DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: P93R
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
1. MEDICARE/MEDICAID PROVIDER NO.
245424
(L1)
(L4) 3220 LAKE JOHANNA BOULEVARD
2.STATE VENDOR OR MEDICAID NO.
(L2)
369842400
5. EFFECTIVE DATE CHANGE OF OWNERSHIP
01 Hospital
03/01/2016
8. ACCREDITATION STATUS:
0 Unaccredited
2 AOA
To
(b) :
05 HHA
09 ESRD
13 PTIP
02 SNF/NF/Dual
06 PRTF
10 NF
14 CORF
03 SNF/NF/Distinct
07 X-Ray
11 ICF/IID
15 ASC
04 SNF
08 OPT/SP
12 RHC
16 HOSPICE
2. Recertification
3. Termination
4. CHOW
5. Validation
6. Complaint
7. On-Site Visit
9. Other
FISCAL YEAR ENDING DATE:
(L35)
09/30
10.THE FACILITY IS CERTIFIED AS:
X A. In Compliance With
And/Or Approved Waivers Of The Following Requirements:
Program Requirements
Compliance Based On:
1. Acceptable POC
12.Total Facility Beds
208 (L18)
13.Total Certified Beds
208 (L17)
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/Room
B. Not in Compliance with Program
Requirements and/or Applied Waivers:
(L12)
A*
* Code:
15. FACILITY MEETS
14. LTC CERTIFIED BED BREAKDOWN
18 SNF
1. Initial
8. Full Survey After Complaint
22 CLIA
(L34)
1 TJC
3 Other
7 (L8)
(L7)
(L10)
11. .LTC PERIOD OF CERTIFICATION
(a) :
02
7. PROVIDER/SUPPLIER CATEGORY
(L9)
From
(L6) 55112
(L5) ARDEN HILLS, MN
6. DATE OF SURVEY
Facility ID: 00975
4. TYPE OF ACTION:
3. NAME AND ADDRESS OF FACILITY
(L3) PRESBYTERIAN HOMES OF ARDEN HILLS
18/19 SNF
19 SNF
ICF
IID
(L39)
(L42)
(L43)
(L15)
1861 (e) (1) or 1861 (j) (1):
208
(L37)
(L38)
16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):
17. SURVEYOR SIGNATURE
Date :
Susanne Reuss, Unit Supervisor
18. STATE SURVEY AGENCY APPROVAL
03/01/2016
(L19)
Date:
Kate JohnsTon, Program Specialist
03/08/2016
(L20)
PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY
19. DETERMINATION OF ELIGIBILITY
X
20. COMPLIANCE WITH CIVIL
RIGHTS ACT:
1. Facility is Eligible to Participate
21.
1. Statement of Financial Solvency (HCFA-2572)
2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)
3. Both of the Above :
2. Facility is not Eligible
(L21)
22. ORIGINAL DATE
23. LTC AGREEMENT
24. LTC AGREEMENT
BEGINNING DATE
OF PARTICIPATION
26. TERMINATION ACTION:
ENDING DATE
VOLUNTARY
02/01/1987
(L24)
(L41)
25. LTC EXTENSION DATE:
(L25)
(L30)
00
05-Fail to Meet Health/Safety
02-Dissatisfaction W/ Reimbursement
06-Fail to Meet Agreement
03-Risk of Involuntary Termination
27. ALTERNATIVE SANCTIONS
04-Other Reason for Withdrawal
A. Suspension of Admissions:
OTHER
07-Provider Status Change
00-Active
(L44)
(L27)
INVOLUNTARY
01-Merger, Closure
B. Rescind Suspension Date:
(L45)
28. TERMINATION DATE:
30. REMARKS
29. INTERMEDIARY/CARRIER NO.
03001
(L28)
31. RO RECEIPT OF CMS-1539
(L31)
3RVWHG&R
32. DETERMINATION OF APPROVAL DATE
02/26/2016
(L32)
FORM CMS-1539 (7-84) (Destroy Prior Editions)
(L33)
DETERMINATION APPROVAL
020499
WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
D^ĞƌƚŝĨŝĐĂƚŝŽŶEƵŵďĞƌ;EͿ͗ϮϰϱϰϮϰ DĂƌĐŚϴ͕ϮϬϭϲ
DƐ͘,ĞĂƚŚĞƌ,ĞŝũĞƌŵĂŶ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
ϯϮϮϬ>ĂŬĞ:ŽŚĂŶŶĂŽƵůĞǀĂƌĚ
ƌĚĞŶ,ŝůůƐ͕DŝŶŶĞƐŽƚĂϱϱϭϭϮ
ĞĂƌDƐ͘,ĞŝũĞƌŵĂŶ͗
dŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚĂƐƐŝƐƚƐƚŚĞĞŶƚĞƌƐĨŽƌDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚ^ĞƌǀŝĐĞƐ;D^ͿďLJ
ƐƵƌǀĞLJŝŶŐƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚŝĞƐĂŶĚŶƵƌƐŝŶŐĨĂĐŝůŝƚŝĞƐƚŽĚĞƚĞƌŵŝŶĞǁŚĞƚŚĞƌƚŚĞLJŵĞĞƚƚŚĞ
ƌĞƋƵŝƌĞŵĞŶƚƐĨŽƌƉĂƌƚŝĐŝƉĂƚŝŽŶ͘dŽƉĂƌƚŝĐŝƉĂƚĞĂƐĂƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚLJŝŶƚŚĞDĞĚŝĐĂƌĞƉƌŽŐƌĂŵŽƌĂƐ
ĂŶƵƌƐŝŶŐĨĂĐŝůŝƚLJŝŶƚŚĞDĞĚŝĐĂŝĚƉƌŽŐƌĂŵ͕ĂƉƌŽǀŝĚĞƌŵƵƐƚďĞŝŶƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞǁŝƚŚĞĂĐŚŽĨ
ƚŚĞƌĞƋƵŝƌĞŵĞŶƚƐĞƐƚĂďůŝƐŚĞĚďLJƚŚĞ^ĞĐƌĞƚĂƌLJŽĨ,ĞĂůƚŚĂŶĚ,ƵŵĂŶ^ĞƌǀŝĐĞƐĨŽƵŶĚŝŶϰϮ&ZƉĂƌƚϰϴϯ͕
^ƵďƉĂƌƚ͘ ĂƐĞĚƵƉŽŶLJŽƵƌĨĂĐŝůŝƚLJďĞŝŶŐŝŶƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞ͕ǁĞĂƌĞƌĞĐŽŵŵĞŶĚŝŶŐƚŽD^ƚŚĂƚLJŽƵƌ
ĨĂĐŝůŝƚLJďĞƌĞĐĞƌƚŝĨŝĞĚĨŽƌƉĂƌƚŝĐŝƉĂƚŝŽŶŝŶƚŚĞDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚƉƌŽŐƌĂŵ͘
ĨĨĞĐƚŝǀĞ&ĞďƌƵĂƌLJϭϰ͕ϮϬϭϲƚŚĞĂďŽǀĞĨĂĐŝůŝƚLJŝƐĐĞƌƚŝĨŝĞĚĨŽƌŽƌƌĞĐŽŵŵĞŶĚĞĚĨŽƌ͗ ϮϬϴ
^ŬŝůůĞĚEƵƌƐŝŶŐ&ĂĐŝůŝƚLJͬEƵƌƐŝŶŐ&ĂĐŝůŝƚLJĞĚƐ
zŽƵƌĨĂĐŝůŝƚLJ͛ƐDĞĚŝĐĂƌĞĂƉƉƌŽǀĞĚĂƌĞĂĐŽŶƐŝƐƚƐŽĨĂůůϮϬϴƐŬŝůůĞĚŶƵƌƐŝŶŐĨĂĐŝůŝƚLJďĞĚƐ͘
zŽƵƐŚŽƵůĚĂĚǀŝƐĞŽƵƌŽĨĨŝĐĞŽĨĂŶLJĐŚĂŶŐĞƐŝŶƐƚĂĨĨŝŶŐ͕ƐĞƌǀŝĐĞƐ͕ŽƌŽƌŐĂŶŝnjĂƚŝŽŶ͕ǁŚŝĐŚŵŝŐŚƚĂĨĨĞĐƚ
LJŽƵƌĐĞƌƚŝĨŝĐĂƚŝŽŶƐƚĂƚƵƐ͘
/Ĩ͕ĂƚƚŚĞƚŝŵĞŽĨLJŽƵƌŶĞdžƚƐƵƌǀĞLJ͕ǁĞĨŝŶĚLJŽƵƌĨĂĐŝůŝƚLJƚŽŶŽƚďĞŝŶƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞLJŽƵƌ
DĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚƉƌŽǀŝĚĞƌĂŐƌĞĞŵĞŶƚŵĂLJďĞƐƵďũĞĐƚƚŽŶŽŶͲƌĞŶĞǁĂůŽƌƚĞƌŵŝŶĂƚŝŽŶ͘
WůĞĂƐĞĐŽŶƚĂĐƚŵĞŝĨLJŽƵŚĂǀĞĂŶLJƋƵĞƐƚŝŽŶƐ͘
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
DĂƌĐŚϴ͕ϮϬϭϲ
WĂŐĞϮ
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ĐĐ͗
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ
WZKdd/E'͕D/Ed/E/E'E/DWZKs/E'd,,>d,K&>>D/EE^KdE^
DĂƌĐŚϴ͕ϮϬϭϲ
DƐ͘,ĞĂƚŚĞƌ,ĞŝũĞƌŵĂŶ͕ĚŵŝŶŝƐƚƌĂƚŽƌ
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
ϯϮϮϬ>ĂŬĞ:ŽŚĂŶŶĂŽƵůĞǀĂƌĚ
ƌĚĞŶ,ŝůůƐ͕DŝŶŶĞƐŽƚĂϱϱϭϭϮ
Z͗WƌŽũĞĐƚEƵŵďĞƌ^ϱϰϮϰϬϮϱ
ĞĂƌDƐ͘,ĞŝũĞƌŵĂŶ͗
KŶ&ĞďƌƵĂƌLJϮ͕ϮϬϭϲ͕ǁĞŝŶĨŽƌŵĞĚLJŽƵƚŚĂƚǁĞǁŽƵůĚƌĞĐŽŵŵĞŶĚĞŶĨŽƌĐĞŵĞŶƚƌĞŵĞĚŝĞƐďĂƐĞĚŽŶƚŚĞ
ĚĞĨŝĐŝĞŶĐŝĞƐĐŝƚĞĚďLJƚŚŝƐĞƉĂƌƚŵĞŶƚĨŽƌĂƐƚĂŶĚĂƌĚƐ ƵƌǀĞLJ͕ĐŽŵƉůĞƚĞĚŽŶ:ĂŶƵĂƌLJϭϰ͕ϮϬϭϲ͘dŚŝƐ
ƐƵƌǀĞLJĨŽƵŶĚƚŚĞŵŽƐƚƐĞƌŝŽƵƐĚĞĨŝĐŝĞŶĐŝĞƐƚŽďĞĂƉĂƚƚĞƌŶŽĨĚĞĨŝĐŝĞŶĐŝĞƐƚŚĂƚĐŽŶƐƚŝƚƵƚĞĚŶŽĂĐƚƵĂů
ŚĂƌŵǁŝƚŚƉŽƚĞŶƚŝĂůĨŽƌŵŽƌĞƚŚĂŶŵŝŶŝŵĂůŚĂƌŵƚŚĂƚǁĂƐŶŽƚŝŵŵĞĚŝĂƚĞũĞŽƉĂƌĚLJ;>ĞǀĞůͿǁŚĞƌĞďLJ
ĐŽƌƌĞĐƚŝŽŶƐǁĞƌĞƌĞƋƵŝƌĞĚ͘
KŶDĂƌĐŚϭ͕ϮϬϭϲ͕ƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚĐŽŵƉůĞƚĞĚĂWŽƐƚĞƌƚŝĨŝĐĂƚŝŽŶZĞǀŝƐŝƚ;WZͿďLJ
ƌĞǀŝĞǁŽĨLJŽƵƌƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶĂŶĚŽŶ&ĞďƌƵĂƌLJϭϵ͕ϮϬϭϲƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨWƵďůŝĐ^ĂĨĞƚLJ
ĐŽŵƉůĞƚĞĚĂWZƚŽǀĞƌŝĨLJƚŚĂƚLJŽƵƌĨĂĐŝůŝƚLJŚĂĚĂĐŚŝĞǀĞĚĂŶĚŵĂŝŶƚĂŝŶĞĚĐŽŵƉůŝĂŶĐĞǁŝƚŚĨĞĚĞƌĂů
ĐĞƌƚŝĨŝĐĂƚŝŽŶĚĞĨŝĐŝĞŶĐŝĞƐŝƐƐƵĞĚƉƵƌƐƵĂŶƚƚŽĂƐƚĂŶĚĂƌĚƐƵƌǀĞLJ͕ĐŽŵƉůĞƚĞĚŽŶ:ĂŶƵĂƌLJϭϰ͕ϮϬϭϲ͘tĞ
ƉƌĞƐƵŵĞĚ͕ďĂƐĞĚŽŶLJŽƵƌƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͕ƚŚĂƚLJŽƵƌĨĂĐŝůŝƚLJŚĂĚĐŽƌƌĞĐƚĞĚƚŚĞƐĞĚĞĨŝĐŝĞŶĐŝĞƐĂƐŽĨ
&ĞďƌƵĂƌLJϭϲ͕ϮϬϭϲ͘ĂƐĞĚŽŶŽƵƌWZ͕ǁĞŚĂǀĞĚĞƚĞƌŵŝŶĞĚƚŚĂƚLJŽƵƌĨĂĐŝůŝƚLJŚĂƐĐŽƌƌĞĐƚĞĚƚŚĞ
ĚĞĨŝĐŝĞŶĐŝĞƐŝƐƐƵĞĚƉƵƌƐƵĂŶƚƚŽŽƵƌƐƚĂŶĚĂƌĚƐƵƌǀĞLJ͕ĐŽŵƉůĞƚĞĚŽŶ:ĂŶƵĂƌLJϭϰ͕ϮϬϭϲ͕ĞĨĨĞĐƚŝǀĞ&ĞďƌƵĂƌLJ
ϭϲ͕ϮϬϭϲĂŶĚƚŚĞƌĞĨŽƌĞƌĞŵĞĚŝĞƐŽƵƚůŝŶĞĚŝŶŽƵƌůĞƚƚĞƌƚŽLJŽƵĚĂƚĞĚ&ĞďƌƵĂƌLJϮ͕ϮϬϭϲ͕ǁŝůůŶŽƚďĞ
ŝŵƉŽƐĞĚ͘
WůĞĂƐĞŶŽƚĞ͕ŝƚŝƐLJŽƵƌƌĞƐƉŽŶƐŝďŝůŝƚLJƚŽƐŚĂƌĞƚŚĞŝŶĨŽƌŵĂƚŝŽŶĐŽŶƚĂŝŶĞĚŝŶƚŚŝƐůĞƚƚĞƌĂŶĚƚŚĞƌĞƐƵůƚƐŽĨ
ƚŚŝƐǀŝƐŝƚǁŝƚŚƚŚĞWƌĞƐŝĚĞŶƚŽĨLJŽƵƌĨĂĐŝůŝƚLJΖƐ'ŽǀĞƌŶŝŶŐŽĚLJ͘
ŶĐůŽƐĞĚŝƐĂĐŽƉLJŽĨƚŚĞWŽƐƚĞƌƚŝĨŝĐĂƚŝŽŶZĞǀŝƐŝƚ&Žƌŵ͕;D^ͲϮϱϲϳͿĨƌŽŵƚŚŝƐǀŝƐŝƚ͘ &ĞĞůĨƌĞĞƚŽĐŽŶƚĂĐƚŵĞŝĨLJŽƵŚĂǀĞƋƵĞƐƚŝŽŶƐ͘
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
DĂƌĐŚϴ͕ϮϬϭϲ
WĂŐĞϮ
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ŶĐůŽƐƵƌĞ
ĐĐ͗>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245424
Y1
MULTIPLE CONSTRUCTION
A. Building
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
3/1/2016
Y3
ARDEN HILLS, MN 55112
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
ID Prefix
Correction
ID Prefix
Completed
Reg. #
LSC
02/16/2016
ID Prefix
Reg. #
Reg. #
F0329
483.25(l)
DATE
Y5
ITEM
DATE
Y4
Y5
Correction
ID Prefix
Completed
Reg. #
LSC
02/16/2016
LSC
02/16/2016
Correction
ID Prefix
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
Reg. #
Completed
LSC
F0371
483.35(i)
LSC
Correction
F0441
483.65
Completed
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
SR/KJ
FOLLOWUP TO SURVEY COMPLETED ON
1/14/2016
Form CMS - 2567B (09/92) EF (11/06)
LSC
DATE
SIGNATURE OF SURVEYOR
03/08/2016
DATE
DATE
16022
03/01/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
P93R12
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245424
Y1
MULTIPLE CONSTRUCTION
A. Building 01 - MAIN BUILDING 01
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
2/19/2016
Y3
ARDEN HILLS, MN 55112
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
ID Prefix
Correction
ID Prefix
Completed
Reg. #
02/15/2016
LSC
ID Prefix
Correction
Reg. #
Completed
Reg. #
LSC
NFPA 101
K0011
LSC
DATE
ITEM
DATE
Y4
Y5
Y5
Correction
ID Prefix
Completed
Reg. #
02/15/2016
LSC
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
NFPA 101
K0062
LSC
Correction
NFPA 101
Completed
02/15/2016
K0144
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
TL/KJ
FOLLOWUP TO SURVEY COMPLETED ON
1/26/2016
Form CMS - 2567B (09/92) EF (11/06)
LSC
DATE
SIGNATURE OF SURVEYOR
03/08/2016
DATE
DATE
02/19/2016
12424
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
P93R22
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
POST-CERTIFICATION REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
245424
Y1
MULTIPLE CONSTRUCTION
A. Building 02 - 2006 ADDITION
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
2/19/2016
Y3
ARDEN HILLS, MN 55112
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments
program, to show those deficiencies previously reported on the CMS-2567, Statement of Deficiencies and Plan of Correction, that have been
corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC
provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each requirement on
the survey report form).
ITEM
DATE
ITEM
Y4
Y5
Y4
ID Prefix
Correction
ID Prefix
Completed
Reg. #
02/15/2016
LSC
ID Prefix
Correction
Reg. #
Completed
Reg. #
LSC
NFPA 101
K0062
LSC
DATE
Y5
ITEM
DATE
Y4
Y5
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
02/15/2016
LSC
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
NFPA 101
K0144
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
REVIEWED BY
STATE AGENCY
REVIEWED BY
(INITIALS)
DATE
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
DATE
TL/KJ
FOLLOWUP TO SURVEY COMPLETED ON
1/26/2016
Form CMS - 2567B (09/92) EF (11/06)
SIGNATURE OF SURVEYOR
DATE
12424
03/08/2016
02/19/2016
TITLE
DATE
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
EVENT ID:
YES
P93R22
NO
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
ID: P93R
PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
1. MEDICARE/MEDICAID PROVIDER NO.
245424
(L1)
(L4) 3220 LAKE JOHANNA BOULEVARD
2.STATE VENDOR OR MEDICAID NO.
(L2)
369842400
5. EFFECTIVE DATE CHANGE OF OWNERSHIP
01/14/2016
8. ACCREDITATION STATUS:
0 Unaccredited
2 AOA
05 HHA
09 ESRD
13 PTIP
(L34)
02 SNF/NF/Dual
06 PRTF
10 NF
14 CORF
(L10)
03 SNF/NF/Distinct
07 X-Ray
11 ICF/IID
15 ASC
04 SNF
08 OPT/SP
12 RHC
16 HOSPICE
1 TJC
3 Other
To
(b) :
1. Initial
2. Recertification
3. Termination
4. CHOW
5. Validation
6. Complaint
7. On-Site Visit
9. Other
8. Full Survey After Complaint
22 CLIA
FISCAL YEAR ENDING DATE:
(L35)
09/30
10.THE FACILITY IS CERTIFIED AS:
A. In Compliance With
And/Or Approved Waivers Of The Following Requirements:
Program Requirements
Compliance Based On:
1. Acceptable POC
12.Total Facility Beds
208 (L18)
13.Total Certified Beds
208 (L17)
X B. Not in Compliance with Program
Requirements and/or Applied Waivers:
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/Room
(L12)
B*
* Code:
15. FACILITY MEETS
14. LTC CERTIFIED BED BREAKDOWN
18 SNF
2 (L8)
(L7)
01 Hospital
11. .LTC PERIOD OF CERTIFICATION
(a) :
02
7. PROVIDER/SUPPLIER CATEGORY
(L9)
From
(L6) 55112
(L5) ARDEN HILLS, MN
6. DATE OF SURVEY
Facility ID: 00975
4. TYPE OF ACTION:
3. NAME AND ADDRESS OF FACILITY
(L3) PRESBYTERIAN HOMES OF ARDEN HILLS
18/19 SNF
19 SNF
ICF
IID
(L39)
(L42)
(L43)
(L15)
1861 (e) (1) or 1861 (j) (1):
208
(L37)
(L38)
16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):
17. SURVEYOR SIGNATURE
Date :
Mary Beth Lacina, HFE NE II
18. STATE SURVEY AGENCY APPROVAL
02/12/2016
(L19)
Date:
Kate JohnsTon, Program Specialist
02/24/2016
(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
21.
1. Statement of Financial Solvency (HCFA-2572)
2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)
3. Both of the Above :
2. Facility is not Eligible
(L21)
22. ORIGINAL DATE
23. LTC AGREEMENT
24. LTC AGREEMENT
BEGINNING DATE
OF PARTICIPATION
26. TERMINATION ACTION:
ENDING DATE
VOLUNTARY
02/01/1987
(L24)
(L41)
25. LTC EXTENSION DATE:
(L25)
(L30)
00
05-Fail to Meet Health/Safety
02-Dissatisfaction W/ Reimbursement
06-Fail to Meet Agreement
03-Risk of Involuntary Termination
27. ALTERNATIVE SANCTIONS
04-Other Reason for Withdrawal
A. Suspension of Admissions:
OTHER
07-Provider Status Change
00-Active
(L44)
(L27)
INVOLUNTARY
01-Merger, Closure
B. Rescind Suspension Date:
(L45)
28. TERMINATION DATE:
30. REMARKS
29. INTERMEDIARY/CARRIER NO.
03001
(L28)
31. RO RECEIPT OF CMS-1539
3RVWHG&R
32. DETERMINATION OF APPROVAL DATE
(L32)
FORM CMS-1539 (7-84) (Destroy Prior Editions)
(L31)
(L33)
DETERMINATION APPROVAL
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ĂƚƚĂĐŚĞĚĚĞĨŝĐŝĞŶĐŝĞƐ͘
ĂƚƚĂĐŚĞĚĚĞĨŝĐŝĞŶĐŝĞƐ͘ WůĞĂƐĞŶŽƚĞ͕ŝƚŝƐLJŽƵƌƌĞƐƉŽŶƐŝďŝůŝƚLJƚŽƐŚĂƌĞƚŚĞŝŶĨŽƌŵĂƚŝŽŶĐŽŶƚĂŝŶĞĚŝŶƚŚŝƐůĞƚƚĞƌĂŶĚƚŚĞƌĞƐƵůƚƐŽĨ
ƚŚŝƐǀŝƐŝƚǁŝƚŚƚŚĞWƌĞƐŝĚĞŶƚŽĨLJŽƵƌĨĂĐŝůŝƚLJΖƐ'ŽǀĞƌŶŝŶŐŽĚLJ͘
WZdDEdKEdd
YƵĞƐƚŝŽŶƐƌĞŐĂƌĚŝŶŐƚŚŝƐůĞƚƚĞƌĂŶĚĂůůĚŽĐƵŵĞŶƚƐƐƵďŵŝƚƚĞĚĂƐĂƌĞƐƉŽŶƐĞƚŽƚŚĞƌĞƐŝĚĞŶƚĐĂƌĞ
ĚĞĨŝĐŝĞŶĐŝĞƐ;ƚŚŽƐĞƉƌĞĐĞĚĞĚďLJĂΗ&ΗƚĂŐͿ͕ŝ͘Ğ͕͘ƚŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶƐŚŽƵůĚďĞĚŝƌĞĐƚĞĚƚŽ͗
^ƵƐĂŶŶĞZĞƵƐƐ͕hŶŝƚ^ƵƉĞƌǀŝƐŽƌ
^ƵƐĂŶŶĞZĞƵƐƐ͕hŶŝƚ^ƵƉĞƌǀŝƐŽƌ DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ
W͘K͘ŽdžϲϰϵϬϬ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϳϵϯ &Ădž͗ϲϱϭͲϮϭϱͲϵϲϵϳ
KWWKZdhE/dzdKKZZd
ͲdK&KZZd/KEͲZD/^
KWWKZdhE/dzdKKZZdͲdK&KZZd/KEͲZD/^
ƐŽĨ:ĂŶƵĂƌLJϭϰ͕ϮϬϬϬ͕D^ƉŽůŝĐLJƌĞƋƵŝƌĞƐƚŚĂƚĨĂĐŝůŝƚŝĞƐǁŝůůŶŽƚďĞŐŝǀĞŶĂŶŽƉƉŽƌƚƵŶŝƚLJƚŽĐŽƌƌĞĐƚ
ďĞĨŽƌĞƌĞŵĞĚŝĞƐǁŝůůďĞŝŵƉŽƐĞĚǁŚĞŶĂĐƚƵĂůŚĂƌŵǁĂƐĐŝƚĞĚĂƚƚŚĞůĂƐƚƐƚĂŶĚĂƌĚŽƌŝŶƚĞƌǀĞŶŝŶŐ
ƐƵƌǀĞLJĂŶĚĂůƐŽĐŝƚĞĚĂƚƚŚĞĐƵƌƌĞŶƚƐƵƌǀĞLJ͘zŽƵƌĨĂĐŝůŝƚLJĚŽĞƐŶŽƚŵĞĞƚƚŚŝƐĐƌŝƚĞƌŝŽŶ͘dŚĞƌĞĨŽƌĞ͕ŝĨ
LJŽƵƌĨĂĐŝůŝƚLJŚĂƐŶŽƚĂĐŚŝĞǀĞĚƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞďLJ&ĞďƌƵĂƌLJϮϯ͕ϮϬϭϲ͕ƚŚĞĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ
ǁŝůůŝŵƉŽƐĞƚŚĞĨŽůůŽǁŝŶŐƌĞŵĞĚLJ͗
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^ƚĂƚĞDŽŶŝƚŽƌŝŶŐ͘;ϰϮ&Zϰϴϴ͘ϰϮϮͿ
>dZKE/W>EK&KZZd/KE;ĞWŽͿ
ŶĞWŽĨŽƌƚŚĞĚĞĨŝĐŝĞŶĐŝĞƐŵƵƐƚďĞƐƵďŵŝƚƚĞĚǁŝƚŚŝŶƚĞŶĐĂůĞŶĚĂƌĚĂLJƐŽĨLJŽƵƌƌĞĐĞŝƉƚŽĨƚŚŝƐůĞƚƚĞƌ͘
ƚĞŶĐĂůĞŶĚĂƌĚĂLJƐ
ƚĞŶĐĂůĞŶĚĂƌĚĂLJƐ
zŽƵƌĞWŽŵƵƐƚ͗
Ͳ
ĚĚƌĞƐƐŚŽǁĐŽƌƌĞĐƚŝǀĞĂĐƚŝŽŶǁŝůůďĞĂĐĐŽŵƉůŝƐŚĞĚĨŽƌƚŚŽƐĞƌĞƐŝĚĞŶƚƐĨŽƵŶĚƚŽŚĂǀĞ
ďĞĞŶĂĨĨĞĐƚĞĚďLJƚŚĞĚĞĨŝĐŝĞŶƚƉƌĂĐƚŝĐĞ͖
Ͳ
ĚĚƌĞƐƐŚŽǁƚŚĞĨĂĐŝůŝƚLJǁŝůůŝĚĞŶƚŝĨLJŽƚŚĞƌƌĞƐŝĚĞŶƚƐŚĂǀŝŶŐƚŚĞƉŽƚĞŶƚŝĂůƚŽďĞĂĨĨĞĐƚĞĚ
ďLJƚŚĞƐĂŵĞĚĞĨŝĐŝĞŶƚƉƌĂĐƚŝĐĞ͖
Ͳ
ĚĚƌĞƐƐǁŚĂƚŵĞĂƐƵƌĞƐǁŝůůďĞƉƵƚŝŶƚŽƉůĂĐĞŽƌƐLJƐƚĞŵŝĐĐŚĂŶŐĞƐŵĂĚĞƚŽĞŶƐƵƌĞƚŚĂƚ
ƚŚĞĚĞĨŝĐŝĞŶƚƉƌĂĐƚŝĐĞǁŝůůŶŽƚƌĞĐƵƌ͖
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
&ĞďƌƵĂƌLJϮ͕ϮϬϭϲ
WĂŐĞϯ
Ͳ
/ŶĚŝĐĂƚĞŚŽǁƚŚĞĨĂĐŝůŝƚLJƉůĂŶƐƚŽŵŽŶŝƚŽƌŝƚƐƉĞƌĨŽƌŵĂŶĐĞƚŽŵĂŬĞƐƵƌĞƚŚĂƚƐŽůƵƚŝŽŶƐ ĂƌĞƐƵƐƚĂŝŶĞĚ͘dŚĞĨĂĐŝůŝƚLJŵƵƐƚĚĞǀĞůŽƉĂƉůĂŶĨŽƌĞŶƐƵƌŝŶŐƚŚĂƚĐŽƌƌĞĐƚŝŽŶŝƐĂĐŚŝĞǀĞĚ ĂŶĚƐƵƐƚĂŝŶĞĚ͘dŚŝƐƉůĂŶŵƵƐƚďĞŝŵƉůĞŵĞŶƚĞĚ͕ĂŶĚƚŚĞĐŽƌƌĞĐƚŝǀĞĂĐƚŝŽŶĞǀĂůƵĂƚĞĚĨŽƌ ŝƚƐĞĨĨĞĐƚŝǀĞŶĞƐƐ͘dŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶŝƐŝŶƚĞŐƌĂƚĞĚŝŶƚŽƚŚĞƋƵĂůŝƚLJĂƐƐƵƌĂŶĐĞƐLJƐƚĞŵ͖
Ͳ
Ͳ
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ŝŶĐĂƐĞƐǁŚĞƌĞŶŽƚŝĨŝĐĂƚŝŽŶĂďŽƵƚƚŚĞĂĐĐĞƉƚĂďŝůŝƚLJŽĨƚŚĞŝƌƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶŝƐŶŽƚ ŵĂĚĞƚŝŵĞůLJ͘dŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶǁŝůůƐĞƌǀĞĂƐƚŚĞĨĂĐŝůŝƚLJ͛ƐĂůůĞŐĂƚŝŽŶŽĨĐŽŵƉůŝĂŶĐĞ͖ ĂŶĚ͕
^ƵďŵŝƚĞůĞĐƚƌŽŶŝĐĂůůLJƚŽĂĐŬŶŽǁůĞĚŐĞLJŽƵƌƌĞĐĞŝƉƚŽĨƚŚĞĞůĞĐƚƌŽŶŝĐϮϱϲϳ͕LJŽƵƌƌĞǀŝĞǁ
ĂŶĚLJŽƵƌĞWŽƐƵďŵŝƐƐŝŽŶ͘
dŚĞƐƚĂƚĞĂŐĞŶĐLJŵĂLJ͕ŝŶůŝĞƵŽĨĂƌĞǀŝƐŝƚ͕ĚĞƚĞƌŵŝŶĞĐŽƌƌĞĐƚŝŽŶĂŶĚĐŽŵƉůŝĂŶĐĞďLJĂĐĐĞƉƚŝŶŐƚŚĞ
ĨĂĐŝůŝƚLJΖƐĞWŽŝĨƚŚĞĞWŽŝƐƌĞĂƐŽŶĂďůĞ͕ĂĚĚƌĞƐƐĞƐƚŚĞƉƌŽďůĞŵĂŶĚƉƌŽǀŝĚĞƐĞǀŝĚĞŶĐĞƚŚĂƚƚŚĞ
ĐŽƌƌĞĐƚŝǀĞĂĐƚŝŽŶŚĂƐŽĐĐƵƌƌĞĚ͘
/ĨĂŶĂĐĐĞƉƚĂďůĞĞWŽŝƐŶŽƚƌĞĐĞŝǀĞĚǁŝƚŚŝŶϭϬĐĂůĞŶĚĂƌĚĂLJƐĨƌŽŵƚŚĞƌĞĐĞŝƉƚŽĨƚŚŝƐůĞƚƚĞƌ͕ǁĞǁŝůů
ƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚŽŶĞŽƌŵŽƌĞŽĨƚŚĞĨŽůůŽǁŝŶŐƌĞŵĞĚŝĞƐďĞŝŵƉŽƐĞĚ͗
ͻ
KƉƚŝŽŶĂůĚĞŶŝĂůŽĨƉĂLJŵĞŶƚĨŽƌŶĞǁDĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚĂĚŵŝƐƐŝŽŶƐ;ϰϮ&Z ϰϴϴ͘ϰϭϳ;ĂͿͿ͖
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WĞƌĚĂLJĐŝǀŝůŵŽŶĞLJƉĞŶĂůƚLJ;ϰϮ&Zϰϴϴ͘ϰϯϬƚŚƌŽƵŐŚϰϴϴ͘ϰϰϰͿ͘
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ĂŶĚͬŽƌDĞĚŝĐĂŝĚĂŐƌĞĞŵĞŶƚ͘
WZ^hDWd/KEK&KDW>/EͲZ/>>>'d/KEK&KDW>/E
dŚĞĨĂĐŝůŝƚLJΖƐĞWŽǁŝůůƐĞƌǀĞĂƐLJŽƵƌĂůůĞŐĂƚŝŽŶŽĨĐŽŵƉůŝĂŶĐĞƵƉŽŶƚŚĞĞƉĂƌƚŵĞŶƚΖƐĂĐĐĞƉƚĂŶĐĞ͘zŽƵƌ
ƐŝŐŶĂƚƵƌĞĂƚƚŚĞďŽƚƚŽŵŽĨƚŚĞĨŝƌƐƚƉĂŐĞŽĨƚŚĞD^ͲϮϱϲϳĨŽƌŵǁŝůůďĞƵƐĞĚĂƐǀĞƌŝĨŝĐĂƚŝŽŶŽĨ
ĐŽŵƉůŝĂŶĐĞ͘/ŶŽƌĚĞƌĨŽƌLJŽƵƌĂůůĞŐĂƚŝŽŶŽĨĐŽŵƉůŝĂŶĐĞƚŽďĞĂĐĐĞƉƚĂďůĞƚŽƚŚĞĞƉĂƌƚŵĞŶƚ͕ƚŚĞĞWŽ
ŵƵƐƚŵĞĞƚƚŚĞĐƌŝƚĞƌŝĂůŝƐƚĞĚŝŶƚŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶƐĞĐƚŝŽŶĂďŽǀĞ͘zŽƵǁŝůůďĞŶŽƚŝĨŝĞĚďLJƚŚĞ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͕>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵƐƚĂĨĨĂŶĚͬŽƌƚŚĞĞƉĂƌƚŵĞŶƚŽĨ
WƵďůŝĐ^ĂĨĞƚLJ͕^ƚĂƚĞ&ŝƌĞDĂƌƐŚĂůŝǀŝƐŝŽŶƐƚĂĨĨ͕ŝĨLJŽƵƌĞWŽĨŽƌƚŚĞƌĞƐƉĞĐƚŝǀĞĚĞĨŝĐŝĞŶĐŝĞƐ;ŝĨĂŶLJͿŝƐ
ĂĐĐĞƉƚĂďůĞ͘
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
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WĂŐĞϰ
sZ/&/d/KEK&^h^dEd/>KDW>/E
hƉŽŶƌĞĐĞŝƉƚŽĨĂŶĂĐĐĞƉƚĂďůĞĞWŽ͕ĂŶŽŶƐŝƚĞƌĞǀŝƐŝƚŽĨLJŽƵƌĨĂĐŝůŝƚLJŵĂLJďĞĐŽŶĚƵĐƚĞĚƚŽǀĂůŝĚĂƚĞƚŚĂƚ
ƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞǁŝƚŚƚŚĞƌĞŐƵůĂƚŝŽŶƐŚĂƐďĞĞŶĂƚƚĂŝŶĞĚŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚLJŽƵƌǀĞƌŝĨŝĐĂƚŝŽŶ͘
WŽƐƚĞƌƚŝĨŝĐĂƚŝŽŶZĞǀŝƐŝƚ;WZͿǁŝůůŽĐĐƵƌĂĨƚĞƌƚŚĞĚĂƚĞLJŽƵŝĚĞŶƚŝĨŝĞĚƚŚĂƚĐŽŵƉůŝĂŶĐĞǁĂƐĂĐŚŝĞǀĞĚŝŶ
LJŽƵƌƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͘
/ĨƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞŚĂƐďĞĞŶĂĐŚŝĞǀĞĚ͕ĐĞƌƚŝĨŝĐĂƚŝŽŶŽĨLJŽƵƌĨĂĐŝůŝƚLJŝŶƚŚĞDĞĚŝĐĂƌĞĂŶĚͬŽƌ DĞĚŝĐĂŝĚƉƌŽŐƌĂŵ;ƐͿǁŝůůďĞĐŽŶƚŝŶƵĞĚĂŶĚƌĞŵĞĚŝĞƐǁŝůůŶŽƚďĞŝŵƉŽƐĞĚ͘ŽŵƉůŝĂŶĐĞŝƐĐĞƌƚŝĨŝĞĚĂƐŽĨ
ƚŚĞůĂƚĞƐƚĐŽƌƌĞĐƚŝŽŶĚĂƚĞŽŶƚŚĞĂƉƉƌŽǀĞĚĞWŽ͕ƵŶůĞƐƐŝƚŝƐĚĞƚĞƌŵŝŶĞĚƚŚĂƚĞŝƚŚĞƌĐŽƌƌĞĐƚŝŽŶĂĐƚƵĂůůLJ
ŽĐĐƵƌƌĞĚďĞƚǁĞĞŶƚŚĞůĂƚĞƐƚĐŽƌƌĞĐƚŝŽŶĚĂƚĞŽŶƚŚĞĞWŽĂŶĚƚŚĞĚĂƚĞŽĨƚŚĞĨŝƌƐƚƌĞǀŝƐŝƚ͕ŽƌĐŽƌƌĞĐƚŝŽŶ
ŽĐĐƵƌƌĞĚƐŽŽŶĞƌƚŚĂŶƚŚĞůĂƚĞƐƚĐŽƌƌĞĐƚŝŽŶĚĂƚĞŽŶƚŚĞĞWŽ͘
KƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐŶŽƚĐŽƌƌĞĐƚĞĚ
/ĨLJŽƵƌĨĂĐŝůŝƚLJŚĂƐŶŽƚĂĐŚŝĞǀĞĚƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞ͕ǁĞǁŝůůŝŵƉŽƐĞƚŚĞƌĞŵĞĚŝĞƐĚĞƐĐƌŝďĞĚĂďŽǀĞ͘
/ĨƚŚĞůĞǀĞůŽĨŶŽŶĐŽŵƉůŝĂŶĐĞǁŽƌƐĞŶĞĚƚŽĂƉŽŝŶƚǁŚĞƌĞĂŚŝŐŚĞƌĐĂƚĞŐŽƌLJŽĨƌĞŵĞĚLJŵĂLJďĞŝŵƉŽƐĞĚ͕
ǁĞǁŝůůƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚƚŚŽƐĞŽƚŚĞƌƌĞŵĞĚŝĞƐďĞŝŵƉŽƐĞĚ͘
KƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐŶŽƚĐŽƌƌĞĐƚĞĚĂŶĚŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĨŽƵŶĚĚƵƌŝŶŐƚŚĞƌĞǀŝƐŝƚ
/ĨŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĂƌĞŝĚĞŶƚŝĨŝĞĚĂƚƚŚĞƚŝŵĞŽĨƚŚĞƌĞǀŝƐŝƚ͕ƚŚŽƐĞĚĞĨŝĐŝĞŶĐŝĞƐŵĂLJďĞĚŝƐƉƵƚĞĚƚŚƌŽƵŐŚ
ƚŚĞŝŶĨŽƌŵĂůĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉƌŽĐĞƐƐ͘,ŽǁĞǀĞƌ͕ƚŚĞƌĞŵĞĚŝĞƐƐƉĞĐŝĨŝĞĚŝŶƚŚŝƐůĞƚƚĞƌǁŝůůďĞŝŵƉŽƐĞĚ
ĨŽƌŽƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐŶŽƚĐŽƌƌĞĐƚĞĚ͘/ĨƚŚĞĚĞĨŝĐŝĞŶĐŝĞƐŝĚĞŶƚŝĨŝĞĚĂƚƚŚĞƌĞǀŝƐŝƚƌĞƋƵŝƌĞƚŚĞŝŵƉŽƐŝƚŝŽŶ ŽĨĂŚŝŐŚĞƌĐĂƚĞŐŽƌLJŽĨƌĞŵĞĚLJ͕ǁĞǁŝůůƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚƚŚŽƐĞƌĞŵĞĚŝĞƐďĞ
ŝŵƉŽƐĞĚ͘
KƌŝŐŝŶĂůĚĞĨŝĐŝĞŶĐŝĞƐĐŽƌƌĞĐƚĞĚďƵƚŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĨŽƵŶĚĚƵƌŝŶŐƚŚĞƌĞǀŝƐŝƚ
/ĨŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĂƌĞĨŽƵŶĚĂƚƚŚĞƌĞǀŝƐŝƚ͕ƚŚĞƌĞŵĞĚŝĞƐƐƉĞĐŝĨŝĞĚŝŶƚŚŝƐůĞƚƚĞƌǁŝůůďĞŝŵƉŽƐĞĚ͘/ĨƚŚĞ
ĚĞĨŝĐŝĞŶĐŝĞƐŝĚĞŶƚŝĨŝĞĚĂƚƚŚĞƌĞǀŝƐŝƚƌĞƋƵŝƌĞƚŚĞŝŵƉŽƐŝƚŝŽŶŽĨĂŚŝŐŚĞƌĐĂƚĞŐŽƌLJŽĨƌĞŵĞĚLJ͕ǁĞǁŝůů
ƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞƚŚĂƚƚŚŽƐĞƌĞŵĞĚŝĞƐďĞŝŵƉŽƐĞĚ͘zŽƵǁŝůůďĞƉƌŽǀŝĚĞĚƚŚĞ
ƌĞƋƵŝƌĞĚŶŽƚŝĐĞďĞĨŽƌĞƚŚĞŝŵƉŽƐŝƚŝŽŶŽĨĂŶĞǁƌĞŵĞĚLJŽƌŝŶĨŽƌŵĞĚŝĨĂŶŽƚŚĞƌĚĂƚĞǁŝůůďĞƐĞƚĨŽƌƚŚĞ
ŝŵƉŽƐŝƚŝŽŶŽĨƚŚĞƐĞƌĞŵĞĚŝĞƐ͘
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ŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨŶŽŶĐŽŵƉůŝĂŶĐĞͿ͕ƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞŵƵƐƚĚĞŶLJƉĂLJŵĞŶƚĨŽƌŶĞǁĂĚŵŝƐƐŝŽŶƐĂƐ
ŵĂŶĚĂƚĞĚďLJƚŚĞ^ŽĐŝĂů^ĞĐƵƌŝƚLJĐƚ;ƚŚĞĐƚͿĂƚ^ĞĐƚŝŽŶƐϭϴϭϵ;ŚͿ;ϮͿ;ͿĂŶĚϭϵϭϵ;ŚͿ;ϮͿ;ͿĂŶĚ&ĞĚĞƌĂů
ƌĞŐƵůĂƚŝŽŶƐĂƚϰϮ&Z^ĞĐƚŝŽŶϰϴϴ͘ϰϭϳ;ďͿ͘dŚŝƐŵĂŶĚĂƚŽƌLJĚĞŶŝĂůŽĨƉĂLJŵĞŶƚƐǁŝůůďĞďĂƐĞĚŽŶƚŚĞ
ĨĂŝůƵƌĞƚŽĐŽŵƉůLJǁŝƚŚĚĞĨŝĐŝĞŶĐŝĞƐŽƌŝŐŝŶĂůůLJĐŽŶƚĂŝŶĞĚŝŶƚŚĞ^ƚĂƚĞŵĞŶƚŽĨĞĨŝĐŝĞŶĐŝĞƐ͕ƵƉŽŶƚŚĞ
ŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨŶĞǁĚĞĨŝĐŝĞŶĐŝĞƐĂƚƚŚĞƚŝŵĞŽĨƚŚĞƌĞǀŝƐŝƚ͕ŽƌŝĨĚĞĨŝĐŝĞŶĐŝĞƐŚĂǀĞďĞĞŶŝƐƐƵĞĚĂƐƚŚĞ
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
&ĞďƌƵĂƌLJϮ͕ϮϬϭϲ
WĂŐĞϱ
ƌĞƐƵůƚŽĨĂĐŽŵƉůĂŝŶƚǀŝƐŝƚŽƌŽƚŚĞƌƐƵƌǀĞLJĐŽŶĚƵĐƚĞĚĂĨƚĞƌƚŚĞŽƌŝŐŝŶĂůƐƚĂƚĞŵĞŶƚŽĨĚĞĨŝĐŝĞŶĐŝĞƐǁĂƐ
ŝƐƐƵĞĚ͘dŚŝƐŵĂŶĚĂƚŽƌLJĚĞŶŝĂůŽĨƉĂLJŵĞŶƚŝƐŝŶĂĚĚŝƚŝŽŶƚŽĂŶLJƌĞŵĞĚŝĞƐƚŚĂƚŵĂLJƐƚŝůůďĞŝŶĞĨĨĞĐƚĂƐŽĨ
ƚŚŝƐĚĂƚĞ͘
tĞǁŝůůĂůƐŽƌĞĐŽŵŵĞŶĚƚŽƚŚĞD^ZĞŐŝŽŶsKĨĨŝĐĞĂŶĚͬŽƌƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ƵŵĂŶ
^ĞƌǀŝĐĞƐƚŚĂƚLJŽƵƌƉƌŽǀŝĚĞƌĂŐƌĞĞŵĞŶƚďĞƚĞƌŵŝŶĂƚĞĚďLJ:ƵůLJϭϰ͕ϮϬϭϲ;ƐŝdžŵŽŶƚŚƐĂĨƚĞƌƚŚĞ
ŝĚĞŶƚŝĨŝĐĂƚŝŽŶŽĨŶŽŶĐŽŵƉůŝĂŶĐĞͿŝĨLJŽƵƌĨĂĐŝůŝƚLJĚŽĞƐŶŽƚĂĐŚŝĞǀĞƐƵďƐƚĂŶƚŝĂůĐŽŵƉůŝĂŶĐĞ͘dŚŝƐĂĐƚŝŽŶŝƐ
ŵĂŶĚĂƚĞĚďLJƚŚĞ^ŽĐŝĂů^ĞĐƵƌŝƚLJĐƚĂƚ^ĞĐƚŝŽŶƐϭϴϭϵ;ŚͿ;ϮͿ;ͿĂŶĚϭϵϭϵ;ŚͿ;ϯͿ;ͿĂŶĚ&ĞĚĞƌĂů
ƌĞŐƵůĂƚŝŽŶƐĂƚϰϮ&Z^ĞĐƚŝŽŶƐϰϴϴ͘ϰϭϮĂŶĚϰϴϴ͘ϰϱϲ͘
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/ŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚϰϮ&Zϰϴϴ͘ϯϯϭ͕LJŽƵŚĂǀĞŽŶĞŽƉƉŽƌƚƵŶŝƚLJƚŽƋƵĞƐƚŝŽŶĐŝƚĞĚĚĞĨŝĐŝĞŶĐŝĞƐƚŚƌŽƵŐŚ
ĂŶŝŶĨŽƌŵĂůĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉƌŽĐĞƐƐ͘zŽƵĂƌĞƌĞƋƵŝƌĞĚƚŽƐĞŶĚLJŽƵƌǁƌŝƚƚĞŶƌĞƋƵĞƐƚ͕ĂůŽŶŐǁŝƚŚƚŚĞ
ƐƉĞĐŝĨŝĐĚĞĨŝĐŝĞŶĐŝĞƐďĞŝŶŐĚŝƐƉƵƚĞĚ͕ĂŶĚĂŶĞdžƉůĂŶĂƚŝŽŶŽĨǁŚLJLJŽƵĂƌĞĚŝƐƉƵƚŝŶŐƚŚŽƐĞĚĞĨŝĐŝĞŶĐŝĞƐ͕ƚŽ͗
EƵƌƐŝŶŐ,ŽŵĞ/ŶĨŽƌŵĂůŝƐƉƵƚĞWƌŽĐĞƐƐ
EƵƌƐŝŶŐ,ŽŵĞ/ŶĨŽƌŵĂůŝƐƉƵƚĞWƌŽĐĞƐƐ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
dŚŝƐƌĞƋƵĞƐƚŵƵƐƚďĞƐĞŶƚǁŝƚŚŝŶƚŚĞƐĂŵĞƚĞŶĚĂLJƐLJŽƵŚĂǀĞĨŽƌƐƵďŵŝƚƚŝŶŐĂŶĞWŽĨŽƌƚŚĞĐŝƚĞĚ
ĚĞĨŝĐŝĞŶĐŝĞƐ͘ůůƌĞƋƵĞƐƚƐĨŽƌĂŶ/ZŽƌ//ZŽĨĨĞĚĞƌĂůĚĞĨŝĐŝĞŶĐŝĞƐŵƵƐƚďĞƐƵďŵŝƚƚĞĚǀŝĂƚŚĞǁĞďĂƚ͗
ŚƚƚƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚ͘ƐƚĂƚĞ͘ŵŶ͘ƵƐͬĚŝǀƐͬĨƉĐͬƉƌŽĨŝŶĨŽͬůƚĐͬůƚĐͺŝĚƌ͘ĐĨŵ zŽƵŵƵƐƚŶŽƚŝĨLJD,ĂƚƚŚŝƐǁĞďƐŝƚĞŽĨLJŽƵƌƌĞƋƵĞƐƚĨŽƌĂŶ/ZŽƌ//ZǁŝƚŚŝŶƚŚĞϭϬĐĂůĞŶĚĂƌĚĂLJ
ƉĞƌŝŽĚĂůůŽƚƚĞĚĨŽƌƐƵďŵŝƚƚŝŶŐĂŶĂĐĐĞƉƚĂďůĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͘ĐŽƉLJŽĨƚŚĞĞƉĂƌƚŵĞŶƚ͛ƐŝŶĨŽƌŵĂů
ĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉŽůŝĐŝĞƐĂƌĞƉŽƐƚĞĚŽŶƚŚĞD,/ŶĨŽƌŵĂƚŝŽŶƵůůĞƚŝŶǁĞďƐŝƚĞĂƚ͗
ŚƚƚƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚ͘ƐƚĂƚĞ͘ŵŶ͘ƵƐͬĚŝǀƐͬĨƉĐͬƉƌŽĨŝŶĨŽͬŝŶĨŽďƵů͘Śƚŵ
WůĞĂƐĞŶŽƚĞƚŚĂƚƚŚĞĨĂŝůƵƌĞƚŽĐŽŵƉůĞƚĞƚŚĞŝŶĨŽƌŵĂůĚŝƐƉƵƚĞƌĞƐŽůƵƚŝŽŶƉƌŽĐĞƐƐǁŝůůŶŽƚĚĞůĂLJƚŚĞ
ĚĂƚĞƐƐƉĞĐŝĨŝĞĚĨŽƌĐŽŵƉůŝĂŶĐĞŽƌƚŚĞŝŵƉŽƐŝƚŝŽŶŽĨƌĞŵĞĚŝĞƐ͘ YƵĞƐƚŝŽŶƐƌĞŐĂƌĚŝŶŐĂůůĚŽĐƵŵĞŶƚƐƐƵďŵŝƚƚĞĚĂƐĂƌĞƐƉŽŶƐĞƚŽƚŚĞ>ŝĨĞ^ĂĨĞƚLJŽĚĞĚĞĨŝĐŝĞŶĐŝĞƐ;ƚŚŽƐĞ
ƉƌĞĐĞĚĞĚďLJĂΗ<ΗƚĂŐͿ͕ŝ͘Ğ͕͘ƚŚĞƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶ͕ƌĞƋƵĞƐƚĨŽƌǁĂŝǀĞƌƐ͕ƐŚŽƵůĚďĞĚŝƌĞĐƚĞĚƚŽ͗
Dƌ͘dŽŵ>ŝŶŚŽĨĨ͕^ƵƉĞƌǀŝƐŽƌ
,ĞĂůƚŚĂƌĞ&ŝƌĞ/ŶƐƉĞĐƚŝŽŶƐ
^ƚĂƚĞ&ŝƌĞDĂƌƐŚĂůŝǀŝƐŝŽŶ
ŵĂŝů͗ƚŽŵ͘ůŝŶŚŽĨĨΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
ƚ Žŵ͘ůŝŶŚŽĨĨΛƐƚĂƚĞ͘ŵŶ͘ƵƐ ƚŽŵ͘ůŝŶŚŽĨĨΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
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ĐĐ͗>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
3220 LAKE JOHANNA BOULEVARD
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 000 INITIAL COMMENTS
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
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 329 483.25(l) DRUG REGIMEN IS FREE FROM
SS=D UNNECESSARY DRUGS
F 329
2/16/16
Each resident's drug regimen must be free from
unnecessary drugs. An unnecessary drug is any
drug when used in excessive dose (including
duplicate therapy)or for excessive durationor
without adequate monitoringor without adequate
indications for its useor in the presence of
adverse consequences which indicate the dose
should be reduced or discontinuedor any
combinations of the reasons above.
Based on a comprehensive assessment of a
resident, the facility must ensure that residents
who have not used antipsychotic drugs are not
given these drugs unless antipsychotic drug
therapy is necessary to treat a specific condition
as diagnosed and documented in the clinical
recordand residents who use antipsychotic
drugs receive gradual dose reductions, and
behavioral interventions, unless clinically
contraindicated, in an effort to discontinue these
drugs.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Electronically Signed
(X6) DATE
02/12/2016
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: P93R11
Facility ID: 00975
If continuation sheet Page 1 of 7
PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 329 Continued From page 1
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 329
This REQUIREMENT is not met as evidenced
by:
Based on document review and interview, the
facility failed to ensure medications for 1 of 6
residents (R17) reviewed for unnecessary
medications was administered per physician
ordered parameters.
Findings include:
Document review on 1/12/15, at 2:00 p.m.
indicated R17 had a physician order for
Acetaminophen 500 mg (milligrams) Give 2 tablet
by mouth every 24 hours as needed for Pain max
APAP 4GM/24HRS (maximum acetaminophen 4
grams in 24 hours) and Tylenol Extra Strength
Tablet 500 MG (Acetaminophen) Give 2 tablet by
mouth three times a day for Pain.
Review of R17's medication administration record
(MAR) for December 2015, indicated R17
received 2 doses of as needed Acetaminophen in
24 hours on 12/17/15. (5 grams in 24 hours)
Review of R17's MAR for November 2015,
indicated R17 received 2 doses of as needed
Acetaminophen on 11/5/15 (5 grams in 24 hours).
Review of R17's MAR for October 2015, indicated
R17 received 2 doses of as needed
Acetaminophen on 10/1/15 and 10/13/15 (5
grams in 24 hours).
Review of R17's MAR for September 2015,
indicated R17 received 2 doses of as needed
Acetaminophen on 9/6/15, 9/8/15 and 9/15/15 (5
grams in 24 hours).
Review of R17's MAR for September 2015,
FORM CMS-2567(02-99) Previous Versions Obsolete
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
Event ID: P93R11
Resident # 17 medication regimen was
reviewed and all other resident Tylenol
orders were reviewed.
Requests for Tylenol order(s) to be
changed to not greater than 3000mg per
day to medical practitioners was initiated
on 1/25/16 and order changes are
ongoing.
License nurse and TMA education on
obtaining and following Tylenol
parameters, including frequency of
medication, and unnecessary medication
was initiated on 2/1/16 and is ongoing.
Random medication review audits on 10%
of residents were initiated on 1/25/16 and
will be completed weekly for 1 month by
nursing and monthly thereafter by the
Pharmacist consultant. Results will be
reported to the QA Committee. Actions
plans will be developed as needed. The
policy for unnecessary medications was
reviewed and is current.
The Pharmacist consultant will utilize the
electronic medical record for review of
medication orders for all residents. A
monthly recommendation report will be
provided to the Clinical Administrator for
review and follow up.
Care Center Administrator and Clinical
Administrator are responsible for ongoing
compliance. Date certain for purpose of
the ongoing compliance is February 16,
Facility ID: 00975
If continuation sheet Page 2 of 7
PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
3220 LAKE JOHANNA BOULEVARD
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 329 Continued From page 2
indicated R 71 received 2 doses of as needed
Acetaminophen on 8/26/15 and 8/29/15 (5 grams
in 24 hours).
Interview with the Clinical Administrator on
1/14/16, at 9:50 a.m., verified the maximum dose
of Tylenol ordered by the physician was exceeded
on those dates and he was going to investigate.
No further information was provided.
F 371 483.35(i) FOOD PROCURE,
SS=E STORE/PREPARE/SERVE - SANITARY
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 329
2016.
F 371
2/16/16
The facility must (1) Procure food from sources approved or
considered satisfactory by Federal, State or local
authoritiesand
(2) Store, prepare, distribute and serve food
under sanitary conditions
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview and document
review, the facility failed to ensure food was
prepared under sanitary conditions in 3 of 4
serving kitchens.
Findings include:
A tour of the facility's serving kitchens was
conducted on 1/14/16, from 11:00 a.m. to 11:30
a.m. During the tour the grease catchers on the
griddles in the second, third and fourth floor
serving kitchens were observed to have an
accumulation of brown and black debris
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: P93R11
The second, third and fourth floor serving
kitchen griddles were immediately
removed and thoroughly cleaned.
Staff education initiated on February 1,
2016 and is ongoing.
Audits will be completed two times a week
for four weeks. Results will be reported to
the QA committee and the need for
ongoing audits and action plans initiated
as appropriate.
The Gables Griddle Cleaning Policy and
Procedure was reviewed and updated on
1/29/2016 and is current.
Facility ID: 00975
If continuation sheet Page 3 of 7
PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
3220 LAKE JOHANNA BOULEVARD
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 371 Continued From page 3
throughout the grease catchers. There was
cooked on debris in the corners of each of the
griddles grease catchers.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 371
The Nutrition and Culinary Director will be
responsible for compliance by February
16, 2016.
On 1/14/16, at 12:27 p.m. the culinary director
and administrator verified the condition of each of
the griddles. The culinary director stated the
griddles were used three times a week and were
being cleaned at this time.
Also at this time the culinary director provided the
surveyor a copy of the facility's undated policy
titled, CC Griddle Cleaning Procedure. The policy
did not address cleaning of the griddle grease
catchers. The culinary manager stated he could
revise the policy.
F 441 483.65 INFECTION CONTROL, PREVENT
SS=E SPREAD, LINENS
F 441
2/16/16
The facility must establish and maintain an
Infection Control Program designed to provide a
safe, sanitary and comfortable environment and
to help prevent the development and transmission
of disease and infection.
(a) Infection Control Program
The facility must establish an Infection Control
Program under which it (1) Investigates, controls, and prevents infections
in the facility
(2) Decides what procedures, such as isolation,
should be applied to an individual residentand
(3) Maintains a record of incidents and corrective
actions related to infections.
(b) Preventing Spread of Infection
(1) When the Infection Control Program
determines that a resident needs isolation to
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: P93R11
Facility ID: 00975
If continuation sheet Page 4 of 7
PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
3220 LAKE JOHANNA BOULEVARD
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 441 Continued From page 4
prevent the spread of infection, the facility must
isolate the resident.
(2) The facility must prohibit employees with a
communicable disease or infected skin lesions
from direct contact with residents or their food, if
direct contact will transmit the disease.
(3) The facility must require staff to wash their
hands after each direct resident contact for which
hand washing is indicated by accepted
professional practice.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 441
(c) Linens
Personnel must handle, store, process and
transport linens so as to prevent the spread of
infection.
This REQUIREMENT is not met as evidenced
by:
Based on observation, interview, and document
review, the facility failed to ensure proper
infection control techniques were followed to
minimize the spread of infection related to storing
reusable ice packs with food, in freezers on three
floors affecting residents that stored or ate food
from the freezers.
Findings include:
On 1/12/16 at 11:04 a.m., during random
observation of second floor south dining room's
freezer, 2 unlabeled ice packs were observed to
be stored in the refrigerator freezer next to 13 - 4
fluid ounces (fl. oz.) unlabeled frozen nutritional
treat.
On 1/12/16 at 11:20 a.m., during observation on
third floor south dining room's refrigerator's
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: P93R11
The facility initiated immediate correction
of ice pack storage on 1/12/16 upon
notification. All resident refrigerators were
checked and a communication plan on
proper ice pack storage was initiated at
that time.
The policy and procedure was reviewed
and updated on 1/29/16 to address
storage. Staff education on the updated
procedure was initiated on 2/4/16 and is
ongoing.
Weekly audits will be completed three
times weekly for one month by nursing.
Results will be reported to the QA
committee and the need for ongoing
audits and actions plans initiated as
needed.
Care Center Administrator and Clinical
Administrator are responsible for ongoing
Facility ID: 00975
If continuation sheet Page 5 of 7
PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
3220 LAKE JOHANNA BOULEVARD
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
F 441 Continued From page 5
freezer, 3 unlabeled ice packs were observed to
be stored in the refrigerator freezer with 10 - 4 fl.
oz. unlabeled frozen nutritional treat, 13 - 4 fl. oz.
unlabeled frozen sherbet, 5 unlabeled ice cream
coated with orange sherbet, 1 unlabeled pack of
raisin bread cinnamon swirl and 11 unlabeled
peanut butter & jelly sandwich's.
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
ID
PREFIX
TAG
(X5)
COMPLETION
DATE
F 441
compliance. Date certain for purpose of
the ongoing compliance is February 16,
2016.
On 1/12/16 at 11:49 a.m., during observation of
the refrigerator in the day room on first floor, 4
unlabeled ice packs were observed to be stored
in the refrigerator freezer with R161's tomato
basil soup.
During an interview with registered nurse (RN)-A
on 1/12/16, at 11:33 a.m. verified findings and
removed the ice packs from the freezer. In
addition, RN-A stated, "We do not mix the ice
packs and food.
During an interview with RN-B on 1/12/16, at
11:42 a.m. confirmed findings, removed the 2 ice
packs from the freezer and indicated, "ice packs
are not supposed to be stored with food."
During an interview with RN-C on 1/12/16, at
11:52 a.m. verified findings, removed R161's
tomato basil soup and stated, R161 might have
put it in the freezer and maybe R161 did not
know, but will let R161 know not to store food with
ice packs.
During an interview with clinical administrator
(CA), on 1/13/16, at 10:54 a.m., CA stated, the
ice packs should have been stored separately
and initiated reeducation of staff regarding
storage of the ice packs. In addition, CA
mentioned, "My expectations are ice packs to be
stored separately."
The facility policy dated December 2014, titled,
Ice Packs, reviewed on 1/13/16, at 10:55 a.m. did
not address storage of ice packs with food.
FORM CMS-2567(02-99) Previous Versions Obsolete
Event ID: P93R11
Facility ID: 00975
If continuation sheet Page 6 of 7
PRINTED: 02/12/2016
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
245424
OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
NAME OF PROVIDER OR SUPPLIER
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
FORM CMS-2567(02-99) Previous Versions Obsolete
01/14/2016
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
(X4) ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
A. BUILDING ______________________
Event ID: P93R11
ID
PREFIX
TAG
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
Facility ID: 00975
(X5)
COMPLETION
DATE
If continuation sheet Page 7 of 7
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ĚĞĨŝĐŝĞŶĐŝĞƐĐŝƚĞĚŚĞƌĞŝŶĂƌĞŶŽƚĐŽƌƌĞĐƚĞĚ͕ĂĐŝǀŝůĨŝŶĞĨŽƌĞĂĐŚĚĞĨŝĐŝĞŶĐLJŶŽƚĐŽƌƌĞĐƚĞĚƐŚĂůůďĞĂƐƐĞƐƐĞĚ
ŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚĂƐĐŚĞĚƵůĞŽĨĨŝŶĞƐƉƌŽŵƵůŐĂƚĞĚďLJƌƵůĞŽĨƚŚĞDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͘
dŽĂƐƐŝƐƚŝŶĐŽŵƉůLJŝŶŐǁŝƚŚƚŚĞĐŽƌƌĞĐƚŝŽŶŽƌĚĞƌ;ƐͿ͕Ă͞ƐƵŐŐĞƐƚĞĚŵĞƚŚŽĚŽĨĐŽƌƌĞĐƚŝŽŶ͟ŚĂƐďĞĞŶĂĚĚĞĚ͘
dŚŝƐƉƌŽǀŝƐŝŽŶŝƐďĞŝŶŐƐƵŐŐĞƐƚĞĚĂƐŽŶĞŵĞƚŚŽĚƚŚĂƚLJŽƵĐĂŶĨŽůůŽǁƚŽĐŽƌƌĞĐƚƚŚĞĐŝƚĞĚĚĞĨŝĐŝĞŶĐLJ͘ WůĞĂƐĞƌĞŵĞŵďĞƌƚŚĂƚƚŚŝƐƉƌŽǀŝƐŝŽŶŝƐŽŶůLJĂƐƵŐŐĞƐƚŝŽŶĂŶĚLJŽƵĂƌĞŶŽƚƌĞƋƵŝƌĞĚƚŽĨŽůůŽǁŝƚ͘&ĂŝůƵƌĞƚŽ
ĨŽůůŽǁƚŚĞƐƵŐŐĞƐƚĞĚŵĞƚŚŽĚǁŝůůŶŽƚƌĞƐƵůƚŝŶƚŚĞŝƐƐƵĂŶĐĞŽĨĂƉĞŶĂůƚLJĂƐƐĞƐƐŵĞŶƚ͘zŽƵĂƌĞƌĞŵŝŶĚĞĚ͕
ŚŽǁĞǀĞƌ͕ƚŚĂƚƌĞŐĂƌĚůĞƐƐŽĨƚŚĞŵĞƚŚŽĚƵƐĞĚ͕ĐŽƌƌĞĐƚŝŽŶŽĨƚŚĞĚĞĨŝĐŝĞŶĐLJǁŝƚŚŝŶƚŚĞĞƐƚĂďůŝƐŚĞĚƚŝŵĞ
ĨƌĂŵĞŝƐƌĞƋƵŝƌĞĚ͘dŚĞ͞ƐƵŐŐĞƐƚĞĚŵĞƚŚŽĚŽĨĐŽƌƌĞĐƚŝŽŶ͟ŝƐĨŽƌLJŽƵƌŝŶĨŽƌŵĂƚŝŽŶĂŶĚĂƐƐŝƐƚĂŶĐĞŽŶůLJ͘
zŽƵŚĂǀĞĂŐƌĞĞĚƚŽƉĂƌƚŝĐŝƉĂƚĞŝŶƚŚĞĞůĞĐƚƌŽŶŝĐƌĞĐĞŝƉƚŽĨ^ƚĂƚĞůŝĐĞŶƐƵƌĞŽƌĚĞƌƐĐŽŶƐŝƐƚĞŶƚǁŝƚŚƚŚĞ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ/ŶĨŽƌŵĂƚŝŽŶĂůƵůůĞƚŝŶϭϰͲϬϭ͕ĂǀĂŝůĂďůĞĂƚ
ŚƚƚƉ͗ͬͬǁǁǁ͘ŚĞĂůƚŚ͘ƐƚĂƚĞ͘ŵŶ͘ƵƐͬĚŝǀƐͬĨƉĐͬƉƌŽĨŝŶĨŽͬŝŶĨŽďƵů͘Śƚŵ͘dŚĞ^ƚĂƚĞůŝĐĞŶƐŝŶŐŽƌĚĞƌƐĂƌĞĚĞůŝŶĞĂƚĞĚ
ŽŶƚŚĞĂƚƚĂĐŚĞĚDŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚŽƌĚĞƌƐďĞŝŶŐƐƵďŵŝƚƚĞĚƚŽLJŽƵĞůĞĐƚƌŽŶŝĐĂůůLJ͘dŚĞ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚŝƐĚŽĐƵŵĞŶƚŝŶŐƚŚĞ^ƚĂƚĞ>ŝĐĞŶƐŝŶŐŽƌƌĞĐƚŝŽŶKƌĚĞƌƐƵƐŝŶŐĨĞĚĞƌĂů
ƐŽĨƚǁĂƌĞ͘dĂŐŶƵŵďĞƌƐŚĂǀĞďĞĞŶĂƐƐŝŐŶĞĚƚŽDŝŶŶĞƐŽƚĂƐƚĂƚĞƐƚĂƚƵƚĞƐͬƌƵůĞƐĨŽƌEƵƌƐŝŶŐ,ŽŵĞƐ͘
dŚĞĂƐƐŝŐŶĞĚƚĂŐŶƵŵďĞƌĂƉƉĞĂƌƐŝŶƚŚĞĨĂƌůĞĨƚĐŽůƵŵŶĞŶƚŝƚůĞĚΗ/WƌĞĨŝdždĂŐ͘ΗdŚĞƐƚĂƚĞƐƚĂƚƵƚĞͬƌƵůĞ
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^ƚĂƚĞŵĞŶƚŽĨĞĨŝĐŝĞŶĐŝĞƐΗĐŽůƵŵŶĂŶĚƌĞƉůĂĐĞƐƚŚĞΗdŽŽŵƉůLJΗƉŽƌƚŝŽŶŽĨƚŚĞĐŽƌƌĞĐƚŝŽŶŽƌĚĞƌ͘dŚŝƐ
ĐŽůƵŵŶĂůƐŽŝŶĐůƵĚĞƐƚŚĞĨŝŶĚŝŶŐƐƚŚĂƚĂƌĞŝŶǀŝŽůĂƚŝŽŶŽĨƚŚĞƐƚĂƚĞƐƚĂƚƵƚĞĂĨƚĞƌƚŚĞƐƚĂƚĞŵĞŶƚ͕ΗdŚŝƐZƵůĞ
ŝƐŶŽƚŵĞƚĂƐĞǀŝĚĞŶĐĞĚďLJ͘Η&ŽůůŽǁŝŶŐƚŚĞƐƵƌǀĞLJŽƌƐĨŝŶĚŝŶŐƐĂƌĞƚŚĞ^ƵŐŐĞƐƚĞĚDĞƚŚŽĚŽĨŽƌƌĞĐƚŝŽŶ
ĂŶĚƚŚĞdŝŵĞWĞƌŝŽĚ&ŽƌŽƌƌĞĐƚŝŽŶ͘
ŶĞƋƵĂůŽƉƉŽƌƚƵŶŝƚLJĞŵƉůŽLJĞƌ
WƌĞƐďLJƚĞƌŝĂŶ,ŽŵĞƐŽĨƌĚĞŶ,ŝůůƐ
&ĞďƌƵĂƌLJϮ͕ϮϬϭϲ
WĂŐĞϮ
W>^/^Z'Zd,,/E'K&d,&KhZd,K>hDEt,/,^dd^͕
ΗWZKs/ZΖ^W>EK&KZZd/KE͘Ηd,/^WW>/^dK&Z>&//E/^
KE>z͘d,/^t/>>WWZKE,W'͘ d,Z/^EKZYh/ZDEddK^hD/dW>EK&KZZd/KE&KZs/K>d/KE^K&D/EE^Kd^dd
^ddhd^ͬZh>^͘ ůƚŚŽƵŐŚŶŽƉůĂŶŽĨĐŽƌƌĞĐƚŝŽŶŝƐŶĞĐĞƐƐĂƌLJĨŽƌ^ƚĂƚĞ^ƚĂƚƵƚĞƐͬZƵůĞƐ͕ƉůĞĂƐĞĞŶƚĞƌƚŚĞǁŽƌĚΗĐŽƌƌĞĐƚĞĚΗŝŶ
ƚŚĞďŽdžĂǀĂŝůĂďůĞĨŽƌƚĞdžƚ͘zŽƵŵƵƐƚƚŚĞŶŝŶĚŝĐĂƚĞŝŶƚŚĞĞůĞĐƚƌŽŶŝĐ^ƚĂƚĞůŝĐĞŶƐƵƌĞƉƌŽĐĞƐƐ͕ƵŶĚĞƌƚŚĞ
ŚĞĂĚŝŶŐĐŽŵƉůĞƚŝŽŶĚĂƚĞ͕ƚŚĞĚĂƚĞLJŽƵƌŽƌĚĞƌƐǁŝůůďĞĐŽƌƌĞĐƚĞĚƉƌŝŽƌƚŽĞůĞĐƚƌŽŶŝĐĂůůLJƐƵďŵŝƚƚŝŶŐƚŽƚŚĞ
DŝŶŶĞƐŽƚĂĞƉĂƌƚŵĞŶƚŽĨ,ĞĂůƚŚ͘tĞƵƌŐĞLJŽƵƚŽƌĞǀŝĞǁƚŚĞƐĞŽƌĚĞƌƐĐĂƌĞĨƵůůLJ͕ŝƚĞŵďLJŝƚĞŵ͕ĂŶĚŝĨLJŽƵ
ĨŝŶĚƚŚĂƚĂŶLJŽĨƚŚĞŽƌĚĞƌƐĂƌĞŶŽƚŝŶĂĐĐŽƌĚĂŶĐĞǁŝƚŚLJŽƵƌƵŶĚĞƌƐƚĂŶĚŝŶŐĂƚƚŚĞƚŝŵĞŽĨƚŚĞĞdžŝƚ
ĐŽŶĨĞƌĞŶĐĞĨŽůůŽǁŝŶŐƚŚĞƐƵƌǀĞLJ͕LJŽƵƐŚŽƵůĚŝŵŵĞĚŝĂƚĞůLJĐŽŶƚĂĐƚ^ƵƐĂŶŶĞZĞƵƐƐ͕hŶŝƚ^ƵƉĞƌǀŝƐŽƌĂƚ ;ϲϱϭͿϮϬϭͲϯϳϵϯ͘ zŽƵŵĂLJƌĞƋƵĞƐƚĂŚĞĂƌŝŶŐŽŶĂŶLJĂƐƐĞƐƐŵĞŶƚƐƚŚĂƚŵĂLJƌĞƐƵůƚĨƌŽŵŶŽŶͲĐŽŵƉůŝĂŶĐĞǁŝƚŚƚŚĞƐĞŽƌĚĞƌƐ
ƉƌŽǀŝĚĞĚƚŚĂƚĂǁƌŝƚƚĞŶƌĞƋƵĞƐƚŝƐŵĂĚĞƚŽƚŚĞĞƉĂƌƚŵĞŶƚǁŝƚŚŝŶϭϱĚĂLJƐŽĨƌĞĐĞŝƉƚŽĨĂŶŽƚŝĐĞŽĨ
ĂƐƐĞƐƐŵĞŶƚĨŽƌŶŽŶͲĐŽŵƉůŝĂŶĐĞ͘
WůĞĂƐĞŶŽƚĞŝƚŝƐLJŽƵƌƌĞƐƉŽŶƐŝďŝůŝƚLJƚŽƐŚĂƌĞƚŚĞŝŶĨŽƌŵĂƚŝŽŶĐŽŶƚĂŝŶĞĚŝŶƚŚŝƐůĞƚƚĞƌĂŶĚƚŚĞƌĞƐƵůƚƐŽĨƚŚŝƐ
ǀŝƐŝƚǁŝƚŚƚŚĞWƌĞƐŝĚĞŶƚŽĨLJŽƵƌĨĂĐŝůŝƚLJ͛Ɛ'ŽǀĞƌŶŝŶŐŽĚLJ͘
WůĞĂƐĞĨĞĞůĨƌĞĞƚŽĐĂůůŵĞǁŝƚŚĂŶLJƋƵĞƐƚŝŽŶƐ͘
^ŝŶĐĞƌĞůLJ͕
<ĂƚĞ:ŽŚŶƐdŽŶ͕WƌŽŐƌĂŵ^ƉĞĐŝĂůŝƐƚ
WƌŽŐƌĂŵƐƐƵƌĂŶĐĞhŶŝƚ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶWƌŽŐƌĂŵ
,ĞĂůƚŚZĞŐƵůĂƚŝŽŶŝǀŝƐŝŽŶ ϴϱĂƐƚ^ĞǀĞŶƚŚWůĂĐĞ͕^ƵŝƚĞϮϮϬ
W͘K͘ŽdžϲϰϵϬϬ
^ƚ͘WĂƵů͕DŝŶŶĞƐŽƚĂϱϱϭϲϰͲϬϵϬϬ
ŬĂƚĞ͘ũŽŚŶƐƚŽŶΛƐƚĂƚĞ͘ŵŶ͘ƵƐ
dĞůĞƉŚŽŶĞ͗;ϲϱϭͿϮϬϭͲϯϵϵϮ&Ădž͗;ϲϱϭͿϮϭϱͲϵϲϵϳ
ŶĐůŽƐƵƌĞ;ƐͿ
ĐĐ͗KƌŝŐŝŶĂůͲ&ĂĐŝůŝƚLJ
>ŝĐĞŶƐŝŶŐĂŶĚĞƌƚŝĨŝĐĂƚŝŽŶ&ŝůĞ
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
(X4) ID
PREFIX
TAG
2 000 Initial Comments
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 000
*****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:
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/inf
obul.htm The State licensing orders are
delineated on the attached Minnesota
Minnesota Department of Health
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Electronically Signed
STATE FORM
(X6) DATE
02/12/16
6899
P93R11
If continuation sheet 1 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 000 Continued From page 1
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 000
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 1/11/2016, 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.
Minnesota Department of Health is documenting
the State Licensing Correction Orders using
federal software. Tag numbers have been
assigned to Minnesota state statutes/rules for
Nursing Homes.
The assigned tag number appears in the far left
column entitled "ID Prefix Tag." The state
statute/rule out of compliance is listed in the
"Summary Statement of Deficiencies" column
and replaces the "To Comply" portion of the
correction order. This column also includes the
findings which are in violation of the state statute
after the statement, "This Rule is not met as
evidence by." Following the surveyors findings
are the Suggested Method of Correction and
Time period for Correction.
PLEASE DISREGARD THE HEADING OF THE
FOURTH COLUMN WHICH STATES,
"PROVIDER'S PLAN OF CORRECTION." THIS
APPLIES TO FEDERAL DEFICIENCIES ONLY.
THIS WILL APPEAR ON EACH PAGE.
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 2 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
2 000 Continued From page 2
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
2 000
THERE IS NO REQUIREMENT TO SUBMIT A
PLAN OF CORRECTION FOR VIOLATIONS OF
MINNESOTA STATE STATUTES/RULES.
21015 MN Rule 4658.0610 Subp. 7 Dietary Staff
21015
2/16/16
Requirements- Sanitary conditi
Subp. 7. Sanitary conditions. Sanitary
procedures and conditions must be maintained in
the operation of the dietary department at all
times.
This MN Requirement is not met as evidenced
by:
Based on observation, interview and document
review, the facility failed to ensure food was
prepared under sanitary conditions in 3 of 4
serving kitchens.
Corrected
Findings include:
A tour of the facility's serving kitchens was
conducted on 1/14/16, from 11:00 a.m. to 11:30
a.m. During the tour the grease catchers on the
griddles in the second, third and fourth floor
serving kitchens were observed to have an
accumulation of brown and black debris
throughout the grease catchers. There was
cooked on debris in the corners of each of the
griddles grease catchers.
On 1/14/16, at 12:27 p.m. the culinary director
and administrator verified the condition of each of
the griddles. The culinary director stated the
griddles were used three times a week and were
being cleaned at this time.
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 3 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
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SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21015 Continued From page 3
ID
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(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21015
Also at this time the culinary director provided the
surveyor a copy of the facility's undated policy
titled, CC Griddle Cleaning Procedure. The policy
did not address cleaning of the griddle grease
catchers. The culinary manager stated he could
revise the policy.
SUGGESTED METHOD OF CORRECTION: The
culinar director should revise the facility's policy
on griddle cleaning to include cleaning of the
grease catchers. Dietary staff using the griddles
to prepare food should be educated on the new
policy and procedure. The culinary director or
designee could randomly observe cleaning of the
griddles and/or observe the griddles for
cleanliness
TIME PERIOD FOR CORRECTION: Fourteen
(14) days.
21390 MN Rule 4658.0800 Subp. 4 A-I Infection Control
21390
2/16/16
Subp. 4. Policies and procedures. The infection
control program must include policies and
procedures which provide for the following:
A. surveillance based on systematic data
collection to identify nosocomial infections in
residents
B. a system for detection, investigation, and
control of outbreaks of infectious diseases
C. isolation and precautions systems to
reduce risk of transmission of infectious agents
D. in-service education in infection
prevention and control
E. a resident health program including an
immunization program, a tuberculosis program as
defined in part 4658.0810, and policies and
procedures of resident care practices to assist in
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 4 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21390 Continued From page 4
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21390
the prevention and treatment of infections
F. the development and implementation of
employee health policies and infection control
practices, including a tuberculosis program as
defined in part 4658.0815
G. a system for reviewing antibiotic use
H. a system for review and evaluation of
products which affect infection control, such as
disinfectants, antiseptics, gloves, and
incontinence productsand
I. methods for maintaining awareness of
current standards of practice in infection control.
This MN Requirement is not met as evidenced
by:
Based on observation, interview, and document
review, the facility failed to ensure proper
infection control techniques were followed to
minimize the spread of infection related to storing
reusable ice packs with food, in freezers on three
floors affecting residents that stored or ate food
from the freezers.
Corrected
Findings include:
On 1/12/16 at 11:04 a.m., during random
observation of second floor south dining room's
freezer, 2 unlabeled ice packs were observed to
be stored in the refrigerator freezer next to 13 - 4
fluid ounces (fl. oz.) unlabeled frozen nutritional
treat.
On 1/12/16 at 11:20 a.m., during observation on
third floor south dining room's refrigerator's
freezer, 3 unlabeled ice packs were observed to
be stored in the refrigerator freezer with 10 - 4 fl.
oz. unlabeled frozen nutritional treat, 13 - 4 fl. oz.
unlabeled frozen sherbet, 5 unlabeled ice cream
coated with orange sherbet, 1 unlabeled pack of
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 5 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21390 Continued From page 5
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21390
raisin bread cinnamon swirl and 11 unlabeled
peanut butter & jelly sandwich's.
On 1/12/16 at 11:49 a.m., during observation of
the refrigerator in the day room on first floor, 4
unlabeled ice packs were observed to be stored
in the refrigerator freezer with R161's tomato
basil soup.
During an interview with registered nurse (RN)-A
on 1/12/16, at 11:33 a.m. verified findings and
removed the ice packs from the freezer. In
addition, RN-A stated, "We do not mix the ice
packs and food.
During an interview with RN-B on 1/12/16, at
11:42 a.m. confirmed findings, removed the 2 ice
packs from the freezer and indicated, "ice packs
are not supposed to be stored with food."
During an interview with RN-C on 1/12/16, at
11:52 a.m. verified findings, removed R161's
tomato basil soup and stated, R161 might have
put it in the freezer and maybe R161 did not
know, but will let R161 know not to store food with
ice packs.
During an interview with clinical administrator
(CA), on 1/13/16, at 10:54 a.m., CA stated, the
ice packs should have been stored separately
and initiated reeducation of staff regarding
storage of the ice packs. In addition, CA
mentioned, "My expectations are ice packs to be
stored separately."
The facility policy dated December 2014, titled,
Ice Packs, reviewed on 1/13/16, at 10:55 a.m. did
not address storage of ice packs with food.
SUGGESTED METHOD OF CORRECTION: The
Director of Nursing (DON) or desigee could
conduct refrigerator/freezer audits, interventions
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 6 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21390 Continued From page 6
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21390
and monitoring to ensure residents cold packs
are not stored with food. The DON could ensure
the staff were educated on the importance of
infection control and individual resident ice packs
in the freezer contaminating food items.
TIME PERIOD FOR CORRECTION: Fourteen
(14) days.
21426 MN St. Statute 144A.04 Subd. 3 Tuberculosis
21426
2/16/16
Prevention And Control
(a) A nursing home provider must establish and
maintain a comprehensive tuberculosis
infection 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,
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 observation, interview, and document
Minnesota Department of Health
STATE FORM
Corrected
6899
P93R11
If continuation sheet 7 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 7
ID
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TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21426
review, the facility failed to document the
induration measurement of millimeter (mm)
results of tuberculin skin test (TST) for 5 of 5
residents reviewed, (R10, R35, R36, R61 and
R195), per Centers for Disease Control and
Prevention (CDC) recommendations.
Findings include:
R10 was admitted to the facility on 10/15/15.
R10's medical record indicted R10 received the
first step of TST, the results were read on
10/16/15 as negative interpretation. R10 then
received the second step TST, results were read
on 10/26/15, as negative interpretation however
no induration was indicated on both.
R35 was admitted to the facility on 2/5/14. R35's
medical record indicted R35 received the first
step of TST on 2/6/15, and the results were read
as negative interpretation of reading on 2/9/15.
R35 then received the second step TST on
2/19/15, results were read on 2/22/15 as negative
interpretation however no induration was
indicated on both.
R36 was admitted to the facility on 2/17/15. R36's
medical record indicted R36 received the first
step of TST, the results were read on 12/18/15 as
negative interpretation. R36 then received the
second step TST, results were read on 3/25/15
as negative interpretation however no induration
was indicated on both.
R61 was admitted to the facility on 7/31/15. R61's
medical record indicted R61 received the first
step of TST, the results were read on 8/1/15 as
negative interpretation however no induration was
indicated. R61 then received the second step
TST, results were read on 8/5/15 as 0 mm with a
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 8 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 8
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TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21426
negative interpretation.
R195 was admitted to the facility on 12/9/13.
R195's medical record indicted R195 received the
first step of TST on 12/10/13, and the results
were read as negative interpretation of reading on
12/13/13. R195 then received the second step
TST on 12/21/13, results were read on 12/24/13
as negative interpretation however no induration
was indicated on both.
On 1/13/16 at 10:27 a.m. the clinical administrator
(CA) acknowledged the TST reading for R10,
R35, R36, R61 and R195 should have both the
induration and interpretation. CA stated,
resident's records are lacked of the induration
measurement of mm. In addition, CA mentioned,
going forward, the software will be updated to
prompt the staff to record both the induration
measurement of mm and interpretation of
positive or negative.
Regulation for Tuberculosis Control in Minnesota
Health Care Settings dated July 2013, Screening
residents directed, ALL REPORTS OR COPIES
OF THE TST OR IGRA AND ANY CHEST
X-RAYS AND MEDICAL EVALUATIONS
CONDUCTED SHOULD BE MAINTAINED IN
THE RESIDENT'S MEDICAL 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), AND INTERPRETATION
(I.E., POSITIVE OR NEGATIVE). IF THIS
INFORMATION IS NOT AVAILABLE,
DOCUMENTATION OF A HISTORY OF
INFECTION WITH TB (E.G., A PREVIOUS
POSITIVE SKIN TEST OR HISTORY OF ACTIVE
TB DISEASE) BY A PHYSICIAN IN THE
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 9 of 10
PRINTED: 02/12/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
00975
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PRESBYTERIAN HOMES OF ARDEN HILLS
3220 LAKE JOHANNA BOULEVARD
ARDEN HILLS, MN 55112
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
21426 Continued From page 9
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
01/14/2016
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
21426
RESIDENT'S MEDICAL RECORD IS
ACCEPTABLE.
SUGGESTED METHOD OF CORRECTION: The
Director of Nursing (DON) or designee could
conduct resident tuberculin skin testing audits,
interventions and monitoring to ensure residents
are free from communicable disease. The DON
could ensure the staff were educated on the
importance of induration tuberculin testing. The
DON or designee could randomly audit resident's
to ensure adequate measurements of induration
are documented.
TIME PERIOD FOR CORRECTION: Fourteen
(14) days.
Minnesota Department of Health
STATE FORM
6899
P93R11
If continuation sheet 10 of 10