DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS … · CMS Certification Number (CCN): 24-5450 September 7, 2017 Mr. Mark Anderson, Administrator Three Links Care Center 815 Forest

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: 00564

ID: ULPP

NORTHFIELD, 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)

770343100

7

09/30

05/01/2017

THREE LINKS CARE CENTER245450

02

815 FOREST AVENUE

55057

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 101 (L18)

13.Total Certified Beds 101 (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)

101

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

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

See Attached Remarks

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

09/01/1987

00

01111

06/22/2017

05/22/2017 09/07/2017

21.

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

Shellae Dietrich, Certification SpecialistMary Bruess, NFE NE II




ID: ULPP

C&T REMARKS - CMS 1539 FORM STATE AGENCY REMARKS

CCN: 24-5450

On February 28, 2017, an abbreviated standard survey was completed at this facility. The deficiency cited at F323 was at the

S/S level of G.

On March 23, 2017, a standard survey was completed at this facility. The most serious deficiencies were cited at a S/S level of

F.

As a result of the survey findings, and as authorized by the CMS RO, we notified the facility of imposition of the following:

- Category 1 remedy of State monitoring, effective March 26, 2017

- Mandatory denial of payment for new Medicare and Medicaid Admissions (DPNA), effective May 28, 2017.

If DOPNA were to go into effect, the facility would be subject to a two year loss of NATCEP, beginning May 28, 2017.

On April 14, 2017 the Department of Public Safety completed a PCR and found the facility had corrected the life safety code

deficiencies.

On May 1, 2017 the Department of Health completed a PCR and found the health deficiencies related to the abbreviated

standard and the standard surveys were corrected as well.

As a result of finding, the facility achieved compliance, the Department discontinued the Category 1 remedy of State

monitoring, as of April 13, 2017

In addition, we recommended the following actions to the CMS RO as it relates to the remedies detailed in our letters of

March 21, 2017 and April 5, 2017 and CMS concurred:

- CMP for deficiency cited at F323, be imposed.

- Mandatory denial of payment for new Medicare and Medicaid Admissions (DPNA), effective May 28, 2017, be rescinded.

Since DPNA did not go into effect. The facility would not be subject to a two year loss of NATCEP, which was to begin,

May 28, 2017.


CMS Certification Number (CCN): 24-5450 September 7, 2017

Mr. Mark Anderson, Administrator

Three Links Care Center

815 Forest Avenue

Northfield, Minnesota 55057

Dear Mr. Anderson:

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 April 13, 2017 the above facility is certified for:

101 Skilled Nursing Facility/Nursing Facility Beds

Your facility�s Medicare approved area consists of all 101 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,

Shellae Dietrich, Certification Specialist

Program Assurance Unit

Licensing and Certification Program

Health Regulation Division

Minnesota Department of Health

P.O. Box 64900

St. Paul, MN 55164-0900

Telephone #: 651-201-4106 Fax #: 651-215-9697

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.

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ID: ULPP

NORTHFIELD, MN

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)

2

09/30

03/23/2017

THREE LINKS CARE CENTER

MEDICARE/MEDICAID PROVIDER

NO.(L1) 245450

STATE VENDOR OR MEDICAID NO.

(L2) 770343100

02

815 FOREST AVENUE

55057

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 101 (L18)

13.Total Certified Beds 101 (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)

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

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

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

09/01/1987

00

06201

04/18/201705/19/2017

21.


Kamala Fiske-Downing, Enforcement SpecialistSandra Tatro, HFE NE II

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A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X3) DATE SURVEY COMPLETED

PRINTED: 04/19/2017FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

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

245450 03/23/2017STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

815 FOREST AVENUETHREE LINKS CARE CENTER

NORTHFIELD, MN 55057

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

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

(X5)COMPLETION

DATE

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TAG

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TAG

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

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

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

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

F 278

SS=D

483.20(g)-(j) ASSESSMENT ACCURACY/COORDINATION/CERTIFIED

(g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status.

(h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

(i) Certification(1) A registered nurse must sign and certify that the assessment is completed.

(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

(j) Penalty for Falsification(1) Under Medicare and Medicaid, an individual who willfully and knowingly-

F 278 4/10/17

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

04/11/2017Electronically 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 ULPP11Event ID: Facility ID: 00564 If continuation sheet Page 1 of 10

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F 278 Continued From page 1 F 278

(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment��or

(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.

(2) Clinical disagreement does not constitute a material and false statement.This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to completely assess 1 of 1 resident (R140) who experienced a change in condition but lacked a significant change assessment.

Findings include:

R140's admission Minimum Data Set (MDS) completed 11/24/16, indicated the resident required limited assistance (highly involved in activity��staff provided guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility, transferring and locomotion on the unit, and had no incontinence. A subsequent quarterly MDS completed 2/24/17, revealed the resident had declined and required extensive assistance with bed mobility, transferring locomotion on the unit, and was occasionally incontinent, however, a a quarterly assessment versus a significant change assessment was completed.

The corresponding Care Area Assessment (CAA) dated 11/29/16, noted R140 had poor balance and coordination, but was receiving physical and

F000Although Three Links Care Center objects to and disagrees with both the findings of non-compliance and the level of deficiency cited, We will work closely with the Department of Health to remedy them. Three links Care Center does not believe that the conditions have caused actual harm or substandard quality of care.

This Credible Allegation of Compliance has been prepared and timely submitted. Submission of this Credible Allegation of Compliance is not a legal admission that a deficiency exists or that the Statement of Deficiency were correctly cited, and is also not to be construed as an admission against interest of the Facility, its Administrator or any employees, agents or other individuals who draft or may be discussed in this Credible Allegation of Compliance. In addition, preparation and submission of this Credible Allegation of Compliance does not constitute an admission or agreement of any kind by


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occupational therapies (PT and OT). R140 was walking three times daily 150 feet with a walker, gait belt, and one staff, and had a restorative dressing program to increase independence.

Progress Notes for R140 showed on 11/21/16 and 12/22/16, the resident required limited assistance with bed mobility, transferring, and locomotion on the unit, however, on 12/29/16, documentation reflected resident required extensive assistance. The note also indicated R140's occupational therapy had been discontinued on 12/23/16, and a restorative nursing program has been started. R140 had edema and weeping (excess fluid in the tissues) in her lower legs, however, restorative notes dated 1/10/17, indicated R140 continued walking 150 feet with one assist.

A bladder assessment dated 11/23/16, indicated R140 was continent of bladder and bowel. The care plan initiated on 12/8/16, indicated R140 had occasional bowel incontinence. A subsequent assessment dated 2/22/17, indicated resident had urine leakage on the way to the bathroom. A social services note dated 12/1/16, revealed R140 had cognitive testing completed and scored in the moderate functional decline level which indicated "24/7 supervision is recommended."

Progress notes were as follows: 1) 12/5/16, the resident was continent and required limited assistance from staff. "A lot of her assistance simply involves cueing her as to where she is going and where the next location is."

Facility of the truth of any facts alleged or the correctness of any conclusions set forth in this allegation by the survey agency.

Accordingly, we are submitting this Credible Allegation of Compliance solely because state and federal law mandate submission of a Credible Allegation of Compliance within ten (10) days of receipt of the Statement of deficiencies as a condition to participate in the Medicare & Medical Assistance programs. The submission of the Credible Allegation of Compliance within this time frame should in no way be considered or construed as agreement with the allegations of non-compliance or admissions by the facility.

F278SS=D 483.20 ASSESSMENT/ACCURACY/COORDINATION/CERTIFIED

It is the policy of Three Links Care Center to update the care plan, initiate new assessments, update the MDS and initiate a significant change evaluation, and notify the MD, the resident family or family representative of any change in the resident�s condition.

Resident-R140

The resident�s care plan has been reviewed and revised by the interdisciplinary team and has been


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2) 12/9/16, "Noted resident has 2 cm [centimeter] x 1 cm open area between gluteal folds at top of coccyx, area is odorous. Small amt [amount] of serous drainage on pull up that resident was wearing."

3) 12/15/16, "Resident noted to have two open areas to left lower extremity which are vascular in nature due to cellulitis [infection from opening in skin]. There is a large open area on her left lateral ankle, that measures 5.3 cm wide and 5 cm. long.--see wound flowsheet for details including current Tx [treatment] in place. The front of her left leg has multiple small areas that are open. See wound flow sheet. Resident's weight was 168.5 lbs. today, and 171.0 last week."

4) 12/26/16, Lower extremity dressing changes daily: Right leg is completed healed, no longer needs cleansing or dressings. [Dressings lower legs]...Buttocks/top of coccyx open area in fold measures 0.7 cm x 0.2 cm today...."

5) 12/29/16, indicated "Resident is extensive assist of 1 with bed mobility, transferring, toileting, hygiene, dressing, and bathing. She is walking with 1 staff to and from all destinations in facility with gait belt and walker. Rarely uses w/c [wheelchair]. She is continent of bowel, does wear pull ups 'just in case' for occ leakage of bladder."

6) 2/19/17, R140 required extensive assistance five times from staff with transfers from 2/19 to 2/24/17.

7) 2/22/17, R140 required limited support for bed mobility, transferring, walking on the unit, and extensive assist off the unit. R140 participated in

reviewed with the physician.

Polices for notification of condition change have been reviewed.

A daily clinical IDT (interdisciplinary team) meeting has been initiated every morning Monday through Friday (unless holiday) to review all clinical changes with residents in the building. This includes nursing, MDS, DON, and education. Significant change assessments are put into place when warranted in these meetings.

Residents are monitored for change in condition daily with shift to shift report, 24-hour report with daily unit manager oversight. 24 hour report (72hour over weekend reports) are generated daily and discussed at IDT for changes in condition. Monitoring of this practice will be completed by the Director of Nursing or designee.

The Director of Nursing or designee will report quarterly to the facility QA on progress for 4 quarters. Facility Director of Nursing or designee will be responsible for maintaining compliance.

The facility alleges that it will be in substantial compliance and complete all action items by 4/8/17


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dressing and undressing, washing and teeth brushing, but needed extensive assist for other hair combing and toileting. The resident wore pull ups for occasional leakage of urine and needed assistance with pericare and pad changes due to balance concerns. The MDS indicated six restorative nursing sessions had been provided, however, one of the sessions on 3/21/17, was only 8 minutes versus the required 15 minutes. In the look back period for completing the assessment the resident was walking an average of 300-400 feet per day, however, the MDS reflected extensive assistance versus limited assistance.

On 3/21/17, at 2:02 p.m. during an interview with the resident she stated she felt she was feeling well and felt she was getting stronger every day.

On 3/23/17, notes reflected the same level of care but that the resident, was continent of bowel but wore pull ups for occasional urine leakage. Charting reflected R140 was walking with one staff to and from all destinations in facility with gait belt and walker and rarely used a wheelchair.

On 3/23/17. at 8:48 a.m. registered nurse (RN)-D stated, all of the MDS information should have matched and added, "We will want to get this straightened out." RN-D explained one nurse had documented a higher level of care for R140 on 12/29/17, and "Then there was a bunch of copy and paste business. There probably needs to be more education for the nursing assistants [NAs] too. It was like, who did they talk to? This should have been caught back in December. If she lost that ability in one week, she should have gone back on therapy. She should have been evaluated and if there were two or more changes


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a significant change MDS should have been completed."

RN-D stated on 3/22/17, at 1:13 p.m. she was responsible for scheduling MDS assessments, including significant change assessments. She did not recall discussion related to R140's decline in condition. RN-D said nursing assessments were completed by the RN, and that information carried over to the MDS. In addition, information documented in the iPad by NAs carried over into the MDS. RN-D said the RN who competed the assessment should have initiated a significant change MDS, since R140 experienced two or more areas of decline.

On 3/23/17, at 9:28 a.m. the interim director of nursing (IDON) recalled, "The resident was having some decline in her condition, but I think she got better again."

On 3/23/17, at 9:55 a.m. the registered physical therapist (RPT) director explained, R140 "did have a short course of therapy after she went to the long term care side." She recalled the resident had experienced some falls and said staff was concerned there was something going on with the resident. The RPT did not know if it was a urinary tract infection. Physical therapists saw R140 for a short time and again instituted a restorative program in that environment.

The facility's 11/16, Resident Assessment Instrument Using Minimum Data Set, CAA, Summary and Utilization Guidelines policy read, "Significant Change in Status Reassessment 1. Each resident's status is assessed on an ongoing basis in an effort to intervene to assist the resident to meet his/her highest practicable level


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of physical, mental and psychosocial well-being. 2. A 'significant change' is defined as a decline or improvement in the resident's status that ...b. Impacts on more than one area of the resident's health status, and c. Requires interdisciplinary review and/or revision of the care plan. 3. The 'guidelines for Determining Significant Change in Resident Status' of the RAI [Resident Assessment Instrument] User's Manual are followed."

F 441

SS=D

483.80(a)(1)(2)(4)(e)(f) INFECTION CONTROL, PREVENT SPREAD, LINENS

(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:

(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 (facility assessment implementation is Phase 2)�

(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�

F 441 4/10/17


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(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 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.

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

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

(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:


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B. WING _____________________________








(X5)COMPLETION

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Based on observation, interview and document review, the facility failed to minimize the risk for spread of infection related to the cleansing of the blood glucose monitoring machines, potentially affecting 3 of 3 residents (R4, R25, R50) who shared the same glucometer.

Findings include:

During an observation of blood glucose monitoring on 3/20/17, at 4:41 p.m. registered nurse (RN)-A verbally stated glucometers were cleansed with a Sani Cloth Germicidal Disposable Wipe for one minute. She donned gloves, proceeded to test the blood sugar for R25, and using a Sani Wipe, wiped the machine continuously for 45 seconds then set the unit on a paper towel on the medication cart. At 5:38 p.m. RN-A again used the glucose monitoring machine for a resident and repeated the process. This time she wiped the unit for 50 seconds and placed it on a paper towel on the medication cart. The unit remained wet another 40 seconds for a total of 90 seconds or 1.5 minutes. When asked how she knew if the time for cleansing the unit was completed, she explained that she used the time on the lower right side of the computer. This time indicates the minutes, but not seconds. She explained that when the time moved to the next minute, her time of wiping was completed.

On 3/21/2017, at 2:20 p.m. licensed practical nurse (LPN)-B indicated that she also used the computer time to know when two minutes were up for disinfection of the blood glucose machines. She understood that by using the computer time, there was a risk of not disinfecting the unit for the complete two minutes.

F441SS=DINFECTION CONTROL/PREVENT SPREAD, LINENS

It is the practice of Three Links Care Center to establish and maintain an effective infection control program.

Infection control policies have been reviewed. Facility staff will have training provided on 4/21/17 and 4/27/17 to review glucometer disinfection policies and procedures with glucometer distributor. All nurses must complete this training.

Routine auditing for infection control practices will be performed weekly until 100% compliant then monthly for 1 year and during routine training and orientation on-going. Results of audits will be reported to the facility QA meeting for 4 quarters. Director of Nursing/designee will be responsible for overall compliance.


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During an interview with RN-C, 3/21/17, at 8:38 a.m. she reported the germicidal Sani Cloths, disinfected in two minutes and it was the expectation that two minutes of continuous wiping of the blood glucose monitoring unit would occur for disinfection. She verified on machine was used for more than one resident on each wing.

The following day in the afternoon of 3/22/17, the interim director of nursing, stated the staff need to disinfect the machine for the full two minutes for it to be effective. The Sani-cloth germicidal disposable wipe disinfects in two minutes. The manufacturer's recommendations for the glucose monitoring machine noted, "Cleaning and disinfecting can be completed by using a commercially available EPA-[Environmental Protection Agency] registered disinfectant detergent or germicide wipe." The facility's Competency for Pro Blood Glucose Monitoring read, "Cleans and disinfects glucometer with Sani wipes for 2 min."


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A. BUILDING: ______________________




PRINTED: 04/19/2017 FORM APPROVED


B. WING _____________________________


00564 03/23/2017

NAME OF PROVIDER OR SUPPLIER


STREET ADDRESS, CITY, STATE, ZIP CODE

815 FOREST AVENUE




(X5)COMPLETE

DATE

IDPREFIX

TAG

(X4) IDPREFIX

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2 000 Initial Comments

*****ATTENTION******

NH LICENSING CORRECTION ORDER

In accordance with Minnesota Statute, section 144A.10, this correction order has been issued pursuant to a survey. If, upon reinspection, it is found that the deficiency or deficiencies cited herein are not corrected, a fine for each violation not corrected shall be assessed in accordance with a schedule of fines promulgated by rule of the Minnesota Department of Health.

Determination of whether a violation has been corrected requires compliance with all requirements of the rule provided at the tag number and MN Rule number indicated below. When a rule contains several items, failure to comply with any of the items will be considered lack of compliance. Lack of compliance upon re-inspection with any item of multi-part rule will result in the assessment of a fine even if the item that was violated during the initial inspection was corrected.

You may request a hearing on any assessments that may result from non-compliance with these orders provided that a written request is made to the Department within 15 days of receipt of a notice of assessment for non-compliance.

INITIAL COMMENTS:

2 000

You have agreed to participate in the electronic receipt of State licensure orders consistent with the Minnesota Department of Health Informational Bulletin 14-01, available at <http://www.health.state.mn.us/divs/fpc/profinfo/infobul.htm> The State licensing orders are delineated on the attached Minnesota

Minnesota Department of HealthLABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

04/11/17Electronically Signed

If continuation sheet 1 of 146899STATE FORM ULPP11

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Department of Health orders being submitted to you electronically. Although no plan of correction is necessary for State Statutes/Rules, please enter the word "corrected" in the box available for text. You must then indicate in the electronic State licensure process, under the heading completion date, the date your orders will be corrected prior to electronically submitting to the Minnesota Department of Health.

On 3/20/17 through 3/23/17, surveyors of this Department's staff, visited the above provider and the following correction orders are issued. Please indicate in your electronic plan of correction that you have reviewed these orders, and identify the date when they will be completed.

2 540 MN Rule 4658.0400 Subp. 1 & 2 Comprehensive Resident Assessment

Subpart 1. Assessment. A nursing home must conduct a comprehensive assessment of each resident's needs, which describes the resident's capability to perform daily life functions and significant impairments in functional capacity. A nursing assessment conducted according to Minnesota Statutes, section 148.171, subdivision 15, may be used as part of the comprehensive resident assessment. The results of the comprehensive resident assessment must be used to develop, review, and revise the resident's comprehensive plan of care as defined in part 4658.0405. Subp. 2. Information gathered. The comprehensive resident assessment must include at least the following information: A. medically defined conditions and prior medical history�� B. medical status measurement��

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C. physical and mental functional status�� D. sensory and physical impairments�� E. nutritional status and requirements�� F. special treatments or procedures�� G. mental and psychosocial status�� H. discharge potential�� I. dental condition�� J. activities potential�� K. rehabilitation potential�� L. cognitive status�� M. drug therapy��and N. resident preferences.

This MN Requirement is not met as evidenced by:Based on interview and document review, the facility failed to completely assess 1 of 1 resident (R140) who experienced a change in condition but lacked a significant change assessment.

Findings include:

R140's admission Minimum Data Set (MDS) completed 11/24/16, indicated the resident required limited assistance (highly involved in activity��staff provided guided maneuvering of limbs or other non-weight-bearing assistance) with bed mobility, transferring and locomotion on the unit, and had no incontinence. A subsequent quarterly MDS completed 2/24/17, revealed the resident had declined and required extensive assistance with bed mobility, transferring locomotion on the unit, and was occasionally incontinent, however, a a quarterly assessment versus a significant change assessment was completed.

The corresponding Care Area Assessment (CAA) dated 11/29/16, noted R140 had poor balance and coordination, but was receiving physical and

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occupational therapies (PT and OT). R140 was walking three times daily 150 feet with a walker, gait belt, and one staff, and had a restorative dressing program to increase independence.

Progress Notes for R140 showed on 11/21/16 and 12/22/16, the resident required limited assistance with bed mobility, transferring, and locomotion on the unit, however, on 12/29/16, documentation reflected resident required extensive assistance. The note also indicated R140's occupational therapy had been discontinued on 12/23/16, and a restorative nursing program has been started. R140 had edema and weeping (excess fluid in the tissues) in her lower legs, however, restorative notes dated 1/10/17, indicated R140 continued walking 150 feet with one assist.

A bladder assessment dated 11/23/16, indicated R140 was continent of bladder and bowel. The care plan initiated on 12/8/16, indicated R140 had occasional bowel incontinence. A subsequent assessment dated 2/22/17, indicated resident had urine leakage on the way to the bathroom. A social services note dated 12/1/16, revealed R140 had cognitive testing completed and scored in the moderate functional decline level which indicated "24/7 supervision is recommended."

Progress notes were as follows: 1) 12/5/16, the resident was continent and required limited assistance from staff. "A lot of her assistance simply involves cueing her as to where she is going and where the next location is."

2) 12/9/16, "Noted resident has 2 cm [centimeter] Minnesota Department of Health


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x 1 cm open area between gluteal folds at top of coccyx, area is odorous. Small amt [amount] of serous drainage on pull up that resident was wearing."

3) 12/15/16, "Resident noted to have two open areas to left lower extremity which are vascular in nature due to cellulitis [infection from opening in skin]. There is a large open area on her left lateral ankle, that measures 5.3 cm wide and 5 cm. long.--see wound flowsheet for details including current Tx [treatment] in place. The front of her left leg has multiple small areas that are open. See wound flow sheet. Resident's weight was 168.5 lbs. today, and 171.0 last week."

4) 12/26/16, Lower extremity dressing changes daily: Right leg is completed healed, no longer needs cleansing or dressings. [Dressings lower legs]...Buttocks/top of coccyx open area in fold measures 0.7 cm x 0.2 cm today...."

5) 12/29/16, indicated "Resident is extensive assist of 1 with bed mobility, transferring, toileting, hygiene, dressing, and bathing. She is walking with 1 staff to and from all destinations in facility with gait belt and walker. Rarely uses w/c [wheelchair]. She is continent of bowel, does wear pull ups 'just in case' for occ leakage of bladder."

6) 2/19/17, R140 required extensive assistance five times from staff with transfers from 2/19 to 2/24/17.

7) 2/22/17, R140 required limited support for bed mobility, transferring, walking on the unit, and extensive assist off the unit. R140 participated in dressing and undressing, washing and teeth brushing, but needed extensive assist for other



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hair combing and toileting. The resident wore pull ups for occasional leakage of urine and needed assistance with pericare and pad changes due to balance concerns. The MDS indicated six restorative nursing sessions had been provided, however, one of the sessions on 3/21/17, was only 8 minutes versus the required 15 minutes. In the look back period for completing the assessment the resident was walking an average of 300-400 feet per day, however, the MDS reflected extensive assistance versus limited assistance.

On 3/21/17, at 2:02 p.m. during an interview with the resident she stated she felt she was feeling well and felt she was getting stronger every day.

On 3/23/17, notes reflected the same level of care but that the resident, was continent of bowel but wore pull ups for occasional urine leakage. Charting reflected R140 was walking with one staff to and from all destinations in facility with gait belt and walker and rarely used a wheelchair.

On 3/23/17. at 8:48 a.m. registered nurse (RN)-D stated, all of the MDS information should have matched and added, "We will want to get this straightened out." RN-D explained one nurse had documented a higher level of care for R140 on 12/29/17, and "Then there was a bunch of copy and paste business. There probably needs to be more education for the nursing assistants [NAs] too. It was like, who did they talk to? This should have been caught back in December. If she lost that ability in one week, she should have gone back on therapy. She should have been evaluated and if there were two or more changes a significant change MDS should have been completed."



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RN-D stated on 3/22/17, at 1:13 p.m. she was responsible for scheduling MDS assessments, including significant change assessments. She did not recall discussion related to R140's decline in condition. RN-D said nursing assessments were completed by the RN, and that information carried over to the MDS. In addition, information documented in the iPad by NAs carried over into the MDS. RN-D said the RN who competed the assessment should have initiated a significant change MDS, since R140 experienced two or more areas of decline.

On 3/23/17, at 9:28 a.m. the interim director of nursing (IDON) recalled, "The resident was having some decline in her condition, but I think she got better again."

On 3/23/17, at 9:55 a.m. the registered physical therapist (RPT) director explained, R140 "did have a short course of therapy after she went to the long term care side." She recalled the resident had experienced some falls and said staff was concerned there was something going on with the resident. The RPT did not know if it was a urinary tract infection. Physical therapists saw R140 for a short time and again instituted a restorative program in that environment.

The facility's 11/16, Resident Assessment Instrument Using Minimum Data Set, CAA, Summary and Utilization Guidelines policy read, "Significant Change in Status Reassessment 1. Each resident's status is assessed on an ongoing basis in an effort to intervene to assist the resident to meet his/her highest practicable level of physical, mental and psychosocial well-being. 2. A 'significant change' is defined as a decline or improvement in the resident's status that ...b. Impacts on more than one area of the resident's



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health status, and c. Requires interdisciplinary review and/or revision of the care plan. 3. The 'guidelines for Determining Significant Change in Resident Status' of the RAI [Resident Assessment Instrument] User's Manual are followed."

SUGGESTED METHOD OF CORRECTION: The director of nursing and MDS nurse could review policies, educate appropriate staff, and develop ongoing systems to determine if residents who experienced changes required a significant change MDS assessment. Audits could be conducted and the results brought to the quality committee for review.

TIME PERIOD FOR CORRECTION: Twenty-one (21) days.

21375 MN Rule 4658.0800 Subp. 1 Infection Control��Program

Subpart 1. Infection control program. A nursing home must establish and maintain an infection control program designed to provide a safe and sanitary environment.

This MN Requirement is not met as evidenced by:

21375 4/10/17

Based on observation, interview and document review, the facility failed to minimize the risk for spread of infection related to the cleansing of the blood glucose monitoring machines, potentially affecting 3 of 3 residents (R4, R25, R50) who shared the same glucometer.

Findings include:

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21375Continued From page 8 21375

During an observation of blood glucose monitoring on 3/20/17, at 4:41 p.m. registered nurse (RN)-A verbally stated glucometers were cleansed with a Sani Cloth Germicidal Disposable Wipe for one minute. She donned gloves, proceeded to test the blood sugar for R25, and using a Sani Wipe, wiped the machine continuously for 45 seconds then set the unit on a paper towel on the medication cart. At 5:38 p.m. RN-A again used the glucose monitoring machine for a resident and repeated the process. This time she wiped the unit for 50 seconds and placed it on a paper towel on the medication cart. The unit remained wet another 40 seconds for a total of 90 seconds or 1.5 minutes. When asked how she knew if the time for cleansing the unit was completed, she explained that she used the time on the lower right side of the computer. This time indicates the minutes, but not seconds. She explained that when the time moved to the next minute, her time of wiping was completed.

On 3/21/2017, at 2:20 p.m. licensed practical nurse (LPN)-B indicated that she also used the computer time to know when two minutes were up for disinfection of the blood glucose machines. She understood that by using the computer time, there was a risk of not disinfecting the unit for the complete two minutes.

During an interview with RN-C, 3/21/17, at 8:38 a.m. she reported the germicidal Sani Cloths, disinfected in two minutes and it was the expectation that two minutes of continuous wiping of the blood glucose monitoring unit would occur for disinfection. She verified on machine was used for more than one resident on each wing.

The following day in the afternoon of 3/22/17, the interim director of nursing, stated the staff need to



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disinfect the machine for the full two minutes for it to be effective. The Sani-cloth germicidal disposable wipe disinfects in two minutes. The manufacturer's recommendations for the glucose monitoring machine noted, "Cleaning and disinfecting can be completed by using a commercially available EPA-[Environmental Protection Agency] registered disinfectant detergent or germicide wipe." The facility's Competency for Pro Blood Glucose Monitoring read, "Cleans and disinfects glucometer with Sani wipes for 2 min." SUGGESTED METHOD OF CORRECTION: The administrator or designee could review and revise policies and procedures pertaining to glucometer sanitization to assure they comply with the regulations, retrain staff and develop a monitoring procedure. Audits could be conducted and the results brought to the quality committee.

TIME PERIOD FOR CORRECTION: Fourteen (14) days.

21426 MN St. Statute 144A.04 Subd. 3 Tuberculosis Prevention And Control

(a) A nursing home provider must establish and maintain a comprehensive tuberculosisinfection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division of Tuberculosis Elimination, as published in CDC's Morbidity and Mortality Weekly Report (MMWR). This program must include a tuberculosis infection control plan that covers all paid and unpaid employees, contractors, students,

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residents, and volunteers. The Department of Health shall provide technical assistance regarding implementation of the guidelines.

(b) Written compliance with this subdivision must be maintained by the nursing home.

This MN Requirement is not met as evidenced by:Based on interview and document review, the facility failed to ensure tuberculin skin testing (TST) was administered and read within recommended time frames for 3 of 5 residents (R39, R45, R160) and properly documented for 1 of 5 residents (R45) reviewed for tuberculin (TB) testing. In addition, the facility failed to ensure proper timing of a second step TST for 1 of 5 employees (E-5) whose immunization records were reviewed.

Findings include:

R39 was admitted to the facility on 2/23/17. R39's TST was administered 2/24/17, at 4:17 p.m. and read 2/26/17, at 3:39 p.m. This did not meet the timeline per State guidelines for TST being read 48-72 hours after administered.

R45 was admitted to the facility on 2/10/17. R45's first TST was administered 2/11/17, at 6:16 p.m. and read on 2/13/17, on evening shift with no time documented. R45's second TST was administered 2/25/17, at 11:07 a.m. and read on 2/27/17, evening shift with no time documented as State guidelines recommended. The reading

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indicated the TST was negative but did not indicate the induration reading in millimeters (mm) as State guidelines recommended.

R160 was admitted to the facility on 3/3/17. R160's first TST was administered on 3/4/17, with no time documented as State guidelines recommend and read on 3/6/17, at 7:19 p.m. R160's second TST was administered 3/18/17, at 4:00 p.m. and read on 3/20/17, at 1:14 p.m. not within the State timeline guidelines to read a TST within 48-72 hours after administered.

E-5's date of hire was 10/3/16. E-5's first TST was read on 10/6/16. E-5's second TST was administered on 10/11/16, two days too soon per State guidelines.

During interview with the interim director of nursing (IDON) who was the facility's infection control nurse on 3/23/17, at 9:50 a.m. The IDON verified dates and times of residents' and employees' TST when administered and when read. The IDON stated she had called the nurse who read R160's TST and the nurse had said the induration of the reading was zero mm and that she had forgotten to document that on the record. The IDON stated the TB (Tuberculosis) policy had been updated last August and the facility had decided to not give the TST for the employees but rather have the employees get the Quantiferon test for TB instead. The IDON stated she had talked to medical records about changing the policy and would have the health unit coordinators put in Point Click Care a place for the nurses to put the times in when residents' TST were administered and when read. The IDON stated she was aware of the July 2013 Regulations for Tuberculosis Control in Minnesota Health Care Settings and showed surveyor her



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copy.

The July 2013 Regulations for Tuberculosis Control in Minnesota Health Care Settings indicated TST "Results [read between 48-72 hours]"

The July 2013 Regulations for Tuberculosis Control in Minnesota Health Care Settings indicated "TST documentation should include the date of the test (i.e., month, day, year), the number of millimeters of induration (if no induration, document '0' mm) and interpretation (i.e., positive or negative)."

The July 2013 Regulations for Tuberculosis Control in Minnesota Health Care Settings indicated "If an initial TST result is classified as negative, a second step of a two-step TST should be administered 1-3 weeks after the first TST result was read."

Policy provided by the facility dated 2/14, for Tuberculosis Screening (Resident) indicated "...The test is read between 48-72 hours after administration...Documentation Record the size of induration on MAR and in PCC [Point Click Care] immunization record. TST documentation for residents should include the date (i.e., month, day, year), the number of millimeters of induration [if no induration, document '0' mm)."

Policy provided by the facility dated 8/16, for Tuberculosis Screening and Prevention--Health Care Workers (HCW) indicated "...If results are negative, perform the second step in one to three weeks."

SUGGESTED METHOD OF CORRECTION: The facility could review/develop a system for



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ensuring timely and appropriate TB immunizations to residents and employees, and conduct education with the appropriate employees to ensure implementation. Audits could be conducted and the results brought to the quality committee.

TIME PERIOD FOR CORRECTION: Twenty-one (21) days.



Documents

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS … · CMS Certification Number (CCN): 24-5450 September 7, 2017 Mr. Mark Anderson, Administrator Three Links Care Center 815 Forest