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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESMEDICARE/MEDICAID CERTIFICATION AND TRANSMITTALID: Y64VFacility ID: 00679PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY1. MEDICARE/MEDICAID PROVIDER NO.3. NAME AND ADDRESS OF FACILITY(L3) FAIR OAKS NURSING & REHAB LLC245581(L1)(L4) 201 SHADY LANE DRIVE2.STATE VENDOR OR MEDICAID NO.719475700(L2)(L9)12/13/20186. DATE OF SURVEY8. ACCREDITATION STATUS:0 Unaccredited2 AOATo(b) :05 HHA09 ESRD13 PTIP(L34)02 SNF/NF/Dual06 PRTF10 NF14 CORF(L10)03 SNF/NF/Distinct07 X-Ray11 ICF/IID15 ASC1 TJC3 Other04 SNF08 OPT/SP12 RHC12.Total Facility Beds75 (L18)13.Total Certified Beds75 (L17)(L38)4. CHOW5. Validation6. Complaint7. On-Site Visit9. Other8. Full Survey After Complaint22 CLIAFISCAL YEAR ENDING DATE:(L35)12/31And/Or Approved Waivers Of The Following Requirements:1.Acceptable POCX B.Not in Compliance with ProgramRequirements and/or Applied Waivers:2. Technical Personnel6. Scope of Services Limit3. 24 Hour RN7. Medical Director4. 7-Day RN (Rural SNF)8. Patient Room Size5. Life Safety Code9. Beds/Room(L12)B** Code:15. FACILITY MEETS14. LTC CERTIFIED BED BREAKDOWN(L37)2. Recertification3. Termination16 HOSPICEProgram RequirementsCompliance Based On:18/19 SNF1. Initial10.THE FACILITY IS CERTIFIED AS:A. In Compliance With18 SNF(L7)01 Hospital11. .LTC PERIOD OF CERTIFICATION(a) :027. PROVIDER/SUPPLIER CATEGORY01/01/2004From(L6) 56482(L5) WADENA, MN5. EFFECTIVE DATE CHANGE OF OWNERSHIP2 (L8)4. TYPE OF ACTION:19 SNFICFIID(L39)(L42)(L43)(L15)1861 (e) (1) or 1861 (j) (1):7516. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE):17. SURVEYOR SIGNATUREDate :Denise Erickson HFE - NE II18. STATE SURVEY AGENCY APPROVAL01/17/2019(L19)Date:Joanne Simon, Enforcement Specialist01/25/2019(L20)PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY20. COMPLIANCE WITH CIVILRIGHTS ACT:19. DETERMINATION OF ELIGIBILITYX1. Facility is Eligible to Participate2.Facility is not Eligible22. ORIGINAL DATE23. LTC AGREEMENT24. LTC AGREEMENTBEGINNING DATEENDING DATE(L24)(L41)26. TERMINATION ACTION:VOLUNTARY11/01/1991(L25)0027. ALTERNATIVE SANCTIONS(L30)INVOLUNTARY01-Merger, Closure05-Fail to Meet Health/Safety02-Dissatisfaction W/ Reimbursement06-Fail to Meet Agreement03-Risk of Involuntary Termination04-Other Reason for WithdrawalA. Suspension of Admissions:(L27)1. Statement of Financial Solvency (HCFA-2572)2. Ownership/Control Interest Disclosure Stmt (HCFA-1513)3. Both of the Above :(L21)OF PARTICIPATION25. LTC EXTENSION DATE:21.OTHER07-Provider Status Change00-Active(L44)B. Rescind Suspension Date:(L45)28. TERMINATION DATE:29. INTERMEDIARY/CARRIER NO.30. REMARKS03001(L28)31. RO RECEIPT OF CMS-1539(L31)32. DETERMINATION OF APPROVAL DATE(L32)FORM CMS-1539 (7-84) (Destroy Prior Editions)(L33)DETERMINATION APPROVAL020499

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 sElectronically deliveredDecember 31, 2018AdministratorFair Oaks Nursing & Rehab Llc201 Shady Lane DriveWadena, MN 56482RE: Project Number S5581029Dear Administrator:On December 13, 2018, a standard survey was completed at your facility by the MinnesotaDepartments of Health and Public Safety, to determine if your facility was in compliance with Federalparticipation requirements for skilled nursing facilities and/or nursing facilities participating in theMedicare and/or Medicaid programs.This survey found the most serious deficiencies in your facility to be widespread deficiencies thatconstituted no actual harm with potential for more than minimal harm that was not immediatejeopardy (Level F), as evidenced by the electronically attached CMS-2567 whereby corrections arerequired.OPPORTUNITY TO CORRECT - DATE OF CORRECTIONThe date by which the deficiencies must be corrected to avoid imposition of remedies is January 22,2019.ELECTRONIC PLAN OF CORRECTION (ePoC)Within ten (10) calendar days after your receipt of this notice, you must submit an acceptable plan ofcorrection (ePOC) for the deficiencies cited. An acceptable ePOC will serve as your allegation ofcompliance. Upon receipt of an acceptable ePOC, we will authorize a revisit to your facility todetermine if substantial compliance has been achieved.To be acceptable, a provider's ePOC must include the following: How corrective action will be accomplished for those residents found to have been affected by thedeficient practice.How the facility will identify other residents having the potential to be affected by the samedeficient practice.What measures will be put into place, or systemic changes made, to ensure that the deficientpractice will not recur.How the facility will monitor its corrective actions to ensure that the deficient practice is beingAn equal opportunity employer.

Fair Oaks Nursing & Rehab LlcDecember 31, 2018Page 2 corrected and will not recur.The date that each deficiency will be corrected.An electronic acknowledgement signature and date by an official facility representative.The state agency may, in lieu of a revisit, determine correction and compliance by accepting thefacility's ePoC if the ePoC is reasonable, addresses the problem and provides evidence that thecorrective action has occurred.If an acceptable ePoC is not received within 10 calendar days from the receipt of this letter, we willrecommend to the CMS Region V Office that one or more of the following remedies be imposed: Discretionary denial of payment for new Medicare and Medicaid admissions (42 CFR88.417 (a)); Per day civil money penalty (42 CFR 488.430 through 488.444).Failure to submit an acceptable ePoC could also result in the termination of your facility’s Medicareand/or Medicaid agreement (488.456(b)).DEPARTMENT CONTACTQuestions regarding this letter and all documents submitted as a response to the resident caredeficiencies (those preceded by an "F" tag) and emergency preparedness deficiencies (those precededby an “E” tag), i.e., the plan of correction should be directed to:Gail Anderson, Unit SupervisorFergus Falls Survey TeamLicensing and Certification ProgramHealth Regulation DivisionMinnesota Department of Health1505 Pebble Lake Road, Suite 300Fergus Falls, Minnesota 56537-3858Email: [email protected]: (218) 332-5140Fax: (218) 332-5196PRESUMPTION OF COMPLIANCE - CREDIBLE ALLEGATION OF COMPLIANCEThe facility's ePoC will serve as your allegation of compliance upon the Department's acceptance. Inorder for your allegation of compliance to be acceptable to the Department, the ePoC must meet thecriteria listed in the plan of correction section above. You will be notified by the Minnesota Departmentof Health, Licensing and Certification Program staff and/or the Department of Public Safety, State FireMarshal Division staff, if your ePoC for the respective deficiencies (if any) is acceptable.

Fair Oaks Nursing & Rehab LlcDecember 31, 2018Page 3VERIFICATION OF SUBSTANTIAL COMPLIANCEUpon receipt of an acceptable ePoC, a Post Certification Revisit (PCR), of your facility will be conductedto validate that substantial compliance with the regulations has been attained in accordance with yourverification.If substantial compliance has been achieved, certification of your facility in the Medicare and/orMedicaid program(s) will be continued and remedies will not be imposed. Compliance is certified as ofthe latest correction date on the approved ePoC, unless it is determined that either correction actuallyoccurred between the latest correction date on the ePoC and the date of the first revisit, or correctionoccurred sooner than the latest correction date on the ePoC.FAILURE TO ACHIEVE SUBSTANTIAL COMPLIANCE BY THE THIRD OR SIXTH MONTH AFTER THE LASTDAY OF THE SURVEYIf substantial compliance with the regulations is not verified by March 13, 2019 (three months after theidentification of noncompliance), the CMS Region V Office must deny payment for new admissions asmandated by the Social Security Act (the Act) at Sections 1819(h)(2)(D) and 1919(h)(2)(C) and Federalregulations at 42 CFR Section 488.417(b).In addition, if substantial compliance with the regulations is not verified by June 13, 2019 (six monthsafter the identification of noncompliance) your provider agreement will be terminated. This action ismandated by the Social Security Act at Sections 1819(h)(2)(C) and 1919(h)(3)(D) and Federalregulations at 42 CFR Sections 488.412 and 488.456.Please note that this notice does not constitute formal notice of imposition of alternative remedies ortermination of your provider agreement. Should the Centers for Medicare & Medicaid Servicesdetermine that termination or any other remedy is warranted, it will provide you with a separateformal notification of that determination.INFORMAL DISPUTE RESOLUTION (IDR) / INDEPENDENT INFORMAL DISPUTE RESOLUTION (IIDR)In accordance with 42 CFR 488.331, you have one opportunity to question cited deficiencies throughan informal dispute resolution process. You are required to send your written request, along with thespecific deficiencies being disputed, and an explanation of why you are disputing those deficiencies, to:Nursing Home Informal Dispute ProcessMinnesota Department of HealthHealth Regulation DivisionP.O. Box 64900St. Paul, Minnesota 55164-0900This request must be sent within the same ten days you have for submitting an ePoC for the citeddeficiencies. All requests for an IDR or IIDR of federal deficiencies must be submitted via the web /ltc/ltc idr.cfm

Fair Oaks Nursing & Rehab LlcDecember 31, 2018Page 4You must notify MDH at this website of your request for an IDR or IIDR within the 10 calendar dayperiod allotted for submitting an acceptable electronic plan of correction. A copy of the Department’sinformal dispute resolution policies are posted on the MDH Information Bulletin website /infobul.htmPlease note that the failure to complete the informal dispute resolution process will not delay thedates specified for compliance or the imposition of remedies.Questions regarding all documents submitted as a response to the Life Safety Code deficiencies (thosepreceded by a "K" tag), i.e., the plan of correction, request for waivers, should be directed to:Mr. Tom Linhoff, Fire Safety SupervisorHealth Care Fire InspectionsMinnesota Department of Public SafetyState Fire Marshal Division445 Minnesota Street, Suite 145St. Paul, Minnesota 55101-5145Email: [email protected]: (651) 430-3012Fax: (651) 215-0525Please note, it is your responsibility to share the information contained in this letter and the results ofthis visit with the President of your facility's Governing Body.Feel free to contact me if you have questions.Sincerely,Joanne Simon, Enforcement SpecialistMinnesota Department of HealthLicensing and Certification ProgramProgram Assurance UnitHealth Regulation DivisionTelephone: 651-201-4161 Fax: 651-215-9697Email: [email protected]: Licensing and Certification File

PRINTED: 01/17/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:245581OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONB. WINGNAME OF PROVIDER OR SUPPLIER12/13/2018STREET ADDRESS, CITY, STATE, ZIP CODE201 SHADY LANE DRIVEFAIR OAKS NURSING & REHAB LLC(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDINGWADENA, MN 56482SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)IDPREFIXTAGE 000 Initial CommentsE 000A survey for compliance with CMS Appendix ZEmergency Preparedness Requirements, wasconducted on 12/10/18 through 12/13/18, duringa recertification survey. The facility is incompliance with the Appendix Z EmergencyPreparedness Requirements.F 000 INITIAL COMMENTSF 000(X5)COMPLETIONDATEOn 12/10/18 through 12/13/18, a standard surveywas completed at your facility by the MinnesotaDepartment of Health to determine if your facilitywas in compliance with the requirements of 42CFR Part 483, Subpart B, and Requirements forLong Term Care Facilities.The facility's plan of correction (POC) will serveas your allegation of compliance upon theDepartment's acceptance. Because you areenrolled in ePOC, your signature is not requiredat the bottom of the first page of the CMS-2567form. Your electronic submission of the POC willbe used as verification of compliance.Upon receipt of an acceptable electronic POC, anon-site revisit of your facility may be conducted tovalidate that substantial compliance with theregulations has been attained in accordance withyour verification.F 550 Resident Rights/Exercise of RightsSS D CFR(s): 483.10(a)(1)(2)(b)(1)(2)F 5501/22/19§483.10(a) Resident Rights.The resident has a right to a dignified existence,self-determination, and communication with andaccess to persons and services inside andoutside the facility, including those specified inthis section.LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURETITLEElectronically Signed(X6) DATE01/07/2019Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined thatother safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 daysfollowing 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 14days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedprogram participation.FORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y64V11Facility ID: 00679If continuation sheet Page 1 of 64

PRINTED: 01/17/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:245581OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONB. WINGNAME OF PROVIDER OR SUPPLIER12/13/2018STREET ADDRESS, CITY, STATE, ZIP CODE201 SHADY LANE DRIVEFAIR OAKS NURSING & REHAB LLC(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDINGWADENA, MN 56482SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 550 Continued From page 1PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 550§483.10(a)(1) A facility must treat each residentwith respect and dignity and care for eachresident in a manner and in an environment thatpromotes maintenance or enhancement of his orher quality of life, recognizing each resident'sindividuality. The facility must protect andpromote the rights of the resident.§483.10(a)(2) The facility must provide equalaccess to quality care regardless of diagnosis,severity of condition, or payment source. A facilitymust establish and maintain identical policies andpractices regarding transfer, discharge, and theprovision of services under the State plan for allresidents regardless of payment source.§483.10(b) Exercise of Rights.The resident has the right to exercise his or herrights as a resident of the facility and as a citizenor resident of the United States.§483.10(b)(1) The facility must ensure that theresident can exercise his or her rights withoutinterference, coercion, discrimination, or reprisalfrom the facility.§483.10(b)(2) The resident has the right to befree of interference, coercion, discrimination, andreprisal from the facility in exercising his or herrights and to be supported by the facility in theexercise of his or her rights as required under thissubpart.This REQUIREMENT is not met as evidencedby:Based on observation, interview and documentreview the facility failed to provide a dignifieddining experience for 1 of 1 resident(R29)required a mechanically altered diet of pureedFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y64V111. R29 is being given a dignified diningexperience2. Residents can be effected by this if notFacility ID: 00679If continuation sheet Page 2 of 64

PRINTED: 01/17/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:245581OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONB. WINGNAME OF PROVIDER OR SUPPLIER12/13/2018STREET ADDRESS, CITY, STATE, ZIP CODE201 SHADY LANE DRIVEFAIR OAKS NURSING & REHAB LLC(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDINGWADENA, MN 56482SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 550 Continued From page 2foods, and nectar thickened liquids during 1 of 1observations of the main floor dining room in thefacilty.PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE EF 550treated in a dignified manner3. Staff education on resident rights anddignityFindings include:R29's quarterly Minimum Data Set (MDS) dated11/15/18, identified R29 was cognitively intact,had multiple diagnoses which includedobstructive hydrocephalus (a blockage of cerebralspinal fluid through the ventricles of the brain),seizure disorder and dysphagia(difficultyswallowing). In addition, indicated R29 had selfcare and mobility deficits and required extensiveto total dependence for all ADLs.4. Facility will conduct audits, 3 times aweek, to ensure dignified diningexperience for residents. Negativefindings will be immediately corrected.Audit results will be reviewed at monthlyQAPI meeting to determine need tocontinue or further intervention.SSD/designee will be responsible foraudits.5. Date of compliance: 1/22/19R29's annual Care Area Assessment (CAA) dated3/7/18, identified R29 had memory, andcommunication issues with difficulty makingherself understood/understanding others relatedto history of traumatic brain injury and diagnosisof obstructive hydrocephalus. The CAA indicatedR29 had mental health issues related todiagnoses of anxiety and depression, andidentified issues with excessive disruptiverepetitive communication. In addition, the CAAindicated R29 had difficulty swallowing andrequired a mechanically altered diet of pureedfoods, and nectar thickened liquids.R29's care plan last reviewed on 12/7/18,indicated R29 had communication/cognitiondifficulties related to obstructive hydrocephalusresulting in a day to day changing level offunction and and ability to makes herselfunderstood and and to understand others. Thecare plan indicated R29 had behaviors thatincluded repetitively calling out loudly,inappropriate laughing, and foul language. TheFORM CMS-2567(02-99) Previous Versions ObsoleteEvent ID: Y64V11Facility ID: 00679If continuation sheet Page 3 of 64

PRINTED: 01/17/2019FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:245581OMB NO. 0938-0391(X2) MULTIPLE CONSTRUCTIONB. WINGNAME OF PROVIDER OR SUPPLIER12/13/2018STREET ADDRESS, CITY, STATE, ZIP CODE201 SHADY LANE DRIVEFAIR OAKS NURSING & REHAB LLC(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDINGWADENA, MN 56482SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)F 550 Continued From page 3care plan instructed staff to respond promptly in acalm manner, and provide reassurance asneeded to reduce anxiety. The care plan furtherinstructed staff to encourage R29 to mak