have reported to the nurse if R120 was refusing to be observed. -At 9:20 a.m. RN-F approached stated she had spoken to RN-G who was the clinical unit coordinator and licensed practical nurse (LPN)-C who both stated they had not been informed R120 was refusing to be watched during the nebulizer treatments. RN-F stated R120 was going to be assessed and TMA-B was going to be pulled aside after the morning medication pass and would be re-educated about the facility policy.

reviewed for accuracy. All residents with orders for inhalants were reviewed to determine if they may be appropriate for self-administration if desired. Those residents deemed appropriate were approached and asked if they would prefer to self-administer their inhalants.Measures put in place to ensure deficient practice does not occur:All residents that have been assessed to safely self-administer medications are identified in the electronic medication administration record (EMAR) to safely self-administer a medication. Each medication that can be administered is identified along with an icon and the specific parameters (e.g. “May self-admin neb after set up”) are in the order descriptions. Order sets were created within the EMAR to include the appropriate self-administration criteria and periodic review period to assure instructions and guidance for staff overseeing the administration process are clear and consistent. The Resident Self-Administration of Medications Policy was revised to include levels of ability to allow person-centered care for those that wish to participate in administering their medications at the level that is safe for them to do so. All nurses, TMA’s and Health Information Specialists (HISS)’s were trained on the new practice, policy and the regulations that provide each resident the right to self-administer their own medications provided they can do so safely. Staff were also trained on how to recognize when a resident may be capable and wish to self-administer


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medications or when they may no longer be able.Effective implementation of actions will be monitored by:Facility Clinical Managers will be responsible for overseeing the self-administration assessment process and periodic review. Clinical Managers will interface with their nurses and TMA’s to assure that resident changes are identified and necessary re-assessments or adjustments to relevant care plan interventions are updated to maintain compliance.Those responsible to maintain compliance will be:The Director of Nursing and/or designee will audit 4 records a week for 4 weeks and then 2 records for 8 weeks for self-administration assessments, care pan interventions and orders. During that same time, Nursing Administration will do random, periodic observational audits of nurses and TMA’s for compliance with medication self-administration policy. The data collected will be presented and discussed monthly at the Quality Assurance Committee meetings by the Director of Nursing. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies or actions.Completion date for certification purposes only is June 12th, 2018.

F 625

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Notice of Bed Hold Policy Before/Upon TrnsfrCFR(s): 483.15(d)(1)(2)

F 625 6/12/18


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

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility�(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any�(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return��and(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.This REQUIREMENT is not met as evidenced by: Based on interview and document review the facility failed to provide notice of bed hold policy for 1 of 4 residents (R187) reviewed for hospitalization.

Findings include:

R187's Admission Record indicated she admitted to the facility on 3/19/18.

The preparation of the following plan of correction for this deficiency does not constitute and should not be interpreted as an admission nor an agreement by the facility of the truth of the facts alleged on conclusions set forth in the statement of deficiency. The plan of correction prepared for this deficiency was executed solely because it is required by provisions


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An undated Patient Transfer Information sheet indicated R187 was sent to the emergency department for evaluation. Facility Progress Notes dated 3/22/18 to 3/24/18, indicated on 3/22/18, R187 was sent to the hospital for an evaluation. On 3/22/18, the hospital called facility to inform them R187 would not be returning that day. On 3/24/18, R187 was re-admitted to the facility from the hospital. Review of R187's medical record lacked evidence of a bed hod notice.

During an interview on 5/3/18, at 2:56 p.m., social worker (SW)-A stated residents received a bed hold policy on admission to the facility. He stated R187 should have received a bed hold notice. SW-A stated R187 went to the hospital on a Thursday and stated he did not work on Fridays. SW-A stated he thought RN-E attempted to call R187's family member regarding the bed hold but was unable to find evidence of attempts to reach family.

A facility policy titled Bed Hold and Return to Facility dated 4/2018, indicated residents who are transferred to the hospital or go on a therapeutic leave are proved with written information about the states bed hold duration and payment amount before transfer.

of State and Federal law. Without waiving the foregoing statement, the facility states that:

F625It is the policy of Lyngblomsten that before a resident transfers to the hospital or goes on a therapeutic leave that the facility provide written information and notice to the resident or resident representative that specifies-1. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility�2. The reserve bed payment policy in the state plan, if any�3. The nursing facility’s policies regarding bed-hold periods, which must be consistent with regulations, permitting a resident to return.To assure continued compliance the following plan has been implemented:Regarding cited residents:With respect to resident R187, the resident representative has confirmed that they had desired to hold the bed.Actions taken to identify other potential residents having similar occurrences:See next sectionMeasures put in place to ensure deficient practice does not occur:The Bed-hold and Return to Facility policy was reviewed and processes updated. The Daily Census sheet has been updated to require acknowledgement of Bed-hold completion for all transfers to the hospital. Review of bed-hold completion has been added to Morning


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Circle (An Interdisciplinary Team meeting) when discussing Hospital Transfers. A Progress Note template has been developed to guide staff through the appropriate components of bed-hold notification documentation. Confirmation of proper bed-hold notification has been added to the House Supervisors job duties. A script has been developed to assist staff in communicating the bed-hold process, including allowed duration and approximate rates, as these are often deciding factors for residents and their representatives. A algorithm tool was created to assist staff in determining approximate rates to hold a bed. All Licensed Nurses, Social Work Staff and Business Office personnel have been re-educated on the bed-hold notification process.Effective implementation of actions will be monitored by:Director of Social Services will monitor the bed-hold notification process to assure proper completion and follow-up as indicated.Those responsible to maintain compliance will be:The Director of Social Services and/or designee will audit all transfers requiring bed-hold notification for proper completion. The data collected will be presented and discussed monthly at the Quality Assurance Committee meetings by the Director of Social Services. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies.


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Completion date for certification purposes only is June 12th, 2018.

F 640

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Encoding/Transmitting Resident AssessmentsCFR(s): 483.20(f)(1)-(4)

§483.20(f) Automated data processing requirement-§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:(i) Admission assessment.(ii) Annual assessment updates.(iii) Significant change in status assessments.(iv) Quarterly review assessments.(v) A subset of items upon a resident's transfer, reentry, discharge, and death.(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:(i)Admission assessment.(ii) Annual assessment.(iii) Significant change in status assessment.(iv) Significant correction of prior full assessment.

F 640 6/12/18


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(v) Significant correction of prior quarterly assessment.(vi) Quarterly review.(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to ensure Minimum Data Set (MDS's) were submitted timely for 2 of 2 residents (R1, R2) reviewed for Resident Assessment.

Findings include:

R2's diagnoses diagnoses included heart failure, malnutrition, hypertension, asthma and depression obtained from the quarterly MDS dated 12/27/17. During review of R2's MDS's completion dates with the MDS coordinator RN-B, it was revealed R2's quarterly MDS which was supposed to be completed around 3/27/18, had been missed. RN-B verified R2's MDS had been missed and she stated she was going to schedule it to be completed after she was made aware. When asked if there was a system of checking to make sure MDS's were completed both RN's stated they did not have one. RN-B verified the MDS was over 36 days since the last quarterly was completed.


F640It is the policy of Lyngblomsten Care Center that within 7 days after a resident’s assessment is completed the facility encodes and is capable of transmitting the necessary data to CMS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. Within 14 days the facility must


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R1's progress notes it was revealed R1 dead on 12/6/17, with diagnoses including heart failure, renal insufficiency, dementia, anxiety, depression and atrial fibrillation obtained from the significant change MDS dated 12/5/17. During further review of the medical record, it was revealed R1 had dead at the facility on 12/6/18.

On 5/2/18, at 2:45 p.m. registered nurse (RN)-A and RN-B verified the R1's MDS had been completed however was never submitted to indicate R1 had a death at the facility. RN-B stated she had completed the MDS however she had not submitted it as she pointed to the submission area.

On 5/3/18, at 3:17 p.m. the director of nursing stated he would expect all resident MDS's to be completed timely.

The Resident Assessment Instrument last updated in October 2017, directed: "Assuming the resident did not experience a significant change in status, was not discharged, and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment. Death In Facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA). The facility must complete a Death in Facility tracking record. A Discharge assessment is not required."

electronically transmit the encoded, accurate and complete MDS data to the CMS system. To assure continued compliance the following plan has been implemented:Regarding cited residents:With respect to resident R1 and R 2, the required MDS’ were submitted.Actions taken to identify other potential residents having similar occurrences:MDS are to be completed on all residents, see next section to see measures to assure deficient practice does not reoccur.Measures put in place to ensure deficient practice does not occur:The process for scheduling the MDS’ and the steps to assure all information and components are successfully completed was reviewed and updated. The MDS Coordinators will use the scheduling tool with the facility Electronic Health Record (EHR) to schedule and manage the MDS’ to be completed. The tool affords a method of tracking to assure that all required MDS’ are completed timely. The schedule is reviewed the first week of each month for the following month, any needed adjustments are made at that time. The MDS Coordinator forwards that list to the Interdisciplinary Team (IDT). Then each week the MDS Coordinator will open the MDS’ due for the following week and activate the required tasks for documentation. The MDS Coordinators will monitor the submission process to assure that all scheduled and completed MDS’ are submitted- exported and accepted, timely. All MDS Coordinators


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have been re-educated on the MDS scheduling and submission process.Effective implementation of actions will be monitored by:Director of Nursing and/or designee will monitor the MDS scheduling and submission process to assure accuracy and follow-up as indicated.Those responsible to maintain compliance will be:The Director of Nursing and/or designee will audit 10 MDS per month for 2 months and then 5 MDS for 4 months for proper and timely completion. The data collected will be presented and discussed monthly at the Quality Assurance Committee meetings by the Director of Nursing. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies.Completion date for certification purposes only is June 12th, 2018.

F 686

SS=D

Treatment/Svcs to Prevent/Heal Pressure UlcerCFR(s): 483.25(b)(1)(i)(ii)

§483.25(b) Skin Integrity§483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable��and(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to

F 686 6/12/18


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promote healing, prevent infection and prevent new ulcers from developing.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review the facility failed to provide timely repositiong for 2 of 6 residents (R106, R76) reviewed for pressure ulcers.

Findings include:

R106's quarterly Minimum Data Set dated 3/7/18, indicated he was severely cognitively impaired, required assistance to reposition in bed and was frequently incontinent of bowel and bladder. A Lyngblomsten Care Center Progress Noted dated 4/25/18, indicated R106 develop three new open areas to R106's buttocks, all areas measuring 0.5 centimeters (cm) x 0.5 cm. R106's care plan dated 4/30/18, identified impaired physical mobility and directed staff to turn and reposition in bed every two hours. The care plan further identified impaired skin related to two stage II pressure ulcers to the buttocks and one unstageable pressure ulcer to the coccyx.

During continuous observation on 5/3/18, at 7:44 a.m. R106 was lying in bed with his head elevated to approximately 45 degrees. R106's feet were pressed against the foot board in bed. R106 remained in bed with no staff assistance or offers to reposition until 10:25 a.m. at which time nursing assistant (NA) - C entered his room. NA - C stated she had to find another staff member to help her reposition R106 and left the room. At 10:28 a.m., NA- C returned to R106's room and stated the other NA on the floor was bathing another resident and the nurse was in a meeting. She said, "it might be a little while before I can


F686It is the policy of Lyngblomsten Care Center that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable��and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. To assure continued compliance the following plan has been implemented:Regarding cited residents:With respect to residents R106 and R76, R106 has deceased and R76’s wound has healed.Actions taken to identify other potential residents having similar occurrences:


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find someone." At 10:37 a.m., 2 hours and 44 minutes, NA-C and registered nurse (RN) - D repositioned and completed care for R106. During the observation R106 was noted to have three pressure ulcers. Two small stage II areas on his buttock and approximately 2.5 cm x 3 cm oval shaped unstageable ulcer to his coccyx.

During an interview on 5/3/18, at 10:44 a.m. NA-C stated she was unsure the last time R106 had been repositioned. She stated the first time she repositioned him on her shift, she removed a pillow. NA-C stated she though it was around 7:30 a.m. NA-C stated he should have been repositioned every two hours.

During interview on 5/3/18, at 1:38 p.m. the director of nursing stated staff should be following the plan of care for repositioning.

A facility policy related to following the plan of care was requested but not provided.

R76's Diagnosis Report indicated R76 had diagnosis that included diabetes mellitius type two and peripheral vascular disease. R76 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 on the last Minimum Data Set (MDS) Quarterly Review assessment dated 2/21/18.

During initial interview on 5/1/18, at 9:23 a.m. resident (R)76 stated she did not get out of bed because she had two pressure sores on her buttocks. Resident stated being able to reposition self.

Review of R76's history and physical dated

The records of all residents with wounds have been audited and all necessary updates have been completed. Residents with wounds that are not compliant with the recommended treatment plan have been counseled on the risk and benefits of non-compliance and the discussion has been documented in the resident record. Periodic review of the risk and benefits for non-compliance has been scheduled.Measures put in place to ensure deficient practice does not occur:A method of identifying those residents at high risk for skin injury has been developed and all high risk residents have been reviewed to assure appropriate preventative measures have been implemented. Facility processes have been updated to include��daily, at Morning Circle, the number of current Facility Acquired Pressure Ulcers (FAPU) are checked, significant changes in condition are reviewed, new or changing skin conditions are discussed and changes in resident’s nutritional status (weight loss, decreased intake, difficulty swallowing, etc.) are considered. Information gathered is then utilized to develop and consider appropriate interventions to prevent the development, or promote healing of, pressure ulcers. Facility providers have been educated on the Federal regulation for the prevention and treatment of pressure ulcers, including routine documentation and treatment evaluation, along with the concept of an “unavoidable” pressure ulcer. To assure scheduled interventions are completed timely, nursing staff have been directed to


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11/28/17, from the last hospitalization indicated R76 had two sacral pressure ulcers to the right of midline and old scars from previous ulcers. R76's Care Area Assessment (CAA) for skin dated 6/2/17 indicated R76 was at risk for pressure ulcer due to impaired mobility and obesity. Review of a Skin Check - Routine dated 3/29/18, 4/5/18, and 4/26/18 indicated R76 had an open area or pressure injury, however there was no documentation regarding the location, stage or size. R76's serum albumin (protein) level was low at 2.5 grams per deciliter indicating wound healing could be impaired for R76.

During continuous observation of R76 on 5/2/18, from 7:28 to 10:00 a.m. R76 was lying on her back with the head of bed elevated. At 9:22 a.m. nursing assistant (NA)-A entered R76's room and began collecting supplies to assist R76 with morning cares. After the supplies were gathered R76 rolled onto her left side. NA-A removed the incontinence pad from R76's buttocks. On R76's right inner buttock was an open wound. Another wound was observed on the left inner buttock. At 9:52 a.m. registered nurse (RN)-A entered the room to assess the wounds. RN measured the wound on the right buttock to be 2.8 cm by 1 cm and the wound on the left buttock to be 0.6 cm by 0.5 cm in size.

On 5/02/18, 10:02 a.m. during an interview registered nurse (RN)-A acknowledged the wounds were pressure ulcers.

When interviewed on 5/02/18, at 10:39 a.m. clinical manager (CM)-D stated the nurses did a weekly skin check and documented any skin issues on the skin assessment in the electronic health record (EHR). New skin concerns

call the Nursing Supervisor if they are unable to provide the necessary intervention (wound care, repositioning, etc.) due to a lack of staff availability for support, the Nursing Supervisor is to assure that the necessary resources are secured timely, including providing the support directly. All nursing staff have been re-educated on the updated facility processes and the prevention and healing of pressure ulcers.Effective implementation of actions will be monitored by:Nursing Administration will monitor the facility pressure ulcer prevention and healing process and follow-up as indicated.Those responsible to maintain compliance will be:Director of Nursing and/or designee will audit all resident records with pressure ulcers monthly for 4 months for appropriate interventions, assessments, and documentation to assure accuracy The data collected will be presented and discussed monthly at the Quality Assurance Committee meetings by the Director of Nursing. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies.Completion date for certification purposes only is June 12th, 2018.


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identified were to be reported to the supervisor or wound nurse and if appropriate reported to the nurse practioner or primary physician.

On 5/3/18, R76 was continuously observed from 7:28 a.m. to 10:01 a.m. lying on her back with head of the bed elevated to approximately 45 degrees. At 7:44 a.m licensed practical nurse (LPN)-B entered with R76's medication. At 8:25 a.m. CM-D enter with a sharps container and check R76's blood sugar level. At 9:08 a.m. nursing assistant (NA)-B entered and took R76's meal order and at 9:27 R76 was brought a meal tray. At 9:45 a.m. At 10:00 a.m. CM-D entered R76's room and removed the meal tray. At 10:01 a.m. R76 was interviewed and stated the NA would be in soon to check her incontinent pad.

Review of R76's Care Plan for: Potential for or Actual Impaired Skin Integrity dated 5/2/18, directed staff that R76 was to be repositioned every two hours. Although R76 indicated being able to reposition self, she had not repositioned self, had not been reminded to reposition self and had not been re-positioned by staff anytime during the observation.

On 5/3/18, at 2:12 p.m. director of nursing (DON) was interviewed and stated the nurse was expected to review the skin check progress note, edit, and make a comment or document specifics of any new skin concerns. DON added if a open wound was found a wound assessments was to be completed and needed to include size, location, drainage, pain or any other pertinent data. DON stated the reporting procedure was to let the shift supervisor know of a new concerns and put it on the daily report.


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Lyngblomsten Care Center Practice Guideline and Procedure: Skin Care - The Prevention and Treatment of Wounds revised 11/2016, was reviewed indicated necessary documenting of location, size, depth, tunneling, drainage (exudate), pain, color and type of tissue in the wound bed, and describe the wound edges.

F 689

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Free of Accident Hazards/Supervision/DevicesCFR(s): 483.25(d)(1)(2)

§483.25(d) Accidents.The facility must ensure that -§483.25(d)(1) The resident environment remains as free of accident hazards as is possible��and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.This REQUIREMENT is not met as evidenced by:

F 689 6/12/18

Based on observation, interview and document review, the facility failed to identify patterns of falls and provide adequate supervision in an effort to reduce risk for 3 of 5 residents (R106, R123, R147) reviewed with a pattern of falls.

Findings include:

R106's care area assessment (CAA) dated 12/21/17, identified a risk for falls related to a history of falls, unsteady gait, impaired cognition and poor safety awareness. R106's quarterly Minimum Data Set (MDS) dated 3/17/18, indicated he was severely cognitively impaired, frequently incontinent of bowel and bladder and required assistance with activities of daily living. R106's care plan dated 4/30/18, identified a history of falls and directed staff to check on him


F689It is the policy of Lyngblomsten Care Center that the resident environment remains as free of accidents as is possible and each resident receives


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hourly at night and before 7:00 a.m.

During observation on 4/30/18, at 12:41 p.m. R106 was seated in a padded reclining wheel chair in the dining room. He had a mechanical lift sling under him in the wheel chair.

A review of Lyngblomsten Care Center Progress Notes indicated from 7/14/17 through 5/2/18, R106 sustained 10 falls. Six of the 10 falls occurred between 6:00 a.m. and 7:30 a.m.

7/14/17 - R106 had a fall at 7:00 a.m. non-skid strips and a lipped mattress were initiated. 7/29/17 - R106 had a fall at 7:30 a.m. non-skid shoes or socks and non-skid strips were initiated.

8/24/17 - R106 had a fall at 12:00 a.m,. following the fall the following interventions were put in place, non-skid shoes or socks and recliner can be unplugged to stay in safe sitting position.

9/19/17 - R106 had a fall at 6:15 p.m. fall interventions included placing two walkers in the room, one to use as a barricade and one to walk with.

11/11/17 - R106 had a fall at 7:30 a.m. fall interventions included keeping walker or wheel chair at bed side.

11/17/17 - R106 had a fall at 6:32 a.m. fall interventions included removing wheel chair or walker from bedside.

11/24/17 - R106 sustained a fall at 6:25 a.m. interventions included non-skid shoes or socks.

adequate supervision and assistance devices to prevent accidents. To assure continued compliance the following plan has been implemented:Regarding cited residents:With respect to resident R106, R123, and R147, R106 has deceased. R123 and R157’s falls were reviewed for root cause and implemented interventions assessed for appropriateness. Necessary updates were made to the plan of care.Actions taken to identify other potential residents having similar occurrences:Facility processes for reviewing, analyzing root cause, and evaluating interventions for all falls has been revised. Immediately following a fall a “Fall Huddle” is completed. The Fall Huddle involves the gathering of the immediate staff (all available) to meet briefly and discuss the fall, gather as much information about the fall��all known events/situations prior to the fall and a detailed description of the fall scene. A fall toolkit was created to provide staff suggestions for immediate interventions, based on the information gathered during the Fall Huddle.Measures put in place to ensure deficient practice does not occur:All residents are assessed for fall risk and all identified at high risk have been reviewed to assure appropriate fall prevention measures are in place. Facility processes have been updated to include, a IDT review of recent falls, fall history and previously implemented interventions and analysis of the information gathered and immediate interventions implemented after the fall. The IDT members evaluate


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2/4/18 - R106 had a fall at 7:30 a.m. following the fall new interventions to improve all light access initiated.

4/12/18 - R106 had a fall at 7:15 a.m. fall interventions included keeping the walker or wheel chair at bedside.

4/23/18 - R106 sustained a fall at 8:21 p.m. that resulted in a hip and pelvic fracture. Fall interventions included checking on R106 every hour.

During an interview on 5/2/18, at 3:23 p.m. family member (FM) - A stated she felt the evening shift was "way" under-staffed. FM-A stated the evening R106 fell and fractured his hip and pelvis her brother had to assist the nurse to get him up from the floor because they could not find another staff member.

During in overview on 5/3/18, at 1:03 p.m. FM-B stated she was not sure what was being done regarding R106's falls. FM-B stated the facility had not involved her in conversations regarding fall or interventions to prevent falls. FM-B stated she felt there was not enough staff in the facility.

During interview on 5/3/18, at 10:44 a.m. nursing assistant (NA)-D stated her shift stated at 6:30 a.m. NA-D stated when she arrived for her shift, she would check in the rooms. She stated she had found R106 on the floor during her morning checks. NA-D further stated it was typical to come to the floor at the start of her shift and not see an over night shift staff member. NA-D stated she felt residents were left unattended but stated no one was on a one to one currently.

the process to determine if proper root cause was determined and all possible interventions were considered and implemented, the IDT will make the appropriate adjustments if needed. Periodically all falls are reviewed by nursing administration for patterns related to time and location, any adjustments to staff allocation or policies will be made to address recognized patterns. All nursing staff have been re-educated on the updated facility processes for the prevention of falls. IDT members were educated on Root Cause Analysis.Effective implementation of actions will be monitored by:Nursing Administration will monitor the facility fall prevention and review process and follow-up as indicated.Those responsible to maintain compliance will be:Director of Nursing and/or designee will audit 50% of resident records experiencing falls monthly for 4 months for appropriate root cause analysis, interventions, and documentation to assure accuracy. The data collected will be presented and discussed monthly at the Quality Assurance Committee meetings by the Director of Nursing. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies.Completion date for certification purposes only is June 12th, 2018.


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During interview on 5/3/18, at 1:24 p.m. registered nurse (RN)-E stated all falls were investigated. She stated following a fall the interdisciplinary team would meet and implement new interventions. RN-E stated R106's last fall occurred in the bathroom. RN-E stated prior to the fall that resulted in fractures he was up all the time. RN-E stated R106 was incontinent a lot at night but did not know what to do when he got to the bathroom. She stated sometimes he fell during the day and sometimes at night.

R123's quarterly minimum data set (MDS) dated 3/15/18, indicated she was severely cognitively impaired, was frequently incontinent of bowel and bladder and required extensive assistance of one staff for toileting and transfers. R123's care plan dated 3/29/18, identified a self care deficit related to impaired mobility, weakness and cognitive deficits and a risk for falls related to a history of falls and hypotension. The care plan directed staff to check on R123 every day at midnight and offer a snack if awake, provide non-skid socks when in bed and use of a wheel chair for locomotion. The care plan further directed staff to encourage R123 to remain in a public place when not eating or napping.

During observation on 4/30/18, at 1:09 p.m. R123 was in her room alone. She was sitting in a wheel chair and digging through her dresser drawers.

Review of facility Progress Notes dated 10/11/17 through 4/21/18, identified the following falls.

10/11/17 - R123 fell at 4:35 a.m. in another residents room. Use of non-skid shoes/socks was initiated following the fall.


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10/13/17 - R123 fell at 5:00 p.m. in the hallway by the dining room. Interventions included staff to assist R123 with ambulation.

11/2/17 - R123 had a fall at 12:10 a.m. in the dining room. Fall interventions included replacing or re-aligning dycem in wheel chair.

3/23/18 - R123 had a fall at 8:30 p.m. Interventions included review/adjust toileting program.

4/21/18 - R123 fell at 6:40 a.m. Fall interventions included review/adjust toileting program, provided non -skid socks and call light education.

During interview on 5/3/18, at 11:13 a.m. NA-D stated he was aware R123 had a history of falls. NA-D stated when R123 fell, she would fall forward and stated "I don't know if it's dizziness." He stated she had been hitting her head and was prescribed a helmet but refused to wear it. NA-D stated in regard to fall interventions, "you will have to ask the nurse manager."

During interview on 5/3/18, at 1:17 p.m. RN-E stated R123 had fallen multiple times. RN-E stated R123 had some problems with postural hypotension and has hit her head multiple times. She stated a new intervention was implemented with each fall but were not successful. RN-E stated the interdisciplinary team looked at a lot of falls in the morning and some later at night. She stated she felt the last time R123 fell she was trying to get to the bathroom and reviewed her toileting plan.


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R147's quarterly MDS dated 3/21/18, indicated she was severely cognitively impaired, was incontinent of bowel and bladder and required assistance of one staff for transfers and toileting. R147's care plan dated 3/12/18, identified a self-care deficit related to cognitive deficits, history of humerus fracture and impaired mobility. The care plan further identified a risk for falls related to fall history, unsteady gait and impaired balance. The care plan directed staff to Provide a floor mat when in bed, offer toileting at night if awake and put dycem over/under chair cushions to prevent slipping.

During observation on 5/1/18, at 2:03 p.m. R147 was asleep in her wheel chair leaning to the right. An activity was in progress in a common area of the floor.

During observation on 5/2/18, at 10:01 a.m. R147 was asleep in her wheel chair in her room. An activity was in progress in the common area.

A review of facility Progress Notes dated 8/5/17 through 4/22/18 identified the following falls:

8/5/17 - R147 fell at 3:09 p.m. in her room. Fall interventions included non-skid socks or shoes.

8/25/17 - R147 fell at 6:05 a.m. in her room. Interventions included review/adjust toileting schedule.

10/24/17 - R147 fell at 1:50 a.m. in her room. Fall interventions included non-skid shoes/socks.

11/2/17 - R147 fell at 5:55 a.m. in her room. Fall interventions included non-skid shoes/socks and self locking brakes on wheel chair.


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12/1/17 - R147 fell at 4:35 a.m. in her room. Fall interventions included encourage R147 to use her call light.

12/23/17 - R147 fell at 7:45 a.m. in her room. Interventions implemented after the fall included improve call light access.

12/28/17 - R147 fell at 5:20 a.m. in her bathroom, Fall interventions included non-skid shoes or socks and offer toileting at 5:00 a.m. every day.

1/15/18 - R147 fell at 3:45 p.m. in her room. Interventions post fall included putting Dycem on her wheel chair cushion.

3/27/18 - R147 fell at 10:06 p.m. in her room. The following intervention was put in place: Dycem in wheel chair and non-skid socks.

3/30/18 - R147 had a fall at 12:45 p.m. in the door way of her room. The fall resulted in a head strike and laceration to her right eyebrow. Interventions included putting her in a common area to be seen by staff at all times.

4/22/18 - R147 fell at 4:30 p.m. near the door way to her room. Fall interventions included realign or replace Dycem in her wheel chair.

During interview on 5/3/18, at 1:21 p.m. RN-E stated sometimes R147 had falls out of bed even though she had a body pillow. RN-E stated R147 was impulsive and had a few falls getting up on her own at night and stated R147 kept removing the Dycem from her chair. She stated the interdisciplinary team was unable to identify any


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patterns related to R147's falls.

During an interview on 5/3/18, at 1:38 p.m. the director of nursing (DON) stated every morning the interdisciplinary team had a meeting. The DON stated falls were one of the first things reviewed each day. He stated anyone in the group could offer insight as to the cause of a fall. The DON stated he lead the investigations into the root cause of resident's falls. In regard to patterns of falls and identifying trends, the DON stated "I rely on my clinical managers to know their people at that level for me."

A facility policy titled Fall Report and Investigation dated 8/2016, indicated an identified purpose of further fall prevention and enhancement of quality of life. The policy indicated when a fall occurred designated staff enter the incident in the incident tracking system and the fall undergoes root cause analysis by the interdisciplinary team.


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.

F 761

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Label/Store Drugs and BiologicalsCFR(s): 483.45(g)(h)(1)(2)

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

§483.45(h) Storage of Drugs and Biologicals

F 761 6/12/18


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§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to ensure a multi-dose vial of Tubersol (used to test for tuberculosis) was dated when opened and destroyed in a timely manner. This had the potential to affect 13 residents who received Tubersol solution after 4/18/18.

Findings include:

On 5/1/18, at 3:50 p.m., during review of medication refridgerator with registered nurse (RN)-C an open vial of Tubersol solution was observed undated with manufacture expiration date of 8/9/20. RN-C was interviewed at this time and verified no open date was located on the Tubersol vial nor was there a date open sticker affixed to the vial. RN-C stated would check on how long an opened Tubersol vial could be used. RN-C further indicated nursing administration only gave the unit one Tubersol vial at a time.


F761It is the policy of Lyngblomsten Care Center that drugs and biologicals are labeled in accordance with the currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. To assure


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On 5/3/18, at 12:59 p.m., during an interview with nursing administration special assistant RN-F indicated the most recent dates which pharmacy delivered Tubersol was on 3/18/18 and 4/22/18. RN-F further indicated all 20 vials were accounted for the 4/22/18, delivery date. RN-F verified undated opened Tubersol vial was from 3/18/18, delivery date.

On 5/3/18, at 2:53 p.m., during an interview with director of nursing (DON) indicated facility staff expectations on multi dose vials have date open sticker on them.

U.S. Department of Health and Human Services website under U.S. Food and Drug Administration for product information of Tubersol Package Insert indicated on page 13 of 16 line 262 "A vial of TUBERSOL which has been entered and in use for 30 days should be discarded."

Facility policy and procedure titled Omincare LTC Facility Pharmacy Services and Procedures Manual policy#/Title: 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles revision date of 1/1/13, directed facility staff to "record the date opened on the medication container when the medication has a shortened expiration date once opened."

continued compliance the following plan has been implemented:Regarding cited residents:With respect to the potential residents affected by the use of unlabeled Tubersol, the Tubersol vials have a maximum of 10 doses per vial, only one vial was not labeled when opened. With respect to resident R74, the resident was not affected by the placement of his prescribed scheduled medication being stored in the top section of the cart.Actions taken to identify other potential residents having similar occurrences:The vast majority of residents admitted to the facility are required to be tested for tuberculosis, facility protocol dictates the use of Tubersol to perform a tuberculin skin test. With regard to the storage, distribution and administration of scheduled medications, many residents can be affected by improper practice. See next section to see measures to assure deficient practice does not reoccur.Measures put in place to ensure deficient practice does not occur:Facility processes for the dating of Tubersol vials has been reviewed and system changes were made. All Tubersol is to be delivered to the Nursing Administration team and stored in the secured refrigerator in the Nursing Staffing Supervisor’s office. When received the Supervisor will assure that a blank date opened sticker is in place on the vial and does not obscure the lot or expiration date. All requests for Tubersol will be directed to the Nursing Supervisor who will deliver the Tubersol and assure


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Based on observation, interview and document review the facility failed to proper store a schedule two controlled substance for 1 of 1 resident (R74).

On 5/2/18, at 10:18 a.m. during observation of the medication cart on Fergstad neighborhood an envelope containing a single pill was observed in the upper long drawer of the cart. The envelope was labeled for resident (R)74 and indicated the pill was an oxycodone (a schedule two controlled substance) 5mg tablet. The drawer was the top single lock drawer next to the drawer with the narcotic box in it. When asked about the oxycodone licensed practical nurse (LPN-A) stated the controled medication are supposed to be logged in by two staff and one needed to be a licensed staff person. Then the pill was supposed to be locked in the narcotics box on the medication cart until it was time to administer it to the resident.

During an interview on 5/2/18, at 10:39 a.m. clinical manager (CM-D) stated when a narcotic is placed on a care it was to be placed under double lock in the narcotics box. The staff were supposed to log the controlled medications onto the narcotics log sheets for controlled medications removed from the passport medication dispensing machine. Documentation on the log was supposed to signed by two staff members. One of those staff members needed to be a licensed nurse.

On 5/3/18, at 7:36 a.m. during an interview LPN-B stated on Fergstad only two staff members had access to the medication cart keys.

that the date opened is documented on the placed sticker. Reminder signage to “Date When Opened”, will be placed on the refrigerator where the Tubersol is stored. Facility processes for the handling, storage, and reconciliation of all scheduled medications was reviewed, no updates were needed. The staff directly involved in the deficient practice cited was coached on her error. All nursing staff have been educated on the updated facility processes for the handling of Tubersol and re-educated on the dating and storage of medications.Effective implementation of actions will be monitored by:Clinical Nursing and Nursing Administration will monitor the facility labeling and storage of medications process and follow-up as indicated.Those responsible to maintain compliance will be:Director of Nursing and/or designee will audit all medication refrigerators monthly for 4 months for appropriate storage and labeling of Tubersol. 4 times per month for 2 months Nursing Administration will conduct random spontaneous audits of a medication carts to assure the proper storage of all scheduled medications. The data collected will be presented and discussed monthly at the Quality Assurance Committee meetings by the Director of Nursing. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies.Completion date for certification purposes only is June 12th, 2018.


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One was the CM and one was the staff member passing medications.

On 5/3/18, at 2:12 p.m. the director of nursing (DON), when interviewed about controlled medication storage, stated staff were expected to place the controlled medication out of the passport dispenser under a double lock and log the medication into the passport log sheet. The DON went on to state controlled medications were not to be stored in the under a single locked drawer on the medication cart.

Lyngblomsten Care Center Practice Guideline and Procedure: Controlled Substances revised 10/2016, was reviewed and indicated controlled substances must be stored in a locked container separate from containers for non-controlled medications. This container must remained locked at all times, except when it is accessed to obtain medications for residents.

R74's Admission Report dated 5/14/18, and medication administration record (MAR) for 5/2018, were requested, but not received. R74's Minimum Data Set (MDS) Quarterly Review dated 2/21/18, indicated R76 received opiod narcotic medication seven days prior to the resident assessment date.

F 880

SS=D

Infection Prevention & ControlCFR(s): 483.80(a)(1)(2)(4)(e)(f)

§483.80 Infection ControlThe facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable

F 880 6/12/18


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diseases and infections.

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

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

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:(i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility�(ii) When and to whom possible incidents of communicable disease or infections should be reported�(iii) Standard and transmission-based precautions to be followed to prevent spread of infections�(iv)When and how isolation should be used for a resident��including but not limited to:(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility


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must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease��and(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

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

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

§483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to follow appropriate hand washing, gloving, and perineal care for 3 of 6 residents (R44, R41, R76) reviewed.

Findings include:

On 5/1/18, at 8:57 a.m. nursing assistant (NA)-E was observed approach R44, then unfastened the incontinent pad. NA-E then provided pericare in the front then pat dried the area then applied cream. NA-E then asked R44 to turn and was observed provide pericare using a wash towel. During the observation, NA-E was observed to wipe stool using a wash cloth then pat dried R44's bottom, applied cream and a clean pad while still wearing the same gloves used to provide pericare. During the observation, NA-E


F880It is the policy of Lyngblomsten Care Center that the facility establish and maintain an infection control program designed to provide a safe, sanitary and


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never changed the gloves used to provide pericare and used the same gloves to touch R44's hands and legs as she assisted him to turn side to side. -At 9:02 a.m. registered nurse (RN)-G came into the room to assist NA-E to reposition R44. NA-E still was wore the same gloves as she repositioned R44 and adjusted the pillow. -At 9:04 a.m. NA-E removed the gloves and then went to the bathroom and washed her hands. -At 9:10 a.m. NA-E acknowledged she had not changed her gloves after pericare and stated she was nervous from R44 not assisting with turning side to side. NA-E further stated she was supposed to remove the gloves after she provided pericare, wash her hands and then continue with the rest of cares.

On 5/2/18, at 1:03 p.m. when asked about gloving RN-G stated if the staff was going from dirty to clean they were supposed to change gloves and wash their hands.

On 5/2/18, at 2:29 p.m. the infection control nurse stated staff was supposed to wear gloves when in contact with body fluids and they were to remove gloves after dirty tasks, wash their hands and apply a clean pair of gloves to continue with cares.

R41's significant change Minimum Data Set (MDS) dated 2/6/18, indicated R 41 was dependent on staff for activities of daily living including toileting, incontinent of bowel and bladder and was on hospice.

On 5/2/18, at 2:30 p.m., trained medication aides (TMA)-A and TMA-D entered R41's room and explained they were going to change R41's

comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Lyngblomsten requires that staff wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. To assure continued compliance the following plan has been implemented.Regarding cited residents:With respect to resident R44, R41, and R76, all were monitored to assure no negative outcomes resulted from the infection control breach. Residents are currently infection free. Residents of the facility have been monitored and show no increase in infections or other negative effects from the poor infection control practices observed on the 5-1-18, 5-2-18, and 5-3-18. Actions taken to identify other potential residents having similar occurrences:All residents receiving direct care are at risk for infection if proper infection control practices are not maintained, see next section to see measures to assure deficient practice does not reoccur.Measures put in place to ensure deficient practice does not occur:All staff have been re-educated on proper infection control practices with particular focus on peri-care, glove use and hand washing/disinfection process and sequence. Proper peri-care training was added to annual training. Infection surveillance and tracking continues with analysis of data used to determine if staff practices are contributing to the


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incontinence brief. TMA-A and TMA-D gathered supplies, washed hands and put on gloves. TMA-D pulled back R41's sheets, loosened incontinence brief and rolled R41 on to left side. TMA-A wiped R41's bottom from front to back with a wash cloth. There was brown stool on the wash cloth. TMA-A removed gloves and did not wash hands or use alcohol based sanitizer. TMA-A put a new pair of gloves on, applied barrier cream to R41's bottom. TMA-A again removed gloves and put new gloves on without washing hands or using an alcohol based sanitizer TMA-A applied a new incontinence brief and adjusted R41's blankets. TMA-A removed gloves and washed hands.

During interview on 5/2/18, at 2:41 p.m., TMA-A verified did not use sanitizer between glove changes. TMA-A stated would normally just wash hands or use sanitizer at the beginning and at the end incontinence cares.

During interview on 5/3/18, at 1:51 p.m., the director of nurses stated staff were to wash hands or use sanitizer after every glove change.

R76's Admission Record dated 5/3/18 indicated R76 was a 68 year old female. R76's Diagnosis Report indicated R76 had diagnoses of chronic respiratory failure with hypoxia, rheumatoid arthritis, psoriasis, cellulitis, diabetes mellitus with circulatory complications and systemic lupus erythematous. R76's Minimum Data Set (MDS) dated indicated R76 had a Brief (BIMS) score of 15 out of 15. R76's Resident Care Sheet dated 5/1/18 indicated R76 was to be checked and changed every 2 hours and R76's perineal and buttocks were to be patted not wiped dry.

development and transmission of infections. New data analysis includes infection data cross referenced by area to determine if trending can be attributed to a specific location.Effective implementation of actions will be monitored by:Infection Preventionist will monitor facility adherence to practices, polices and/or procedures and follow-up as indicated.Those responsible to maintain compliance will be:The Infection Preventionist and/or designee will complete 5 audits each week for one month and then 5 audits every other week for two months to include proper compliance with procedures. The data collected will be presented to the Quality Assurance committee by the Infection Preventionist. The data will be reviewed/discussed at the monthly Quality Assurance Meeting. At that time the Quality Assurance committee will make the decision/recommendation regarding any necessary follow-up studies.Completion date for certification purposes only is June 12th, 2018.


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During observation of morning cares on 5/2/18, at 9:22 a.m. for resident (R76) nursing assistant-(NA) A entered R76's room and collected supplies to provide the care. R76 was lying in bed on her back. NA-A had prepared two basins. One basin had soapy water in it and the other contained just water. NA-A had R76 roll over onto her left side. On R76's right buttocks there was a open wound approximately 2.5 centimeters (cm) by 1.5 cm. On the left buttock there was another open wound measuring approximately 0.25 cm by 0.25 cm. The surrounding tissue was a very dark brown color. NA-A took a washcloth out of the soapy water and wiped R76's buttocks from back to front 3 times. NA-A placed the used washcloth in a plastic bag. NA-A took a wet washcloth out of the basin with plain water and wiped R76's buttocks from back to front 3 times. NA-A placed the washcloth in a plastic bag. Then NA-A took a dry towel and wiped the buttocks from back to front again. NA-A asked R76 to roll onto her back. Without changing gloves or water NA-A took a washcloth out of the basin with soapy water washed R76's perineum from front to back multiple times. NA-A then took a washcloth from the plain water and wiped the perineum from from front to back multiple times. NA-A dried R76's perineal area with a clean towel.

On 5/2/18, at 10:35 a.m. NA-A was interviewed regarding R76's morning cares. NA-A stated R76 told NA-A to clean the buttocks before the perineal area. NA-A stated "I was taught to wash the perineal and buttocks from front to back, but because of the open sores I washed from back to front so I don't contaminate the open sore." NA-A added R76 asked to have the buttocks washed first.


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- At 10:39 a.m. clinical manager (CM)-D stated during an interview the nursing assistants were taught to wash the perineal area from front to back to prevent infections. CM-D also stated the nursing assistants should wash the perineal area and buttock towards the end of the care if it is full body bed bath, and if the nursing assistant was providing peri-care wiping was always to be front to back. CM-D stated nursing staff received infection control education on hire and annually.

On 5/3/18, at 2:12 p.m. director of nursing (DON) was asked about perineal care. DON stated the nursing assistants are expected to follow the training on perineal care received on hire and annually. DON added wiping should always be front to back and if the resident requested a different procedure the nursing assistants were expected to discuss the request with the nurse or the clinical manager for that resident.

Other documents reviewed included Tena Perineal Care Checklist undated, which noted female perineal care was to be done front to back to prevent bacteria from the rectum getting into the urethra��Perineal Care Policy dated 03/18 instructed staff to wash the front perineal area first and then assist resident to side lying position and wash the buttocks.


susanne reuss, unit supervisor alison helm, enforcement ... · 06-fail to meet agreement other...

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