December 2, 2015

Email: LisaL@southviewcommunities.com December 2, 2015 Mr. Ben Welna, Administrator Arbor Lakes Senior Living 12001 80th Avenue North Maple Grove, MN 55369 Re: Enclosed State Licensing Orders Project Number SL27690005 Dear Mr. Welna: On November 19, 2015, staff of the completed a follow up survey of your agency to determine correction of orders found on the survey completed on March 20, 2015, with orders received by you on April 24, 2015; follow up survey completed on June 10, 2015, with orders including penalties received by you on July 13, 2015; and follow up survey completed on August 20, 2015, with orders received by you on September 21, 2015. Penalty assessments resulting from the June 10, 2015, follow up survey were paid in full. At this time these correction orders were found corrected and are listed on the attached State Form: Revisit Report. If you have questions, contact Jeri Cummins at (218) 302 6193. It is your responsibility to share the information contained in this letter and the results of the visit with the President of your organization s Governing Body. Sincerely, Paula Bastian Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program cc: Home Care & Assisted Living File Kathy Rogers, Hennepin County Long Term Services & Supports Michael Budion, Minnesota Department of Human Services Cheryl Hennen, Office of the Ombudsman Protecting, maintaining and improving the health of all Minnesotans

AH Form Approved 12/2/2015 (Y1) Provider / Supplier / CLIA / Identification Number H27690 Name of Facility State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 11/19/2015 This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date 00930 11/19/2015 144A.4792, Subd. 7 0930 Reviewed By MDH Reviewed By PMB State Agency Reviewed By Reviewed By CMS RO Followup to Survey on: 3/20/2015 : REVISIT REPORT (5/99) Date: 12/02/15 Date: Signature of Surveyor: 20196 Signature of Surveyor: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Page 1 of 1 Event : Date: 11/19/15 Date: YES LI4914 NO

Certified Mail # 7015 1520 0000 6771 1830 Email: LISAL@SOUTHVIEWCOMMUNITIES.COM September 14, 2015 Mr. Ben Welna, Administrator Arbor Lakes Senior Living 12001 80th Avenue North Maple Grove, MN 55369 Re: Enclosed Follow-up Survey Results - Project #SL27690005 Dear Mr. Welna: On August 20, 2015, survey staff of the completed a follow-up survey of your agency to determine correction of orders found on the survey completed on March 20, 2015, with orders received by you on April 24, 2015; and follow-up survey completed on June 10, 2015, with penalty assessment orders received by you on July 13, 2015. Penalty assessments were paid in full on August 17, 2015. At this time these correction orders were found corrected and are listed on the attached State Form: Revisit Report. Also, at the time of this reinspection completed on August 20, 2015, additional violations were cited. They are delineated on the attached State Form. Only the Tag in the left hand column without brackets will identify these licensing orders. Please note, it is your responsibility to share the information contained in this letter and the results of this visit with the President of your facility's Governing Body. If you should have any questions, please do not hesitate to contact Jeri Cummins at (218) 302-6193. Sincerely, Protecting, Maintaining and Improving the Health of Minnesotans Paula Bastian Senior Health Program Representative Health Regulation Division cc: Home Care & Assisted Living File Kathy Rogers, Henn Cty Long Term Svs & Supports Michael Budion, Minnesota Department of Human Services Cheryl Hennen, Office of the Ombudsman Health Regulation Division Home Care & Assisted Living Program General Information: 651-201-5000 Toll-free: 888-345-0823 http://www.health.state.mn.us An equal opportunity employer

AH Form Approved 9/14/2015 (Y1) Provider / Supplier / CLIA / Identification Number H27690 Name of Facility State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 8/20/2015 This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date 00935 08/20/2015 144A.4792, Subd. 8 0935 Reviewed By MDH Reviewed By PBastian State Agency Reviewed By Reviewed By CMS RO Followup to Survey on: 3/20/2015 : REVISIT REPORT (5/99) Date: 9/14/15 Date: Signature of Surveyor: 20196 Signature of Surveyor: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Page 1 of 1 Event : Date: 8/20/15 Date: YES LI4913 NO

PRINTED: 09/14/2015 R H27690 08/20/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 000} Initial Comments {0 000} *****ATTENTION****** HOME CARE PROVER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144A.43 to 144A.482, this correction order(s) has been issued pursuant to a survey. Determination of whether a violation has been corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: On August 20, 2015, a surveyor of this Department's staff conducted a revisit at the above provider to follow-up on orders issued pursuant to a survey completed on March 20, 2015, and June 10, 2015. At the time of the survey, there were 80 clients that were receiving services under the comprehensive license. As a result of the revisit, the following orders were reissued. 0 930 144A.4792, Subd. 7 Delegation of Medication Administration 0 930 Subd. 7. Delegation of medication administration. When administration of medications is delegated to unlicensed personnel, the comprehensive home care provider must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) LI4913 If continuation sheet 1 of 3

PRINTED: 09/14/2015 R H27690 08/20/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 930 Continued From page 1 proper methods to administer the medications, and the unlicensed personnel has demonstrated the ability to competently follow the procedures; (2) specified, in writing, specific instructions for each client and documented those instructions in the client's records; and (3) communicated with the unlicensed personnel about the individual needs of the client. 0 930 This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure unlicensed personnel (ULP) received instructions on the proper methods to administer inhalant medications for one of one ULP observed (employee C), and the registered nurse (RN) specified instructions for one of one client (#9) who received inhalants. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at a pattern scope (more than a limited number of clients were affected but was not found to be pervasive). The findings include: The licensee failed to ensure ULP were instructed that following administration of corticosteroid inhalant medications, clients were provided assistance/direction to rinse their mouth; and failed to ensure those instructions were specified in writing by the RN. This had the potential to affect all the clients who received assistance with LI4913 If continuation sheet 2 of 3

PRINTED: 09/14/2015 R H27690 08/20/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 930 Continued From page 2 oral corticosteriod inhalants. On the morning of August 20, 2015, employee C (ULP) assisted client #9 with medications, including a Flovent inhaler (oral corticosteroid, for maintenance of asthma). Employee C handed client #9 the inhaler, which was kept in a locked box, in the client's room. Client #9 took 2 puffs, and was not instructed to rinse his mouth following administration. Client #9 had physician orders dated November 21, 2014, for Flovent 2 puffs, twice a day. According to the Nursing 2015, Drug Handbook, "Instruct patient to rinse his mouth and spit water out after inhalation" in order to minimize the risk of oral candidiasis (yeast infection). On August 20, 2015, employee E (clinical services director) verified ULP were not instructed on the procedure to rinse the mouth following administration of oral corticosteroids, and that there were no directions specified in the client records stating such. Employee B (registered nurse) verified there were other clients who received oral corticosteroid inhalers, but did not know how many clients received the medication. The licensee's policy and procedure "Inhalers" dated June 1, 2014, noted "provide client the opportunity to rinse out mouth." TIME PERIOD FOR CORRECTION: Seven (7) days 0 930 LI4913 If continuation sheet 3 of 3

Certified Mail # 7014 1200 0000 8065 4039 Email: benw@arborlakesseniorliving.com July 7, 2015 Mr. Ben Welna, Administrator Arbor Lakes Senior Living 12001 80th Avenue North Maple Grove, MN 55369 Re: Enclosed Follow-up Survey Results - Project #SL27690005 Dear Mr. Welna: Protecting, Maintaining and Improving the Health of Minnesotans On June 10, 2015, survey staff of the completed a follow-up survey of your agency to determine correction of orders found on the survey completed on March 20, 2015, with orders received by you on April 24, 2015. State licensing orders issued pursuant to the last survey completed on March 20, 2015, and found corrected at the time of the June 10, 2015, follow-up survey are listed on the attached State Form: Revisit Report. In accordance with Minnesota Statutes, sections 144A.474, subd. 11, state licensing orders issued pursuant to the survey completed on March 20, 2015, and found not corrected at the time of the June 10, 2015, follow-up survey now subject to penalty assessments are as follows: $100.00 Level/2; Scope/Isolated Documentation of Admin. of Medication, Minn. Stat. Sec. 144A.4792, subd. 8 The details of the violations noted at the time of this follow-up survey completed on June 10, 2015, (listed above), are on the attached State Form. Brackets around the Tag in the left hand column, e.g., {2 ---} will identify the uncorrected tags. Therefore, in accordance with Minnesota Statute, sections 144A.43 to 144A.482, the total amount you are assessed is: $100.00. IMPOSITION OF FINES: Level 1, no fines or enforcement. Level 2, fines ranging from $0 to $500, in addition to any of the enforcement mechanisms authorized in section 144A.475 for widespread violations. Level 3, fines ranging from $500 to $1,000, in addition to any of the enforcement mechanisms authorized in section 144A.475. Level 4, fines ranging from $1,000 to $5,000, in addition to any of the enforcement mechanisms Health Regulation Division Home Care & Assisted Living Program General Information: 651-201-5000 Toll-free: 888-345-0823 http://www.health.state.mn.us An equal opportunity employer

Arbor Lakes Senior Living July 7, 2015 Page 2 authorized in section 144A.475. CORRECTION ORDER RECONSERATION PROCESS: In accordance with Minnesota Statutes, section 144A.474, subd. 12, you have one opportunity to challenge the correction order issued, including the level and scope, and any fine assessed through the correction order reconsideration process. This written request must be received by the Department within 15 calendar days of the correction order receipt date. You are required to send your written request to the following: Home Health Agency Order Reconsideration Process Health Regulation Division P.O. Box 64900 St. Paul, Minnesota 55164-0900 You may request a hearing on the above assessment provided that a written request is made to the, Health Regulation Division, within 15 days of the receipt of this notice. Any request for a hearing as well as payment of the assessment shall be sent to the Minnesota Department of Health, Health Regulation Division, P.O. Box 64900, St. Paul, Minnesota 55164-0900. Failure to correct state licensing correction orders may result in enforcement actions in accordance with the provisions of Minnesota Statutes, sections 144A.43 to 144A.482. We urge you to review these orders carefully. If you have questions, please contact Alice Sanders at (651) 201-3993. Please note, it is your responsibility to share the information contained in this letter and the results of this visit with the President of your agency s Governing Body. Sincerely, Josh Berg, Program Manager Health Regulation Division Home Care and Assisted Living Program P.O. Box 64900 St. Paul, Minnesota 55164 Telephone Number: (651) 201-3708 Fax: (651) 215-9697 Encl. cc: Home Care & Assisted Living Program Kathy Rogers, Hennepin County Long Term Svs & Supports Michael Budion, Department of Human Services Sherilyn Moe, Office of Ombudsman Kelly Kemp, Office of the Attorney General Penalty Assessment Deposit Staff

AH Form Approved 7/7/2015 (Y1) Provider / Supplier / CLIA / Identification Number H27690 Name of Facility State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 6/10/2015 This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey report form). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date 00265 06/10/2015 00815 06/10/2015 00860 06/10/2015 144A.44, Subd. 1(2) 0265 144A.479, Subd. 7 0815 144A.4791, Subd. 8 0860 00865 06/10/2015 00930 06/10/2015 01145 06/10/2015 144A.4791, Subd. 9(a-e) 0865 144A.4792, Subd. 7 0930 144A.4795, Subd. 7(b) 1145 01155 06/10/2015 01245 06/10/2015 144A.4795, Subd. 7(d) 1155 144A.4798, Subd. 1 1245 Reviewed By MDH Reviewed By PMB State Agency Reviewed By Reviewed By CMS RO Followup to Survey on: 3/20/2015 : REVISIT REPORT (5/99) Date: 7/7/15 Date: Signature of Surveyor: 20196 Signature of Surveyor: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Page 1 of 1 Event : Date: 6/10/15 Date: YES LI4912 NO

PRINTED: 07/07/2015 R H27690 06/10/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 000} Initial Comments {0 000} *****ATTENTION****** HOME CARE PROVER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144A.43 to 144A.482, this correction order(s) has been issued pursuant to a survey. Determination of whether a violation has been corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: On June 9 and 10, 2015, a surveyor of this Department's staff conducted a revisit at the above provider to follow-up on orders issued pursuant to a survey completed on On March 16, 17, 18, 19, and 20, 2015. At the time of the survey, there were 82 clients that were receiving services under the comprehensive license. As a result of the revisit, the following orders were reissued. {0 935} 144A.4792, Subd. 8 Documentation of Administration of Medication {0 935} Subd. 8. Documentation of administration of medications. Each medication administered by comprehensive home care provider staff must be documented in the client's record. The documentation must include the signature and title of the person who administered the medication. The LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) LI4912 If continuation sheet 1 of 4

PRINTED: 07/07/2015 R H27690 06/10/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 935} Continued From page 1 documentation must include the medication name, dosage, date and time administered, and method and route of administration. The staff must document the reason why medication administration was not completed as prescribed and document any follow-up procedures that were provided to meet the client's needs when medication was not administered as prescribed and in compliance with the client's medication management plan. {0 935} This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure medications were administered as prescribed for two of two clients (#12 and #13) observed during medication administration. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety) and is issued at an isolated scope (one or a limited number of clients affected). The findings include: Client #12 and #13's eye drops were not administered as directed by the physician. Client #12 had physician orders, dated December 19, 2012, for Artificial Tears one drop each eye at 8:00 a.m., 2:00 p.m. and 8:00 p.m. and Refresh Celluvisc (dated February 24, 2015), one drop every hour while awake, beginning at 7:00 a.m. (both eye lubricants). LI4912 If continuation sheet 2 of 4

PRINTED: 07/07/2015 R H27690 06/10/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 935} Continued From page 2 Client #12's medication administration record (MAR), dated June 2015, noted Artificial Tears were to be administered in the "AM" without a time specified, and the Refresh eye drops every hour while awake beginning at 7:00 a.m. The directions for unlicensed personnel (dated June 10, 2015) noted the refresh eye drops at 7:00 a.m., but failed to include the Artificial Tears. On June 10, 2015, at 7:00 a.m. employee K (unlicensed personnel/ulp) assisted client #12 with eye drops. Employee K administered two drops of Artificial Tears in each eye, but did not administer any Refresh Celluvisc eye drops. Employee K verified she administered two drops of Artificial Tears in each eye. Client #13 had physician orders, dated October 18, 2013, for Refresh eye drops, one drop both eyes at 8:00 a.m. and 8:00 p.m. Client #13's MAR, dated June 2015, noted Refresh eye drops "AM" but did not specify how many drops. The directions for client #13's eye drops, included on the daily schedule noted Refresh eye drops "1 drop in each eye." On June 10, 2015, at 8:50 a.m. employee K retrieved a unit dose (single dose) of Refresh eye drops and used the entire unit dose. When questioned how many drops were administered, employee K reported "about three or four drops" each eye. On June 10, 2015, employee B (registered nurse) and E (clinical director) verified client #12 and #13's medications should be administered as prescribed. {0 935} The licensee's policy and procedure "Medication LI4912 If continuation sheet 3 of 4

PRINTED: 07/07/2015 R H27690 06/10/2015 REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 935} Continued From page 3 Administration-Documentation" dated June 1, 2014, noted medications were to be safely and correctly administered to clients. {0 935} LI4912 If continuation sheet 4 of 4

Protecting, Maintaining and Improving the Health of Minnesotans Certified Mail # 7014 1200 0000 8065 2929 April 20, 2015 Mr. Ben Welna, Administrator Arbor Lakes Senior Living 12001 80th Avenue North Maple Grove, MN 55369 Re: Enclosed State Licensing Orders - Project Number SL27690005 Dear Mr. Welna: A survey of the Home Care Provider named above was completed on March 20, 2015, for the purpose of assessing compliance with State licensing regulations. At the time of survey, the survey team from the, Health Regulation Division, Home Care & Assisted Living Program, noted one or more violations of these rules that are issued in accordance with Minnesota Statutes, sections 144A.43 to 144A.47. If, upon reinspection, it is found that the correction order(s) cited herein are not corrected, a civil fine for each order not corrected shall be assessed in accordance with a schedule of fines promulgated by rule of the. State licensing orders are delineated on the attached State Form. The is documenting the State Licensing Orders using federal software. Tag numbers have been assigned to Minnesota state statutes/rules for Home Care Providers. The assigned tag number appears in the far left column entitled " Tag." The state statute/rule number and the corresponding text of the state statute/rule out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by." We urge you to review these orders carefully, item by item, and if you find that any of the orders are not in accordance with your understanding at the time of the exit conference following the survey, you should immediately contact our office at 651-201-5273. A written plan for correction of licensing orders is not required. 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. Health Regulation Division Home Care & Assisted Living Program General Information: 651-201-5000 Toll-free: 888-345-0823 http://www.health.state.mn.us An equal opportunity employer

Arbor Lakes Senior Living April 20, 2015 Page 2

Arbor Lakes Senior Living April 20, 2015 Page 3 Please note, it is your responsibility to share the information contained in this letter and the results of the visit with the President of your organization s Governing Body. Sincerely, Alice Sanders Home Care & Assisted Living Program Phone: 651-201-3993 Fax: 651-215-9697 cc: Home Care & Assisted Living File Kathy Rogers, Hennepin County Long Term Services & Supports Michael Budion, Minnesota Department of Human Services Sherilyn Moe, Office of the Ombudsman

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 000 Initial Comments 0 000 *****ATTENTION****** HOME CARE PROVER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144A.43 to 144A.47, this correction order(s) has been issued pursuant to a survey. If, upon reinspection, it is found that the correction order or orders cited herein are not corrected, a fine for each violation not corrected shall be assessed in accordance with a schedule of fines. Determination of whether a violation has been corrected requires compliance with all requirements provided at the tag number and Minnesota Rule or Statute number indicated below. When Minnesota Rule or Statute 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: is documenting the State Licensing Orders using federal software. Tag numbers have been assigned to Minnesota state Statutes for Home Care Providers. The assigned tag number appears in the far left column entitled " Prefix Tag." The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the surveyors' findings is the Time Period for. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES/RULES, THOUGH, THE COMMISIONER MAY REQUEST A COPY OF THE DOCUMENTATION OF ANY ACTION TAKEN TO COMPLY WITH THE CORRECTION ORDER AS NEEDED. On March 16, 17, 18, 19, and 20, 2015, surveyors of this Department's staff, visited the above Comprehensive Class provider and the following correction orders are issued. At the time of the survey, there were 82 clients that were receiving LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 000 Continued From page 1 0 000 services under the comprehensive license. 0 265 144A.44, Subd. 1(2) Up-To-Date Plan/Accepted Standards Practice 0 265 Subdivision 1. Statement of rights. A person who receives home care services has these rights: (2) the right to receive care and services according to a suitable and up-to-date plan, and subject to accepted health care, medical or nursing standards, to take an active part in developing, modifying, and evaluating the plan and services; This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to provide care and services according to accepted medical and nursing standards for three of seven (#4, #6 and #10) clients observed with bed rails. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety), and is issued at a pattern scope, (when more than a limited number of clients are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly, or in several locations, but is not found to be pervasive.) The findings include: Client #4 Client #4 lacked an accurate bed rail assessment, which identified potential risks for injury. In addition, the licensee failed to ensure If continuation sheet 2 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 265 Continued From page 2 0 265 the rail was properly secured. On March 17, 2015, one half bed rail was observed on the left side of client #4's bed. The bed rail was not secured, and was easily moved back and forth. Another bed rail was observed on the floor near a sofa. Employee H (ULP) was queried why the client had bed rails and said, " She's high fall risk." Employee H said the right bed rail was removed because it was broken. Client #4's "Side Rail Assessment" dated June 26, 2014, consisted of a checklist that noted the client used the device as an "enabler for repositioning." The assessment noted the client had cognitive deficits, was not able to safely get out of bed without assistance, and required assistance of one to transfer. The assessment noted there were bilateral rails, and that the client did not have any risks associated with use of the side rails. On March 17, 2015, employee B (RN) verified client #4's bed rail was loose and attempted to secure the rail. Client #4's fall incident reports, dated March 12, 2015, at 10:08 p.m. noted the client was found underneath her bed on a safety check, and at 12:00 a.m. the client was found "laying on the floor between the dresser and her white cupboard." On March 13, 2015, at 8:30 p.m. the client was found under her bed. On March 19, 2015, client #4's falls from bed were reviewed with employee B and E (RN). Employee B did not think the client's bed rail was a safety risk for client #4. Employee B verified there was one rail on the bed, and was unaware why the other rail was removed, or who removed it. Employee B and E were queried if other interventions had been considered, such as a high/low bed, or floor mat. The employees replied that high/low beds were expensive, and a mat could increase a fall risk. Employee E said If continuation sheet 3 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 265 Continued From page 3 0 265 the licensee did not use motion detectors or alarms. Client #6 Client #6 lacked an accurate bed rail assessment, which identified potential risks for injury and the risks and benefits of use. In addition, the licensee failed to ensure the bed rail was properly secured. Client #6 was admitted for services on September 27, 2011, with the diagnosis of congestive heart failure and a cerebral vascular accident (CVA/stroke.) On March 17, 2015, at 7:00 a.m., client #6 was observed sitting in a bedroom chair. Client #6's bed had one U-shaped right sided bed rail, measuring 18 inches long, 15 inches high, with two horizontal bars tucked unsecured, under the mattress and between the box spring. The bed rail was easily pushed out from the bed; as verified by employee F (unlicensed personnel/ulp). Employee F also verified the bed rail was not secured with any retention straps. Client #6 stated, "a therapist got me the bar, long time ago." Client #6 verified he used the side rail for repositioning in bed and for support while moving from a lying to a sitting position. Client #6's vulnerability assessment, dated April 6, 2014, indicated a "Hx (history) of CVA-uses walker independently. Has a Grab bar on (R) side of bed to help with supine to sitting/standing. Uses walker for mobility. Limited ROM (range of motion) in (L) shoulder-assist prn (as needed)." The vulnerability assessment form had an additional note dated, January 21, 2015, by If continuation sheet 4 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 265 Continued From page 4 0 265 employee B (registered nurse/rn), "Resident has right upper grab bar on her bed. See Side Rail assessment." Client #6"s "Side Rail Assessment," dated January 21, 2015, noted the client bed rail to: "prevent falls and as an enabler for repositioning." The form indicated "Is bed/side rail in compliance with FDA entrapment guidelines? (measurements within guidelines), No." The form lacked evidence of any modifications to address non-compliance with FDA entrapment guidelines. In addition, the assessment lacked documentation the client's family had been informed of the potential entrapment associated with that particular bed rail, and lacked information that the Consumer Product Safety Commission (CPSC) had issued a warning regarding its use. On March 17, 2015, employee E (RN and clinical services director) verified the RN was responsible for evaluating the resident for the appropriate and safe use of a bed rail for repositioning and transfer support. Employee E stated she was not aware client #6's U-shaped bed rail was not securely attached to the bed frame. Client #10 Client #10 lacked an accurate bed rail assessment, which identified potential risks for injury and the risks and benefits of use. In addition, the licensee failed to ensure the bed rail was properly secured. On March 17, 2015, employee B (RN) and the surveyor observed client #10's bed rail, which was present on the left side of the client's bed, near the head of the bed. The bed rail had an opening from rail to rail that measured 18 and 1/2 inches. The bed rail was secured with two long If continuation sheet 5 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 265 Continued From page 5 0 265 bars that were placed in between the mattress and box spring. The rail was easily removed and not attached to the frame. According to manufacturer's specifications (which were noted on the bed rail), retention straps were supposed to be used in order to secure the bed rail in place. Employee B verified the bed rail was not secured with the retention straps, and the large opening, was not within guidelines of the FDA. Client #10 had diagnoses that included dementia and memory loss. Client #10's comprehensive assessment, dated January 4, 2014, indicated the client was at risk for falls. In addition, the client required assistance with toileting and was independent with transfers. Client #10's "Side Rail Assessment" dated January 21, 2015, noted the the rail was used to prevent falls and as an enabler for repositioning. The assessment noted the bed rails were not in compliance with FDA entrapment guidelines. In addition, the assessment lacked documentation the client's family had been informed of the potential entrapment associated with that particular bed rail, and that the Consumer Product Safety Commission (CPSC) had issued a warning regarding its use. Employee E said clients' family members sometimes provided bed rails, and that physical therapy had recommended bed rails for client #6 and #10 despite the CPSC's warnings. The Consumer Product Safety Commission (CPSC) warning located on the bed rail indicated the U shaped bed rails (such as client #6's and #10"s) posed a risk of entrapment, if the retention straps were not used as directed to secure the device in place. If continuation sheet 6 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 265 Continued From page 6 0 265 The licensee's policy titled, "5.19 Siderails," dated July 01, 2014, indicated, "Policy: It is the policy of Southview Senior Communities to limit the use of medical devices to those that are considered "safe", based on current standards of practice. When Southview Senior Communities is aware a home care client is utilizing siderails (a medical device) on a bed, Southview Senior Communities shall assess the use, educate the client, and when appropriate, the responsible person, regarding the risks and benefits of siderails, and verify that the siderail in use is of a safe design and utilized consistent with the manufacturer's directions. This policy shall be followed regardless of who owns or is supplying the siderail." According to the "Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment" dated March 10, 2006, the opening from rail to rail should be less than 4 3/4 inches, and small enough to prevent the head from entering. The Food and Drug Administration (FDA), "A Guide to Bed Safety", revised April 2010, included the following information: "When bed rails are used, perform an on-going assessment of the patient's physical and mental status, closely monitor high-risk patients." The FDA also identified; "Patients who have problems with memory impairment, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe." TIME PERIOD FOR CORRECTION: Twenty-one (21) days If continuation sheet 7 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 815 144A.479, Subd. 7 Employee Records 0 815 Subd. 7. Employee records. The home care provider must maintain current records of each paid employee, regularly scheduled volunteers providing home care services, and of each individual contractor providing home care services. The records must include the following information: (1) evidence of current professional licensure, registration, or certification, if licensure, registration, or certification is required by this statute or other rules; (2) records of orientation, required annual training and infection control training, and competency evaluations; (3) current job description, including qualifications, responsibilities, and identification of staff providing supervision; (4) documentation of annual performance reviews which identify areas of improvement needed and training needs; (5) for individuals providing home care services, verification that required health screenings under section 144A.4798 have taken place and the dates of those screenings; and (6) documentation of the background study as required under section 144.057. Each employee record must be retained for at If continuation sheet 8 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 815 Continued From page 8 0 815 least three years after a paid employee, home care volunteer, or contractor ceases to be employed by or under contract with the home care provider. If a home care provider ceases operation, employee records must be maintained for three years. This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure documentation of training was retained in the employee record for three of of three (C, D and H) employees observed and with record review. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety), and is issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all of the clients). The findings include: Employees C, D and H lacked documentation of demonstrated competency by practical skills test on all the required training components. Employees C and D (unlicensed personnel/ulp) had hire dates of August 6, 2014, and January 28, 2014. respectively. Employee C and D's records lacked documentation of demonstrated competency by a practical skills test. Employee C and D were observed to provide cares to clients on March 17, 2015, including dressing, grooming, bathing, transferring and toileting. Both employees stated they received training in If continuation sheet 9 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 815 Continued From page 9 0 815 each of these areas during orientation. Both of the employee's files (C and D) showed evidence that training had been provided by the registered nurse (RN). Each record contained a sheet of paper with each of the tasks, including the step-by-step procedure to complete the task. Each step was labeled with an 'S'. The form failed to explain the steps were performed by the ULP to the RN as a way to demonstrate competency in that task. On March 18, 2015, employee E (registered nurse /RN and clinical services director) verified a RN had instructed the ULP in the procedures, but she was unable to verify if the ULP conducted a return demonstration to the RN as part of the orientation as required. Employee H (ULP) had a hire date of June 26, 2013, and lacked documentation which components of the required training included a demonstration by practical skills test. On March 17, 2015, employee H assisted client #3 with a shower, toileting, and transfers from the bed to the wheelchair. A review of employee H's personnel record failed to include documentation that employee H successfully demonstrated the ability to to competently follow the procedures of bathing, showering, toileting and assisting with transferring. On March 18, 2015, employee E verified a lack of documentation employees had demonstrated the required components. Employee E said some tasks were demonstrated, while some were not (such as bathing, showering), but was unable to identify which tasks were actually demonstrated. If continuation sheet 10 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 815 Continued From page 10 0 815 Employee E said some tasks "they talk though it." The licensee's policy and procedure "Delegated vs. Non-Nursing Services" noted dated June 1, 2014, noted "Documentation is on file indicating the ULP has completed the training and has written proof of the ULP's competency via a written, oral or practical skills demonstration." TIME PERIOD FOR CORRECTION: Twenty-one (21) days 0 860 144A.4791, Subd. 8 Comprehensive Assessment and Monitoring 0 860 Subd. 8. Comprehensive assessment, monitoring, and reassessment. (a) When the services being provided are comprehensive home care services, an individualized initial assessment must be conducted in person by a registered nurse. When the services are provided by other licensed health professionals, the assessment must be conducted by the appropriate health professional. This initial assessment must be completed within five days after initiation of home care services. (b) Client monitoring and reassessment must be conducted in the client's home no more than 14 days after initiation of services. (c) Ongoing client monitoring and reassessment must be conducted as needed based on changes in the needs of the client and cannot exceed 90 days from the last date of the assessment. The If continuation sheet 11 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 860 Continued From page 11 0 860 monitoring and reassessment may be conducted at the client's residence or through the utilization of telecommunication methods based on practice standards that meet the individual client's needs. This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) assessed and re-assessed two of two clients (#3 and #4) for falls. This practice resulted in a level three violation (a violation that harmed a client's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and is issued at a pattern scope, (when more than a limited number of clients are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly, or in several locations, but is not found to be pervasive.) The findings include: FALLS Client #3 and #4 experienced multiple falls and the registered nurse (RN) failed to comprehensively re-assess the clients for contributing (causal factors) in order to minimize the risk of falls. In addition, the licensee failed to ensure interventions to minimize the risk of falls were implemented as directed. Client #3 Client #3 had diagnoses that included Parkinson's disease. The client's vulnerability assessment, dated March 19, 2014, described the client as occasionally forgetful with interventions to remind and redirect as needed. The client was described as has having limited range of motion due to Parkinson's disease, and "stiff at times." Client If continuation sheet 12 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 860 Continued From page 12 0 860 #3 required assistance of one for all transfers, and "EZ stand as needed" (a mechanical device used to transfer individuals). The client required assistance with dressing, grooming, and toileting. On March 17, 2015, client #3's morning cares were observed. The client's call pendant was not around the client's neck, but attached to the bed rail. Employee H (unlicensed personnel) assisted the client to the wheelchair, and attached the pendant necklace on the back handle of the wheelchair (the call pendant rested in the wheelchair next to the client). Client #3 engaged in conversation, and reported she was diagnosed with Parkinson's disease May, 2004. Employee H described client #3 as alert and oriented, and said the client was able to voice the need to void. Employee H indicated the client did not want to wear the pendant around her neck. Later, on March 17, 2015, client #3 was interviewed and said they (staff) don't respond when she pressed her pendant. The client said she had pressed her pendant five times in 30 minutes the other night when she had to use the bathroom. According to the client, "the only reason I call is to go to the bathroom, or when I drop something." Client #3 indicated she had previously had falls when she tried to walk by herself, or if she reached for something she shouldn't. At the time, client #3 said she did not know where her pendant was (it was resting next to her, in the wheelchair). On March 19, 2015, at 10:45 a.m. the surveyor entered client #3's room, after knocking on the door and hearing muffled voices/sounds. Upon entering the room, client #3 was observed lying prone (face down) on the floor, in her bed clothes, next to the bed. The client's pendant was attached on the bed rail. The client complained of arm pain. The surveyor immediately alerted two ULP who were working on the unit, who If continuation sheet 13 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 860 Continued From page 13 0 860 summoned for the RN. The client was unable to move and said, "I don't know if I'm okay. I've been here a while." Client #3 said she fell when she was "trying to get up for the day." Employee J (assigned to care for client #3) and the other two ULP who were working on the unit, verified the client had not been assisted with morning cares (including toileting) had not received any breakfast, had not received her morning medications, and the last safety check was at 6:30 a.m. According to the assignment and directions for ULP, the client's medications were to be administered at 8:00 a.m. which included Sinemet 25/100 milligrams, and Sinemet CR (sustained released) 50/200 milligrams, with instructions the medications were important to administer on time. According to Drugs.com Prescription Drug Information, Interactions & Side Effects. (n.d.). Retrieved March 31, 2015, from http://www.drugs.com/ Sinemet is designed to release ingredients within 30 minutes, and it is important to take at regular intervals according to the schedule outlined by the physician. A review of the licensee's "Resident Incident/Accident Reports" (the licensee's fall assessments), noted client #3 experienced ten falls since January 1, 2015. Eight of the ten falls occurred when the client was in bed, either attempting to get up or reaching for an object. The incident reports noted "Incident Investigation and Management Follow-up," which included an area to document contributing factors, and follow up and prevention interventions. A review of the contributing factors (for eight of the ten falls) included the client's Parkinson's disease, fall history, balance disorder and safety judgement. The fall reduction interventions (for eight of the ten falls) noted to place articles of need within easy reach, remind to ask for help, and remind to push pendant. The fall report, dated January 9, If continuation sheet 14 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 860 Continued From page 14 0 860 2015, included an injury of an abrasion, and a "bump on forehead." The fall report dated February 7, 2015, noted there was bruising on the left shoulder and on March 19, 2015, the client sustained a sore elbow, and abrasion. Client #3's service plan (also care instructions for unlicensed personnel), dated January 28, 2015, noted the following interventions; the client was not to be left alone in her room during the daytime, "make sure she has her pendant on around her neck" and "encourage her to ask for assistance." On March 19, 2015, employee F (registered nurse, clinical services director) said client #3 received hourly safety checks, but verified the safety checks were not documented. The licensee's pendant call record was reviewed. According to the pendant call record, client #3 summoned for assistance on March 19, 2015, at 8:08 a.m., 8:10 a.m., 8:14 a.m. and 8:19 a.m. Employee A (resident director) verified no one responded to the client's request for assistance on March 19, 2015. According to employee A, the pendant notification was sent to cell phones via text message, which the three employees on the unit carried. Employee A explained that employee J (ULP - who was working on the unit the morning of March 19, 2015) stated she did not understand the pendant notification, and said she thought the text was an email (versus a request for assistance). Employee A stated the other two employees working on the unit were aware of the pendant notification, but did not respond to client #3's request. On March 19, 2015, employee B (RN, director of nursing) stated the licensee's pendant call record was reviewed, to see if a request for assistance was made prior to a fall, but verified a lack of documentation. Employee B said toileting schedules and behaviors prior to falls were If continuation sheet 15 of 36

REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION 0 860 Continued From page 15 0 860 evaluated for potential contributing factors, but verified a lack of documentation of assessment for these factors for client #3. Client #3 pressed the pendant four times on March 19, 2015, however the fall assessment report (March 19, 2015) noted the fall reduction plan "remind to ask client for help when needed." Employee B confirmed client #3 should wear the call pendant around her neck. Client #4 Client #4 had diagnoses that included Parkinson's disease, and dementia. The client's vulnerability assessment, dated July 15, 2014, noted a vulnerability with ambulation, "Able to propel self in w/c (wheelchair). Uses walker with SBA (stand by assistance) by staff. Has a Merry Walker (mobility device for ambulation assistance) that she uses to ambulate independently to prevent falls." Client #4 was identified as high risk for falls, due to self-transfers and picking items off the floor. "Encouraged to push pendant and wait for staff assist." On March 17, 2015, client #4 was observed to recieve assistance to use the Merry Walker at approximately 8:45 a.m. and was observed to ambulate in the halls independently. Employee H (ULP) said client #4 "wants to ambulate so bad" and said the client "hates" the Merry Walker. Employee H indicated client #4 did not receive staff assistance to ambulate, and ambulated independently with the Merry Walker. Client #4's ULP instructions, dated March 17, 2015, noted directions at 6:30 a.m. "Put her in her Merry Walker." The instructions indicated this provided independence and "the ability to ambulate without falling." According the the ULP instructions, client #4 was assisted with toileting at 6:15 a.m., 10:30 a.m. 11:35 a.m., and 1:30 p.m. during the day. Client #4's service agreement, dated January 1, If continuation sheet 16 of 36