December 2, Ms. Mindy Nuhring, Administrator Progressive Care 1614 Golf Course Road Grand Rapids, MN PDF Free Download

Email: jwolf@grandlivingmn.com December 2, 2015 Ms. Mindy Nuhring, Administrator Progressive Care 1614 Golf Course Road Grand Rapids, MN 55744 Re: Enclosed State Licensing Orders Project Number SL29046003 Dear Ms. Nuhring: On November 20, 2015, staff of the completed a follow up survey of your agency to determine correction of orders found on the survey completed on July 17, 2015, with orders received by you on August 13, 2015; and follow up survey completed on October 15, 2015, with orders including penalties received by you on November 5, 2015. Penalties resulting from the October 15, 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 Itasca County Social Services 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 H29046 Name of Facility State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 11/20/2015 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 LSC 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 Prefix 00870 Correction Completed 11/20/2015 Prefix 00935 Correction Completed 11/20/2015 Prefix Correction Completed Reg. # 144A.4791, Subd. 9(f) 0870 LSC Reg. # 144A.4792, Subd. 8 0935 LSC Reg. # LSC ZZZZ Prefix Correction Completed Prefix Correction Completed Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ Prefix Correction Completed Prefix Correction Completed Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ Prefix Correction Completed Prefix Correction Completed Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ Prefix Correction Completed Prefix Correction Completed Prefix Correction Completed Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reg. # LSC ZZZZ Reviewed By MDH Reviewed By PMB State Agency Reviewed By Reviewed By CMS RO Followup to Survey Completed on: 7/17/2015 : REVISIT REPORT (5/99) Date: 12/02/15 Date: Signature of Surveyor: 25479 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: 11/20/15 Date: YES 0SR813 NO

Protecting, Maintaining and Improving the Health of Minnesotans Certified Mail # 7015 1520 0000 6771 2462 Email: MNUHRING@GRANDLIVINGMN.COM November 2, 2015 Ms. Mindy Nuhring, Administrator Progressive Care 1614 Golf Course Road Grand Rapids, MN 55744 Re: Enclosed State Licensing Orders - Project # SL29046003 Dear Ms. Nuhring: On October 15, 2015, staff of the completed a follow-up survey of your agency, to determine correction of orders found on the survey completed on July 17, 2015, with orders received by you on August 13, 2015. State licensing orders issued pursuant to the last survey completed on July 17, 2015, and found corrected at the time of the October 15, 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 last survey completed on July 17, 2015, found not corrected at the time of the October 15, 2015, follow-up survey and subject to penalty assessment are as follows: $300.00 Level/2; Scope/Pattern Contents Of Service Plan, Minn. Stat. Sec. 144A.4791, subd. 9 (f) $100.00 Level/2; Scope/Isolated Documentation Of Admin. Of Medication, Minn. Stat. Sec. 144A.4792, subd. 8 TOTAL = $400.00 The details of the violations noted at the time of this revisit completed on October 15, 2015 (listed above), are on the attached State Form. Brackets around the Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. 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

Progressive Care November 2, 2015 Page 2 Therefore, in accordance with Minnesota Statutes, section 144A.43 to 144A.482, the total amount you are assessed is $400.00. This amount is to be paid by check made payable to the Commissioner of Finance, Treasury Division and sent to the, Health Regulation Division, P.O. Box 64900, St. Paul, Minnesota 55164-0900 within 15 days of the receipt of this notice. You may request a hearing on the above assessment provided that a written request is made to the Department of Health, 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. IMPOSITION OF FINES At the time of this survey it was determined, in accordance with Minnesota Statutes, sections 144A.474, subd. 11, the following fines were issued: 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 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 Correction Order Reconsideration Process Health Regulation Division P.O. Box 64900 St. Paul, Minnesota 55164-0900 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.

Progressive Care November 2, 2015 Page 3 We urge you to review these orders carefully. If you have questions, please contact Jeri Cummins at (218) 302-6193. 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 Enclosure cc: Home Care & Assisted Living Program Itasca County Social Services Michael Budion, Minnesota Department of Human Services Cheryl Hennen, Office of Ombudsman Kelly Kemp, Office of Attorney General Penalty Assessment Deposit Staff

AH Form Approved 11/2/2015 (Y1) Provider / Supplier / CLIA / Identification Number H29046 Name of Facility State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 10/15/2015 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 LSC 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 Prefix 00125 Correction Completed 10/15/2015 Prefix 00265 Correction Completed 10/15/2015 Prefix 00805 Correction Completed 10/15/2015 Reg. # 144A.43, Subd. 13 0125 LSC Reg. # 144A.44, Subd. 1(2) 0265 LSC Reg. # 144A.479, Subd. 6(a) 0805 LSC Prefix 00810 Correction Completed 10/15/2015 Prefix 00860 Correction Completed 10/15/2015 Prefix 00865 Correction Completed 10/15/2015 Reg. # 144A.479, Subd. 6(b) 0810 LSC Reg. # 144A.4791, Subd. 8 0860 LSC Reg. # 144A.4791, Subd. 9(a-e) 0865 LSC Prefix 00905 Correction Completed 10/15/2015 Prefix 00930 Correction Completed 10/15/2015 Prefix 01010 Correction Completed 10/15/2015 Reg. # 144A.4792, Subd. 2 0905 LSC Reg. # 144A.4792, Subd. 7 0930 LSC Reg. # 144A.4792, Subd. 22 1010 LSC Prefix 01030 Correction Completed 10/15/2015 Prefix 01035 Correction Completed 10/15/2015 Prefix 01040 Correction Completed 10/15/2015 Reg. # 144A.4793, Subd. 2 1030 LSC Reg. # 144A.4793, Subd. 3 1035 LSC Reg. # 144A.4793, Subd. 4 1040 LSC Prefix 01045 Correction Completed 10/15/2015 Prefix 01155 Correction Completed 10/15/2015 Prefix 01225 Correction Completed 10/15/2015 Reg. # 144A.4793, Subd. 5 1045 LSC Reg. # 144A.4795, Subd. 7(d) 1155 LSC Reg. # 144A.4797, Subd. 3 1225 LSC Reviewed By Reviewed By Date: Signature of Surveyor: Date: State Agency Reviewed By Reviewed By Date: Signature of Surveyor: Date: CMS RO : REVISIT REPORT (5/99) Page 1 of 2 Event : 0SR812

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 11/02/2015 (X3) SURVEY D R H29046 10/15/2015 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) {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 October 13, 2015, through October 15, 2015, surveyors of this Department's staff conducted a revisit at the above provider to follow-up on orders issued pursuant to a survey completed on July 17, 2015. At the time of the survey, there were 32 clients that were receiving services under the comprehensive license. As a result of the revisit, the following orders were reissued. is documenting the State Licensing Correction 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 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 surveyor ' s findings is the Time Period for Correction. 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. {0 870} 144A.4791, Subd. 9(f) Contents of Service Plan {0 870} (f) The service plan must include: (1) a description of the home care services to be provided, the fees for services, and the frequency of each service, according to the client's current review or assessment and client preferences; LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) 0SR812 If continuation sheet 1 of 6

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 11/02/2015 (X3) SURVEY D R H29046 10/15/2015 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) {0 870} Continued From page 1 (2) the identification of the staff or categories of staff who will provide the services; (3) the schedule and methods of monitoring reviews or assessments of the client; (4) the frequency of sessions of supervision of staff and type of personnel who will supervise staff; and (5) a contingency plan that includes: (i) the action to be taken by the home care provider and by the client or client's representative if the scheduled service cannot be provided; (ii) information and a method for a client or client's representative to contact the home care provider; (iii) names and contact information of persons the client wishes to have notified in an emergency or if there is a significant adverse change in the client's condition, including identification of and information as to who has authority to sign for the client in an emergency; and (iv) the circumstances in which emergency medical services are not to be summoned consistent with chapters 145B and 145C, and declarations made by the client under those chapters. {0 870} This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the service plan contained the frequency of sessions of supervision of staff and type of personnel who will supervise staff, for three of nine clients (#2, #3 and #9) with records reviewed. 0SR812 If continuation sheet 2 of 6

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 11/02/2015 (X3) SURVEY D R H29046 10/15/2015 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) {0 870} Continued From page 2 {0 870} 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 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 #2 Client #2 received services which included bathing, dressing, grooming, toileting, assistance with mobility, medication administration and blood glucose monitoring. Client #2's service plan dated September 25, 2014, lacked the frequency of sessions of supervision of staff and type of personnel who will supervise staff. CLIENT #3 Client #3 received services that included bathing, dressing, grooming, toileting, assistance with mobility and medication administration. Client #3's service plan dated February 5, 2015, lacked the frequency of sessions of supervision of staff and type of personnel who will supervise staff. CLIENT #9 Client #9 received services that included bathing, toileting, medication administration and catheter care. Client #9's service plan dated June 6, 2015, 0SR812 If continuation sheet 3 of 6

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 11/02/2015 (X3) SURVEY D R H29046 10/15/2015 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) {0 870} Continued From page 3 lacked the frequency of sessions of supervision of staff and type of personnel who will supervise staff. On October 14, 2015, employee C (Director of nursing/registered nurse/rn) and employee O (RN) verified the service plans for many clients in the assisted living, including client's #2, #3 and #9 lacked the frequency of sessions of supervision of staff and type of personnel who will supervise staff. Both employee's C and O stated they thought revisions to the service plans had been completed. {0 870} The licensee's "Contents of Service Plans and Service Agreement," policy and procedure dated as reviewed September, 2015, indicated the service plan would include "the frequency of supervision of staff providing services and the identification of the supervisor(s) who would be providing the supervision." {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 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 0SR812 If continuation sheet 4 of 6

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 11/02/2015 (X3) SURVEY D R H29046 10/15/2015 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) {0 935} Continued From page 4 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 by the physician for one of five clients (#2) observed for medication administration, with records reviewed. 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 #2's diagnoses included diabetes, hypertension and CVA (cerebral vascular accident). Client #2's physician orders dated September 14, 2015, indicated client #2 was to receive omeprazole (treats gastroesophageal reflux disease [GERD] by decreasing gastric acid) 40 mg (milligram) orally once daily before a meal. Client #2 was observed on October 14, 2015, at 9:10 a.m. to receive assistance from employee Q unlicensed personnel (ULP) with medication administration. Client #2 had just returned to her 0SR812 If continuation sheet 5 of 6

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 11/02/2015 (X3) SURVEY D R H29046 10/15/2015 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) {0 935} Continued From page 5 apartment after eating breakfast in the licensee's dining room. Employee Q prepared the client's medications, which were all to be given at 8:00 a.m. as indicated on the "Medication Sheet," including omeprazole 40 mg. {0 935} The licensee's "Medication Sheet," for October, 2015, indicated client #2 was to receive omeprazole 40 mg orally once daily before a meal. On October 14, 2015, employee C (registered nurse/rn) verified the licensee failed to follow the physicians's orders dated September 14, 2015. The licensee's "Delegation of Nursing Tasks, Treatment, or Therapy Tasks" policy and procedure dated April, 2014, indicated the RN may delegate medication administration to ULP only after the RN had developed specific written instructions on the Individualized Medication Management Plan for each client, and placed the plan with the client's (MAR). No further information was provided. 0SR812 If continuation sheet 6 of 6

Protecting, Maintaining and Improving the Health of Minnesotans Certified Mail # 9590 9401 0031 5168 1865 65 Email: MNUHRING@GRANDLIVINGMN.COM August 10, 2015 Ms. Mindy Nuhring, Administrator Progressive Care 1614 Golf Course Road Grand Rapids, MN 55744 Re: Enclosed State Licensing Orders - Project Number SL29046003 Dear Ms. Nuhring: A survey of the Home Care Provider named above was completed on July 17, 2015, for the purpose of assessing compliance with State licensing regulations. At the time of survey, the survey team from the noted one or more violations of these regulations that are issued in accordance with Minnesota Statutes, sections 144A.43 to 144A.482. State licensing orders are delineated on the attached order form. The is documenting the State Licensing Correction 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 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. If you have questions, please contact Jeri Cummins at (218) 302-6193. DOCUMENTATION OF ACTION TO COMPLY: In accordance with Minnesota Statutes, section 144A.474, subd. 8 (c), by the correction order date, the home care provider must document in the provider's records any action taken to comply with the correction order. The commissioner may request a copy of this documentation and the home care provider's action to respond to the correction orders in future surveys, upon a complaint investigation, and as otherwise needed. 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 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

Progressive Care August 10, 2015 Page 2 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 Correction Order Reconsideration Process 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. 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, Paula Bastian Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program Telephone: 651-201-4105; Email: paula.bastian@state.mn.us Enclosures cc: Home Care & Assisted Living Program Itasca County Social Services Michael Budion, Department of Human Services Cheryl Hennen, Office of Ombudsman

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 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 July 13, 2015, through July 17, 2015, surveyors of this Department's staff, visited the above provider and the following correction orders are issued. At the time of the survey, there were 92 clients that were receiving services under the comprehensive license. is documenting the State Licensing Correction 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 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 surveyor ' s findings is the Time Period for Correction. 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. 0 125 144A.43, Subd. 13 Medication Setup 0 125 This MN Requirement is not met as evidenced by: Based on observation, interview and record review the licensee failed to ensure medications were setup by a nurse or pharmacy for later administration for one of nine clients (#2) observed receiving medications LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 125 Continued From page 1 0 125 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 #2's diagnoses included diabetes, hypertension and CVA (cerebral vascular accident). On July 14, 2015, at 8:40 a.m. client #2's medications were observed to be pre-set up by employee F (unlicensed personnel/ulp) in a clear plastic medication cup, set from a pre-packaged bubble pack that came from the pharmacy. On July 14, 2015, at 8:40 a.m. employee F (ULP) stated she set client #2's medications up earlier in the morning at approximately 7:30 a.m. to facilitate time. In addition, employee F stated she placed the medications from the 8:00 a.m. time slot from the bubble pack and the 10:00 a.m. time slot into the same medication cup. Employee F further added, she "picked" the Carafate (antiulcer medication) out, and placed the medication in a separate medication cup to give at 12:00 p.m. as the MAR indicated; and also stated she "picked" the 8:00 a.m. Carafate out and administered to client #2 earlier. On July 14, 2015, employee B (registered nurse/rn/nurse Consultant) and employee C (Director of Nursing/RN) stated it was not policy for the ULP to set up client medications for later administration. If continuation sheet 2 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 2 0 265 144A.44, Subd. 1(2) Up-To-Date Plan/Accepted Standards Practice 0 265 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 ensure services were provided according to accepted medical or nursing standards for one of one client (#5) who had falls with serious injury; and for three of three clients (#6, #2 and #9) who were observed with bed rails. This practice resulted in a level four violation (a violation that results in serious injury, impairment, or death), and is issued at a pattern scope (when more than a limited number of clients are affected, when more than a limited number of staff are involved, or the situation has occurred repeatedly but is not found to be pervasive). The findings include: CLIENT #5 - FALLS Client #5 was admitted on December 2, 2014, and resided on the memory care unit. The client had 24 falls since March 22, 2015, with one fall which resulted in significant injury (hip fracture). The medical records lacked evidence a registered nurse (RN) had completed a baseline If continuation sheet 3 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 3 assessment or evaluated for fall risk after admission, or re-evaluated the client after the falls to assess for potential causal factors so possible further interventions on the unit could be implemented in an attempt to decrease the risk for further falls and injury. In addition, the client was not re-assessed by the RN after the change in condition. Client #5's diagnoses included dementia, anxiety, osteoporosis, severe arthritis (left hip), left hip fracture (April 27, 2015), and depression. A "Functional Assessment" and a "Fall Risk" evaluation dated November 20, 2014, (12 days prior to admission), indicated the client had dementia, and was forgetful and confused. The client was independent with most activities of daily living (ADL's), used no assistive devices, and required supervision. The client was at risk for falls due to intermittent confusion, and medications. The records further identified the client was ambulatory; continent; had normal gait/balance; and had no falls in the past three months. 0 265 On July 14, 2015, the client was unable to be interviewed due to severe cognitive impairment. The client was observed on the memory care unit sitting in a wheelchair. The client had a sensor pad alarm on the wheelchair (alerts staff via phone call if the client attempts to stand), and was wearing a call pendant necklace. A sensor pad alarm was also observed on the client's bed. Employee H (unlicensed personnel/ulp) stated client #5 required assistance with all activities of daily living (ADL's), and required two staff assistance for transferring as she was not supposed to bear weight on the left leg due to a hip fracture. If continuation sheet 4 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 4 0 265 On July 15, 2015, employee K (ULP) and employee L (ULP) were observed to transfer the client onto the toilet using a transfer belt. The client's incontinent product was wet a large amount and she voided a moderate amount in the toilet. Both employees stated the client required assistance with all ADL's due to not being able to bear weight on the left leg after a fracture. Employee L washed her hands and left the bathroom, and while employee K was washing her hands, (with her back turned to the client), the client attempted to get up on her own from the toilet. Employee K instructed the client to wait for help. Employee L returned and both employees assisted the client back into the wheelchair. The employees were questioned regarding the client's fall prevention measures. Both employees stated every two hour toileting and hourly safety checks were protocol for all clients on the memory care unit, and client #5 also had a chair pad and bed pad sensor alarm. Employee K stated the client was confused and often attempted to self-transfer, and even with the alarm "we can't get there in time." Employee K added, the client also had a call pendant, but did not use it. Client #5's "Progress Notes" from January 17, 2015 to March 21, 2015, indicated the client had ongoing chronic left hip pain and multiple pharmalogical interventions were implemented. A "Physician's Order Sheet" dated March 23, 2015, indicated the client visited a physician regarding the hip pain, and returned with a diagnosis of "severe arthritis in hip." Client #5's "Tenant Incident Reports" and "Progress Notes" dated from March 22, 2015, to July 10, 2015, indicated the client had 24 falls. If continuation sheet 5 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 5 0 265 From March 22, 2015, to April 25, 2015, the client had four falls. The "Tenant Incident Reports" and "Progress Notes" indicated the following: -March 22, 2015, at 1:32 p.m. found on the floor by the bed on her knees. No injuries. RN notified. The note did not indicate if the client's representative or physician were notified. -April 21, 2015, at 1:00 p.m. found on the floor by the bed with her pajamas and socks off. The floor and the client's pajamas were wet. Top of left lip was bleeding a small amount. RN and representative notified. The physician was not notified. -April 24, 2015, at 7:30 p.m. found on the bathroom floor. No injuries. RN and representative notified. The physician was not notified. -April 25, 2015, at 4:30 p.m. found crawling on the floor. No injuries. RN was notified. The note did not indicate if the client's representative or physician were notified. The client's records lacked evidence a re-assessment was completed by the RN after the falls so interventions could be implemented in an attempt to reduce the risk of further falls and injury. Review of the fall which resulted in significant injury was as follows: On April 27, 2015, at 7:30 a.m. the client was found lying naked on the floor in her apartment with a pillow under her head, and the blanket on the floor at the end of the bed. The client's underwear and nightgown were wet on the floor, and the bedding was wet. The client was noted to have increased pain in the left hip and was sent If continuation sheet 6 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 6 to the emergency room (ER) for evaluation. At 1:49 p.m. the ER nurse reported the client had a closed fracture of the left hip, and required an alarm and a "sitter" as she would not sit still. The client returned to the facility at 2:17 p.m. The ER record dated April 27, 2015, indicated the client had diagnoses of closed left hip fracture and osteoarthritis of the left hip. Discharge instructions included for the client to not bear weight on the left hip; no brace required; and referral to orthopedic surgery. The client's medical records lacked evidence a re-assessment by the RN had been completed after the change in condition. Following the fall with a fracture on April 27, 2015, the client had 19 falls from April 28, 2015, to July 10, 2015. The "Tenant Incident Reports" and "Progress Notes" indicated the following: 0 265 -April 28, 2015, at 7:20 a.m. found on the floor in the bathroom. The bathroom floor was wet with urine. No injuries. The note did not indicate if the RN, the representative, or the client's physician was notified. -May 16, 2015, at 6:00 p.m. found sitting on the floor at the foot of wheelchair outside her apartment door. The client stated she had to use the bathroom. No injuries. RN and representative notified. The physician was not notified. -May 16, 2015, at 7:00 p.m. found on the floor in her apartment next to the recliner. No injuries. RN and representative notified. The physician was not notified. -May 18, 2015, at 7:00 p.m. found on the floor in her apartment. No injuries. RN and representative notified. The physician was not notified. -May 25, 2015, at 7:30 p.m. found sitting on the floor in front of the toilet with feces in the toilet If continuation sheet 7 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 7 and on the floor. No injuries. RN and representative notified. The physician was not notified. -May 26, 2015, at 8:30 a.m. found on the floor in the hallway. The client stated she wanted to get some water. No injuries. RN and representative notified. The physician was not notified. -May 27, 2015, at 11:50 a.m. found on the floor in the kitchen area. The client stated she was trying to get some water. No injuries. RN and representative notified. The physician was not notified. -May 28, 2015, at 1:15 p.m. found on the floor (did not indicate where). No injuries. RN and representative notified. The physician was not notified. A "Progress Note" written by the RN dated 5/29/15, indicated the plan would be to purchase a chair sensor to use in the wheelchair when the client was up. -May 31, 2015, at 6:45 p.m. found on the floor between her bed and wheelchair. No injuries. RN and representative notified. The physician was not notified. -June 3, 2015, at 7:24 a.m. found on the floor in her apartment. The client stated she was going to use the bathroom. No injuries. RN and representative notified. The physician was not notified. A "Progress Note" by the RN dated June 5, 2015, indicated "will place a chair sensor in her wheelchair." -June 16, 2015, at 9:00 p.m. found on the floor in her apartment by the recliner. RN and representative notified. The physician was not notified. -June 24, 2015, at 8:00 p.m. found on the floor beside the bed with her pants down. No injuries. RN and representative notified. The physician was not notified. -June 27, 2015, at 12:25 a.m. found on the floor in her apartment in front of the recliner. No 0 265 If continuation sheet 8 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 8 injuries. RN and representative notified. The physician was not notified. -June 27, 2015, at 10:15 p.m. found on the floor by her chair. The client stated she wanted to go to bed. No injuries. RN and representative notified. The physician was not notified. -June 28, 2015, at 8:45 a.m. found on the bathroom floor. The client stated she needed to use the bathroom. No injuries. The client's alarm was not activated per the staff. RN and representative notified. The physician was not notified. July 2, 2015, at 9:45 a.m. found on the floor between her recliner and bed. No injuries. RN and representative notified. The physician was not notified. July 3, 2015, at 8:40 p.m. the client's chair pad alarm alerted staff and she was found on the floor next to the recliner. No injuries. RN was notified. The note did not indicate the client's representative or physician was notified. -July 7, 2015, at 9:40 p.m. the client had a fall (did not indicate where). No injuries. RN notified. The physician was faxed regarding high blood pressures over the past week. The note did not indicate if the client's representative was notified. July 10, 2015, at 8:50 p.m. found on the floor at the foot of the bed. No injuries. RN and representative notified. The physician was not notified. Client #5's "Problem Driven Service Plan" dated December 2, 2014, did not address falls or interventions. 0 265 Although there were several follow-up "Progress Notes" completed by the RN, the notes indicated only the client's medical and physical condition was evaluated. The client's records lacked evidence of an RN evaluation after the falls to If continuation sheet 9 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 9 assess for potential causal factors so possible further interventions on the unit could be implemented in an attempt to decrease the risk for further falls and injury. On July 15, 2015, employee B (nurse consultant/rn) and employee C (director of nursing/rn) confirmed the client lacked an assessment for fall risk after admission, a re-assessment by the RN after the falls for potential causal factors, and after the change in condition. Employee C (RN) stated the licensee's protocol would be to notify the physician only if there was injury. Employee C verified the client's records lacked evidence the primary physician was notified regarding the fall with the fracture. The licensee's "Nursing Assessment of Home Care Clients" policy and procedure dated November 2014, indicated a "Fall Risk Assessment" would be completed on all new clients to identify those at increased risk for falls, and interventions would be implemented based on the assessment to reduce the risk. The policy further noted a "Fall Risk Assessment" would be completed upon admission, at any time the RN feels the client's risks for falling have changed, after any significant change in condition, and upon return from a hospitalization or stay in a skilled nursing facility. Any interventions to prevent or reduce the risk of falls would be incorporated into the client's care plan and would be communicated to staff providing services to the client. 0 265 The licensee's "Initial and On-Going Nursing Assessment of Home Care Clients" policy and procedure dated November 2014, indicated the RN would complete a nursing assessment within five days of the initiation of home care services, If continuation sheet 10 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 10 and would re-assess, and if necessary, would update the assessment and Service Plan whenever the client had returned from a hospital, a change in condition, or experienced an incident such as a fall. 0 265 BED RAILS Client #6, #2 and #9's records lacked evidence the registered nurse (RN) completed an assessment of the client's functional status, and the need for a bed rail, and the risk versus benefits of bed rail use was reviewed with the client and/or responsible person. CLIENT #6 Client #6 resided on the memory care unit, and had diagnoses which included severe dementia, history of subdural hematoma (fall at home August 2014), pacemaker, history of falls, and hypertension. On July 14, 2015, and July 15, 2015, client #6's bed was observed to have two 1/2 bed rails in the up position on both upper sides of the bed. On July 16, 2015, employee C (director of nursing/rn) measured the bed rails to be 32 inches wide from rail to rail by 13 to 18 inches high from rail to rail. The openings within the rails were less than the Food and Drug Administration's (FDA's) Zone 1 guidance (see guidance below) as recommended at 3-1/2 to 3-1/4 inches. Client #6's "Fall Risk" evaluation dated If continuation sheet 11 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 11 September 30, 2014, identified the client was at risk for potential falls due to disorientation, three or more falls in the past three months, assistance with toileting, poor vision, medications, the use of an assistive device, and impaired gait/balance. The record further indicated the client had bed and chair sensors in place at all times. Client #6's "Tenant Incident Reports" and "Progress Notes" from December 12, 2014, to June 13, 2015, indicated the client had six falls. Two of the falls were from the bed. On July 14, 2015, client #6 was observed sitting on the side of the bed with two 1/2 bed rails in place on both upper sides of the bed. The client was assisted to stand by employee I (unlicensed personnel/ulp) using a wheeled walker and did not use the bed rails. Employee I assisted the client to ambulate with the walker to the toilet. The client's incontinent product was wet a moderate amount, and she voided a small amount in the toilet. Employee I then assisted the client with all morning cares. The client was unable to be interviewed due to cognitive impairment, and employee I stated she was unsure why client #6 had the bed rails. Client #6's records lacked evidence the bed rails had been assessed by an RN for functional use, and the risks versus benefits of the bed rails had been discussed with the client's representative. On July 15, 2015, employee B (nurse consultant/rn) confirmed client #6 had bed rails. Employee B verified the bed rails had not been assessed for functional use, and the risks/benefits had not been discussed with the client's representative. 0 265 If continuation sheet 12 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 12 0 265 CLIENT #2 Client #2's diagnoses included diabetes, hypertension and CVA (cerebral vascular accident). Client #2's "Problem Driven Service Plan," dated May 28, 2015, indicated the client was alert and oriented, used a wheeled walker to aide in ambulation with assist of one and transferred with one person assist to and from bed, chair and toilet. In addition, the plan indicated the client is continent and would request assist with toileting as needed. On July 14, 2015, at 8:00 a.m. client #2's twin size bed was observed unoccupied. Client #2's bed had a bed rail on the right side of the bed kept in the down position, and the left rail in the up position. The rails measured 31 and 1/2 inches wide and 18 inches in length at the inner section, with 13 inches in length on the ends. The rails were divided by sectional vertical bars with 2 and 1/4 inches to 3 and 1/2 inches spaced between the inner bars. On July 16, 2015, employee C (Director of Nurses/RN) verified the metal bed rails were attached to the bed frame and the largest gap in between the vertical bars measured 3 and 1/2 inches wide at zone 1, (space between the rails, see guidance below.) If continuation sheet 13 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 13 On July 16, 2015, client #2 stated she used the left side rail to aid in independent bed mobility and transferring in and out of bed. 0 265 CLIENT #9 Client #9's diagnoses included Adrenal myelin neuropathy (a disorder resulting in accumulation of fatty acids in tissues throughout the body, mainly in the central nervous system and the adrenal cortex) and hypertension. Client #9's "Functional Assessment," dated June 12, 2015, indicated the client was alert and oriented, required assist with ADL's (activities of daily living), used an electric scooter for mobility, and required physical assist of one for assistance in transfers. Client #9's "Fall Risk" assessment dated July 3, 2015, indicated the client has had no falls in the past three months, but does have predisposing conditions present. On July 14, 2015, at 7:15 a.m. client #9 was observed lying in her twin size hospital bed. Client #9's bed had a bed rail attached to the upper right side of the bed, kept in the up position. The rails measured 32 inches wide and 18 inches in length at the inner section, with 12 and 1/2 inches in length on the ends. The rails were divided by sectional vertical bars with 2 and 1/4 inches to 3 and 1/4 inches spaced between the inner bars. On July 16, 2015, employee C (Director of Nurses/RN) verified the metal bed rail was attached to the bed frame and the largest gap in between the vertical bars measured 3 and 1/4 inches wide at zone 1, (space between the rails, If continuation sheet 14 of 86

(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) 0 265 Continued From page 14 see guidance below.) On July 16, 2015, client #9 stated she used the right side rail to aid in turning and repositioning while in bed. The March 10, 2006, FDA Side Rail Entrapment Zones and Dimensional Recommendations indicated to reduce the risk of entrapment, zone 1 (space between the rails), should be less than 4 and 3/4 inches. On July 16, 2015, employee B (RN/Nurse consultant) and employee C (RN/Director of Nursing) verified client #2 and #9's records lacked evidence an assessment for the use of a bed rail had been completed, and that the risks versus benefits of bed rail use were reviewed with the client and/or responsible party. 0 265 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." The licensee's "Assessing Side Rails," dated November, 2014, indicated the following: 3. "When notified that a tenant has a side rail, If continuation sheet 15 of 86

December 2, Ms. Mindy Nuhring, Administrator Progressive Care 1614 Golf Course Road Grand Rapids, MN 55744