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

Transcription

1 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 ID: QCIB Facility ID: MEDICARE/MEDICAID PROVIDER NO. (L1) STATE VENDOR OR MEDICAID NO. (L2) EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 09/29/ DATE OF SURVEY 12/14/2015 (L34) 8. ACCREDITATION STATUS: (L10) 0 Unaccredited 2 AOA 1 TJC 3 Other 3. NAME AND ADDRESS OF FACILITY (L3) TRINITY CARE CENTER (L4) TH STREET WEST (L5) FARMINGTON, MN (L6) 7. PROVIDER/SUPPLIER CATEGORY 02 (L7) 01 Hospital 02 SNF/NF/Dual 03 SNF/NF/Distinct 04 SNF 05 HHA 06 PRTF 07 X-Ray 08 OPT/SP 09 ESRD 10 NF 11 ICF/IID 12 RHC 13 PTIP 14 CORF 15 ASC 16 HOSPICE CLIA 4. TYPE OF ACTION: 7(L8) 1. Initial 3. Termination 5. Validation 7. On-Site Visit 8. Full Survey After Complaint 2. Recertification 4. CHOW 6. Complaint 9. Other FISCAL YEAR ENDING DATE: (L35) 12/ LTC PERIOD OF CERTIFICATION From (a): To (b): 12.Total Facility Beds 13.Total Certified Beds (L18) (L17) 10.THE FACILITY IS CERTIFIED AS: X A. In Compliance With Program Requirements Compliance Based On: 1. Acceptable POC B. Not in Compliance with Program Requirements and/or Applied Waivers: And/Or Approved Waivers Of The Following Requirements: 2. Technical Personnel Hour RN 4. 7-Day RN (Rural SNF) 5. Life Safety Code * Code: (L12) A 6. Scope of Services Limit 7. Medical Director 8. Patient Room Size 9. Beds/Room 14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS 18 SNF 18/19 SNF SNF ICF IID 1861 (e) (1) or 1861 (j) (1): (L15) (L37) (L38) (L39) (L42) (L43) 16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE): 17. SURVEYOR SIGNATURE Date : 18. STATE SURVEY AGENCY APPROVAL Date: 12/18/2015 Gayle Lantto, Unit Supervisor (L19) PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY 12/21/2015 (L20) 19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL RIGHTS ACT: 1. Facility is Eligible to Participate 2. Facility is not Eligible (L21) Statement of Financial Solvency (HCFA-2572) 2. Ownership/Control Interest Disclosure Stmt (HCFA-1513) 3. Both of the Above : 22. ORIGINAL DATE OF PARTICIPATION 23. LTC AGREEMENT BEGINNING DATE 24. LTC AGREEMENT ENDING DATE 07/20/1982 (L24) (L41) (L25) 25. LTC EXTENSION DATE: 27. ALTERNATIVE SANCTIONS A. Suspension of Admissions: (L44) (L27) B. Rescind Suspension Date: (L45) 26. TERMINATION ACTION: (L30) VOLUNTARY 01-Merger, Closure Dissatisfaction W/ Reimbursement 03-Risk of Involuntary Termination 04-Other Reason for Withdrawal INVOLUNTARY 05-Fail to Meet Health/Safety 06-Fail to Meet Agreement OTHER 07-Provider Status Change 00-Active 28. TERMINATION DATE: 29. INTERMEDIARY/CARRIER NO. 30. REMARKS (L28) (L31) 31. RO RECEIPT OF CMS DETERMINATION OF APPROVAL DATE (L32) (L33) DETERMINATION APPROVAL FORM CMS-1539 (7-84) (Destroy Prior Editions)

2 CMS Certification Number (CCN): December 18, 2015 Ms. Elizabeth Letich, Administrator Trinity Care Center th Street West Farmington, Minnesota Dear Ms. Letich: The Minnesota Department of Health assists the Centers for Medicare and Medicaid Services (CMS) by surveying skilled nursing facilities and nursing facilities to determine whether they meet the requirements for participation. To participate as a skilled nursing facility in the Medicare program or as a nursing facility in the Medicaid program, a provider must be in substantial compliance with each of the requirements established by the Secretary of Health and Human Services found in 42 CFR part 483, Subpart B. Based upon your facility being in substantial compliance, we are recommending to CMS that your facility be recertified for participation in the Medicare and Medicaid program. Effective November 30, 2015 the above facility is certified for: 65 Skilled Nursing Facility/Nursing Facility Beds Your facility s Medicare approved area consists of all 65 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. Feel free to contact me if you have questions related to this enotice. Sincerely, Mark Meath, Enforcement Specialist Program Assurance Unit Licensing and Certification Program Health Regulation Division Minnesota Department of Health mark.meath@state.mn.us Telephone: (651) Fax: (651) Protecting, maintaining and improving the health of all Minnesotans

3 Electronically delivered December 18, 2015 Ms. Elizabeth Letich, Administrator Trinity Care Center th Street West Farmington, Minnesota RE: Project Number S Dear Ms. Letich: On November 17, 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 29, This survey found the most serious deficiencies to be isolated deficiencies that constituted no actual harm with potential for more than minimal harm that was not immediate jeopardy (Level D), whereby corrections were required. On December 14, 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 29, We presumed, based on your plan of correction, that your facility had corrected these deficiencies as of November 30, Based on our PCR, we have determined that your facility has corrected the deficiencies issued pursuant to our standard survey, completed on October 29, 2015, effective November 30, 2015 and therefore remedies outlined in our letter to you dated November 17, 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 related to this enotice. Sincerely, Mark Meath, Enforcement Specialist Program Assurance Unit Licensing and Certification Program Health Regulation Division Minnesota Department of Health mark.meath@state.mn.us Telephone: (651) Fax: (651) Protecting, maintaining and improving the health of all Minnesotans

4 Department of Health and Human Services Centers for Medicare & Medicaid Services Post-Certification Revisit Report Form Approved OMB NO Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork Reduction Project ( ), Washington, D.C (Y1) Provider / Supplier / CLIA / Identification Number Name of Facility TRINITY CARE CENTER (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code TH STREET WEST FARMINGTON, MN (Y3) Date of Revisit 12/14/2015 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 that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date F /30/2015 F /30/ (n) (h)(2) 0253 Reviewed By State Agency Reviewed By CMS RO Reviewed By Reviewed By Followup to Survey on: 10/29/2015 Date: Date: Signature of Surveyor: GL/mm 12/18/ /14/2015 Signature of Surveyor: Date: Date: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? YES NO Form CMS B (9-92) Page 1 of 1 Event ID: QCIB12

5 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 ID: QCIB Facility ID: MEDICARE/MEDICAID PROVIDER NO. (L1) STATE VENDOR OR MEDICAID NO. (L2) EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 09/29/ DATE OF SURVEY 10/29/2015 (L34) 8. ACCREDITATION STATUS: (L10) 0 Unaccredited 2 AOA 1 TJC 3 Other 3. NAME AND ADDRESS OF FACILITY (L3) TRINITY CARE CENTER (L4) TH STREET WEST (L5) FARMINGTON, MN (L6) 7. PROVIDER/SUPPLIER CATEGORY 02 (L7) 01 Hospital 02 SNF/NF/Dual 03 SNF/NF/Distinct 04 SNF 05 HHA 06 PRTF 07 X-Ray 08 OPT/SP 09 ESRD 10 NF 11 ICF/IID 12 RHC 13 PTIP 14 CORF 15 ASC 16 HOSPICE CLIA 4. TYPE OF ACTION: 2(L8) 1. Initial 3. Termination 5. Validation 7. On-Site Visit 8. Full Survey After Complaint 2. Recertification 4. CHOW 6. Complaint 9. Other FISCAL YEAR ENDING DATE: (L35) 12/ LTC PERIOD OF CERTIFICATION From (a): To (b): 12.Total Facility Beds 13.Total Certified Beds (L18) (L17) 10.THE FACILITY IS CERTIFIED AS: A. In Compliance With Program Requirements Compliance Based On: 1. Acceptable POC X B. Not in Compliance with Program Requirements and/or Applied Waivers: And/Or Approved Waivers Of The Following Requirements: 2. Technical Personnel Hour RN 4. 7-Day RN (Rural SNF) 5. Life Safety Code * Code: B* (L12) 6. Scope of Services Limit 7. Medical Director 8. Patient Room Size 9. Beds/Room 14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS 18 SNF 18/19 SNF 19 SNF ICF IID 1861 (e) (1) or 1861 (j) (1): (L15) 65 (L37) (L38) (L39) (L42) (L43) 16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE): 17. SURVEYOR SIGNATURE Date : 18. STATE SURVEY AGENCY APPROVAL Date: Shawn Soucek, HPR SWS 11/23/ /18/2015 (L19) (L20) PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY 19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL RIGHTS ACT: 1. Facility is Eligible to Participate 2. Facility is not Eligible (L21) Statement of Financial Solvency (HCFA-2572) 2. Ownership/Control Interest Disclosure Stmt (HCFA-1513) 3. Both of the Above : 22. ORIGINAL DATE OF PARTICIPATION 23. LTC AGREEMENT BEGINNING DATE 24. LTC AGREEMENT ENDING DATE 07/20/1982 (L24) (L41) (L25) 25. LTC EXTENSION DATE: 27. ALTERNATIVE SANCTIONS A. Suspension of Admissions: (L44) (L27) B. Rescind Suspension Date: (L45) 26. TERMINATION ACTION: (L30) VOLUNTARY 01-Merger, Closure Dissatisfaction W/ Reimbursement 03-Risk of Involuntary Termination 04-Other Reason for Withdrawal INVOLUNTARY 05-Fail to Meet Health/Safety 06-Fail to Meet Agreement OTHER 07-Provider Status Change 00-Active 28. TERMINATION DATE: 29. INTERMEDIARY/CARRIER NO. 30. REMARKS (L28) (L31) 31. RO RECEIPT OF CMS DETERMINATION OF APPROVAL DATE (L32) (L33) DETERMINATION APPROVAL FORM CMS-1539 (7-84) (Destroy Prior Editions)

6 Electronically delivered November 17, 2015 Ms. Elizabeth Letich, Administrator Trinity Care Center th Street West Farmington, Minnesota RE: Project Number S Dear Ms. Letich: On October 29, 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 isolated deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy (Level D), 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 - 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; 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. Protecting, maintaining and improving the health of all Minnesotans

7 Trinity Care Center November 17, 2015 Page 2 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: Gayle Lantto, Unit Supervisor Metro D Survey Team Licensing and Certification Program Health Regulation Division Minnesota Department of Health Phone: (651) Fax: (651) 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 8, 2015, the Department of Health will impose the following remedy: State Monitoring. (42 CFR ) 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; - 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;

8 Trinity Care Center November 17, 2015 Page 3 - 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 (a)); Per day civil money penalty (42 CFR through ). Failure to submit an acceptable epoc could also result in the termination of your facility s Medicare and/or Medicaid agreement. PRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCE The facility's epoc will serve as your allegation of compliance upon the Department's acceptance. Your signature at the bottom of the first page of the CMS-2567 form will be used as verification of compliance. In order for your allegation of compliance to be acceptable to the Department, the epoc must meet the criteria listed in the plan of correction section above. You will be notified by the Minnesota Department of Health, Licensing and Certification Program staff and/or the Department of Public Safety, State Fire Marshal Division staff, if your epoc for the respective deficiencies (if any) is acceptable. VERIFICATION OF SUBSTANTIAL COMPLIANCE Upon receipt of an acceptable epoc, an onsite revisit of your facility may be conducted to validate that substantial compliance with the regulations has been attained in accordance with your verification. A Post Certification Revisit (PCR) will occur after the date you identified that compliance was achieved in your plan of correction. If substantial compliance has been achieved, certification of your facility in the Medicare and/or Medicaid program(s) will be continued and remedies will not be imposed. Compliance is certified as

9 Trinity Care Center November 17, 2015 Page 4 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 29, 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 (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. 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 29, 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 and

10 Trinity Care Center November 17, 2015 Page 5 INFORMAL DISPUTE RESOLUTION In accordance with 42 CFR , you have one opportunity to question cited deficiencies through an informal dispute resolution process. You are required to send your written request, along with the specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies, to: Nursing Home Informal Dispute Process Minnesota Department of Health Health Regulation Division P.O. Box St. Paul, Minnesota This request must be sent within the same ten days you have for submitting an epoc for the cited deficiencies. All requests for an IDR or IIDR of federal deficiencies must be submitted via the web at: You must notify MDH at this website of your request for an IDR or IIDR within the 10 calendar day period allotted for submitting an acceptable plan of correction. A copy of the Department s informal dispute resolution policies are posted on the MDH Information Bulletin website at: Please note that the failure to complete the informal dispute resolution process will not delay the dates specified for compliance or the imposition of remedies. Feel free to contact me if you have questions related to this enotice. Sincerely, Mark Meath, Enforcement Specialist Program Assurance Unit Licensing and Certification Program Health Regulation Division Minnesota Department of Health mark.meath@state.mn.us

11 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 000 INITIAL COMMENTS F 000 The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance. Because you are enrolled in epoc, your signature is not required at the bottom of the first page of the CMS-2567 form. Your electronic submission of the POC will be used as verification of compliance. F 176 SS=D Upon receipt of an acceptable electronic POC, an on-site revisit of your facility may be conducted to validate that substantial compliance with the regulations has been attained in accordance with your verification (n) RESIDENT SELF-ADMINISTER DRUGS IF DEEMED SAFE F /30/15 An individual resident may self-administer drugs if the interdisciplinary team, as defined by (d)(2)(ii), has determined that this practice is safe. This REQUIREMENT is not met as evidenced by: Based on observation, interview and document review, the facility failed to assess 1 of 1 resident (R54) who was observed to self-administer medications. Findings include: R54 was observed on 10/26/15, at 3:28 p.m. while seated on the edge of her bed. The resident was slightly leaning forward, and had a nebulizer mask on her face (with medication to aid in breathing). A medication cart was in the hall outside R54's room and no licensed nurse A self-administration of medication assessment will be completed for resident R54. Care plan interventions will be developed based off of the assessment. All residents that self-administer nebulizers have the potential to be affected by a deficient practice. All residents who receive nebulized medications will be reassessed for self-administration of the nebulizer and care plans will be updated based upon the individualized assessment. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 11/20/2015 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 1 of 7

12 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 176 Continued From page 1 F 176 present at the cart nor within sight of the resident. Following the observation at 3:30 p.m. the surveyor entered R54's room. The machine was no longer running and mist was not audible or seen coming from the mask. When asked about the nebulizer machine not running R54 explained, "I just shut my neb [nebulizer treatment] off because it has been ten minutes. Usually the nurse comes back after ten minutes." It was noted approximately one quarter to one third of the liquid remained in the nebulizer canister. a nursing assistant (NA)-A then stepped into R54's doorway and surveyor informed her R54 reported she shut off the treatment. NA-A stated, "I will go get the nurse." At 3:34 p.m. a registered nurse (RN)-B came into R54's room. RN-B stated to R54, "I told you ten minutes" and asked the resident why the machine was shut off when the treatment was not finished and liquid medication remained. R54 told RN-B she did not know how the machine had been turned off. RN-B then instructed R54 to keep the mask on and proceeded to turn it back on. RN-B told R54, "I will set the alarm on again" and then turned and left the resident's room. Policies and Procedures were reviewed and revised as needed. All licensed staff was updated on the self-administration of medication policy. Random chart/observation audits will be completed by DON or designee. A minimum of three audits will be completed weekly for four weeks then two audits per month X 2 months. Audit results will be brought to QAPI and reviewed for further recommendation. Staff will be re-educated on an ongoing basis as needed based on results of the audits. Completion date: At 3:40 p.m. RN-B entered R54's room, turned off the nebulizer machine, measured R54's oxygen saturation level, listened to her lungs with a stethoscope and then left the room. A few minutes later RN-B was asked whether R54 had been assessed for self-administration of medication (SAM). RN-B replied, "I don't know if she has an assessment. I am usually around or in the hall." When asked where she was at the time of the observation when R54 had shut off the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 2 of 7

13 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 176 Continued From page 2 F 176 treatment prior to receiving all of the medication RN-B answered, "I was just in another resident's room giving eye drops." At 4:59 p.m. RN-A stated that R54 had experienced some cognitive and visual changes and she was not seeing anything other than peripheral "half vision." RN-A also stated R54 was confused. RN-A further stated, "Usually what I do is set up her neb and have the med [medication] cart in the hall nearby. Sometimes she will take the neb off." RN-A also verified R54 had not been assessed as safe to self-administer medications. R54's quarterly Minimum Data Set (MDS) dated 10/5/15, indicated R54's cognition was moderately impaired. R54's significant change MDS dated 7/20/15, indicated R54's cognition was moderately impaired, but also noted she was experiencing signs and symptoms of delirium (altered mental status) as evidenced by "Inattention present, resident has difficult focusing attention (easily distracted, out of touch, or difficulty following what was said)." R54's Care Area Assessment (CAA) dated 7/24/15, indicated R54 had times of "Delirium, Changing Cognitive Status, Daily Behavioral Symptoms/Decline in Behavior and Communication Problems...Limiting Factors Resulting in Need for Assistance with Any of the ADLs (activities of daily living) with Mental Errors: Sequencing Problems, Incomplete Performance, or Anxiety Limitations...increased problems with her cognition. is able to communicate at times with staff but has increased confusion and decline in cognition." A 10/5/15, progress note indicated "Respiratory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 3 of 7

14 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 176 Continued From page 3 F 176 Assessment: Resident has impaired cognition r/t [related to] dementia. Resident was treated in February for pneumonia." Her current diagnoses that impacted her respiratory status included chronic obstructive pulmonary disease (COPD), shortness of breath, congestive heart failure (CHF) and asthma. She utilized oxygen, and was prescribed Pulmicort [medication decreases irritation and swelling in airway] 0.5 mg/2 ml BID [twice a day] and Albuterol [medication relaxes and opens airways] nebs" four times daily and every two hours as needed. A 9/16/15, progress note indicated R54 tolerated the nebulizer treatment well "with constant supervision" and utilized oxygen (O2) at three liters "which she frequently removes..." A 8/12/15, progress note indicated "Resident ambulating alone in room several times-- difficult to redirect--neb tx [treatment] tol [tolerate] well with constant cueing--resident noted by NAR [nursing assistant] this am to be trying to cut ankle monitor off her leg with a fingernail file--staff did remove file." 5/27/15, progress note read, "Daughter reports that she comes at times and neither O2 tank is on." R54's care plan dated 9/19/14, indicated "Potential for alteration in respiratory status r/t COPD & CHF. Administer medications as ordered." The plan did not include direction to staff to allow R54 to self-administer her own medications. Physician Orders for R54 dated 6/30/15, included "Albuterol neb Nebulizer 4 times daily and every FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 4 of 7

15 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 176 Continued From page 4 F 176 two hours as needed, as well as Pulmicort neb Nebulizer 2 times daily. The electronic treatment administration record for 10/15, indicated R54 had been routinely receiving the Albuterol and Pulmicort nebulizer treatments. On 10/29/15, at approximately 10:00 a.m. the director of nursing (DON) explained that if a resident wanted to self-administer medication, an assessment was completed to determine if it was a sage practice. This would then be noted in their progress notes. In addition, if a resident was not capable of self-administering a nebulizer treatment, it was expected the nurse would be within eyesight of the resident. R54 did not have an assessment indicating she could safely administer her nebulizer treatment, nor would she have been considered safe to do so, as she removed the mask during treatments. F 253 SS=D A 9/1/15, Self Administration Of Medications policy read, "It is the policy of Trinity Care Center to provide each resident with the option of self administration of medications if the Interdisciplinary Team determines that this practice is safe...self administration will be individualized in the resident's care plan." (h)(2) HOUSEKEEPING & MAINTENANCE SERVICES F /30/15 The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This REQUIREMENT is not met as evidenced by: Based on observation, interview and documents Resident R 71 s wheelchair was cleaned FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 5 of 7

16 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 253 Continued From page 5 F 253 review the facility failed to ensure wheelchairs were kept clean for 1 of 5 residents (R71) whose wheelchairs were observed. Findings include: On 10/26/15, at 3:46 p.m. during the initial observation R71's wheelchair was soiled with dark marks and a dried white substance and food spills on the arm rests and seat. The wheelchair remained unclean when observed the three subsequent days of the survey. R71's Minimum Data Set assessment dated 9/11/15, indicated the resident was severely cognitively impaired and required extensive assist with all cares. On 10/29/15, at 9:45 a.m. the administrator stated the housekeeping department had cleaned R71's wheelchair "this week," but said the white marks on the arms and cushion may have been stains. At 12:39 p.m. the administrator and housekeeping director provided a cleaning schedule and policy for wheelchair maintenance. In addition a wheelchair cleaning log was provided for 10/15, that indicated R71's wheelchair had been cleaned. The administrator did state normally if the wheelchair cushion is stained the director of nursing would order a replacement cushion. on 10/29/2015 and 11/3/2015. Resident R 71 was added to a twice per week cleaning schedule and as needed in-between. All residents using wheelchairs have the potential to be affected by a deficient practice. Policy and procedure for wheelchair cleaning was reviewed and revised as needed. The schedule for routine cleaning of wheelchairs was updated. Those wheelchairs requiring more frequent cleaning will be identified and placed on a more frequent routine cleaning schedule. All staff will be educated on the policy of cleaning wheelchairs and the need to clean wheelchairs as needed in-between. Audits of the wheelchairs and scheduled cleaning will be completed at random times throughout the 24 hours per day. 3 audits will be completed weekly for 4 weeks and then 2 audits monthly for 2 months. Audit results will be brought to QAPI and reviewed for further education. Completion date: A 11/3/12, Wheelchair & Geriatric Chair Maintenance policy indicated housekeeping aids were responsible for the cleaning of all chairs weekly or more frequently if needed. All staff were to inform maintenance if a wheelchair needed repair. The purpose of the policy was to maintain neatness and cleanliness for all chairs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 6 of 7

17 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 11/23/2015 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED NAME OF PROVIDER OR SUPPLIER TRINITY CARE CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) B. WING 10/29/2015 ID STREET ADDRESS, CITY, STATE, ZIP CODE TH STREET WEST FARMINGTON, MN PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE F 253 Continued From page 6 F 253 Housekeeping was to inspect chairs weekly for damages and cleaning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QCIB11 Facility ID: If continuation sheet Page 7 of 7

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