Please feel free to contact Jeri Cummins at (218) if you should have any questions.

Email: rosuna@npseniorliving.com & dkeller@npseniorliving.com October 15, 2015 Ms. Pam Zezulka, Administrator Lighthouse of Cloquet & Barnum 702 Horizon Circle Cloquet, MN 55720 Re: State Licensing Orders - Project Number SL21672007 Dear Ms. Zezulka: On September 9, 2015, staff of the completed a follow-up survey of your agency to determine correction of orders found on the survey completed on June 17, 2015, with orders received by you on July 21, 2015. At this time these correction orders were found corrected and are listed on the attached State Form: Revisit Report. 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. Please feel free to contact Jeri Cummins at (218) 302-6193 if you should have any questions. Sincerely, Protecting, Maintaining and Improving the Health of Minnesotans Paula Bastian Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program cc: Home Care & Assisted Living File Carlton County Social Services 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 10/15/2015 (Y1) Provider / Supplier / CLIA / Identification Number H21672 Name of Facility State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code (Y3) Date of Revisit 9/9/2015 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 00265 Correction Completed 09/09/2015 Prefix 00805 Correction Completed 09/09/2015 Prefix 00810 Correction Completed 09/09/2015 Reg. # 144A.44, Subd. 1(2) 0265 LSC Reg. # 144A.479, Subd. 6(a) 0805 LSC Reg. # 144A.479, Subd. 6(b) 0810 LSC Prefix 00860 Correction Completed 09/09/2015 Prefix 00870 Correction Completed 09/09/2015 Prefix 00905 Correction Completed 09/09/2015 Reg. # 144A.4791, Subd. 8 0860 LSC Reg. # 144A.4791, Subd. 9(f) 0870 LSC Reg. # 144A.4792, Subd. 2 0905 LSC Prefix 00920 Correction Completed 09/09/2015 Prefix 01245 Correction Completed 09/09/2015 Prefix 02015 Correction Completed 09/09/2015 Reg. # 144A.4792, Subd. 5 0920 LSC Reg. # 144A.4798, Subd. 1 1245 LSC Reg. # 626.557, Subd. 3 2015 LSC 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 PBastian State Agency Reviewed By Reviewed By CMS RO Followup to Survey Completed on: 6/17/2015 : REVISIT REPORT (5/99) Date: 10/15/15 Date: Signature of Surveyor: 03059 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: 9/9/15 Date: YES FUPQ12 NO

Protecting, Maintaining and Improving the Health of Minnesotans Certified Mail # 7014 1200 0000 8065 4121 Email: rosuna@npseniorliving.com & dkeller@npseniorliving.com July 15, 2015 Ms. Pam Zezulka, Administrator Lighthouse of Cloquet & Barnum 702 Horizon Circle Cloquet, MN 55720 Re: Enclosed State Licensing Orders - Project Number SL21672007 Dear Ms. Zezulka: A survey of the Home Care Provider named above was completed on June 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 reconsideration process. This written request must be received by the Department within 15 calendar 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

Lighthouse of Cloquet & Barnum July 15, 2015 Page 2 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 Enclosure cc: Home Care & Assisted Living File Carlton County Social Services Michael Budion, Minnesota Department of Human Services Sherilyn Moe, Office of the Ombudsman

ENTIFICATION NUMBER: SUMMARY 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 15, 16, and 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 78 clients that were receiving services. 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: LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 1 (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; 0 265 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 acceptable medical or nursing standards for two of two clients (C1, A2) with a history of falls with serious injury. In addition, the licensee failed to ensure one of three employees (BA) maintained infection control standards after a blood glucose check and medication administration. This practice resulted in a level four violation (a violation that results in serious injury, impairment, or death), and is issued at an isolated scope (when one or a limited number of clients are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: CLIENT C1 - FALLS Client C1 had five falls between January 24, 2015, and May 18, 2015. The registered nurse (RN) failed to evaluate the client's falls to assess for causative factors so interventions could be implemented in an attempt to decrease the risk of further falls and injury. Client C1 fell on May 18, 2015, and sustained a hip fracture (serious If continuation sheet 2 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 2 injury). In addition, client C1's change in condition was not re-assessed by an RN after re-admission from the hospital following surgical repair of the hip fracture. Client C1 was admitted for services on February 14, 2014, with diagnoses which included dementia, osteoporosis, history of urinary tract infections (UTI's), and hip fracture. The "Resident Assessment" dated November 18, 2014, indicated client C1 had short term memory loss; was forgetful; ambulated independently with a walker; and required assistance with bathing, dressing, and grooming. In addition, the "Resident Assessment" indicated the client had one fall in the last three months. The client would wear appropriate foot wear; use a walker; the care givers would provide frequent safety checks; and keep the area free of hazards. The "Mobility/Falls Risk Criteria" dated May 12, 2014, indicated client C1 had a history of falls. The falls seemed to occur in the client's room, after getting up, and often later in the day. The client at times would forget to use the walker. In addition, the "Mobility/Falls Risk Criteria" indicated client C1 had a fractured left humorous in May 2014. The physician was faxed with concern regarding PRN. 0 265 Client C1's "Incident Details" reports from January 24, 2015, to May 18, 2015, revealed the following notations: - January 24, 2015, at 3:10 p.m. client C1 fell and was found on the floor next to a broken picture frame. The client's shoes were off and the client stated she was "stretching on the floor." The client had a small cut on the right index finger. Client C1's temperature was "100.5". The report If continuation sheet 3 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 3 indicated the RN was notified at 3:30 p.m. The "Comments/Final Resolution" section of the report signed by the (licensed practical nurse (LPN) on January 26, 2015, indicated the client had no apparent injury or bruising. Vital signs every two hours for 24 hours. Tylenol was administered for a low grade fever. The client's family, physician, and "dow" (Director of Wellness) were aware. The client was given a dose of Ativan earlier that day, and did have a history of falls when given Ativan (anti anxiety). Instructed staff to hold PRN (as necessary medication). -January 24, 2015, at 11:30 p.m. client C1 had a unwitnessed fall. The report indicated the RN was notified on January 25, 2015, at 8:00 a.m. The "Comments/Final Resolution" section of the report signed by the LPN on January 30, 2015, indicated staff heard the client yelling. The staff went to the client's room and found her lying on her back with the client's pants and brief around her ankles. The "nurse" instructed staff to take vital signs every two hours and monitor the client. The client also had a fall earlier in the day. The staff, family and physician were aware. 0 265 -May 6, 2016, at 2:30 p.m. client C1 had a unwitnessed fall in the kitchen. The report indicated the RN was notified at 3:00 p.m. The "Comments/Final Resolution" section of the report signed by the LPN on May 14, 2015, indicated staff heard a "crash from the kitchen." Client C1 was found on her buttocks on the kitchen floor mat, and was scooting on her buttocks across the floor. There was no injury noted and range of motion (ROM) was intact. The client's physician and the "dow" were aware. The staff were directed to take the client's vital signs every two hours for 24 hours. If continuation sheet 4 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 4 0 265 -May 15, 2015, at 10:45 a.m. client C1 had a witnessed fall in the dining room on May 14, 2015. The report indicated the RN was notified on May 16, 2015, at 8:00 a.m. The "Comments/Final Resolution" section of the report signed by the LPN on May 14, 2015, indicated client C1 tripped while walking and was not using her walker. The client turned while grabbing for the chair and landed on her "bottom". The client did not hit their head. The client's physician and "dow" were aware. Staff were to remind the client to use her walker. -May 18, 2015, at 7:50 p.m. client C1 had a unwitnessed fall. The client was found on the floor with her left knee drawn up. The client stated she could not move and her right leg hurt really bad. The client's leg was swollen. The report indicated the RN was notified at 7:50 p.m. and instructed staff to send the client to the emergency room (ER). The "Comments/Final Resolution" section of the report signed by the LPN on June 4, 2015, indicated the client had a unwitnessed fall in her bedroom. The "Adow" (Assistant Director of Wellness) sent the client to the hospital. The client's right femur was displaced and she was diagnosed with a hip fracture. The client had a "Maxx Health bipolar hemiarthroplasty" of the right hip, and returned to the housing with services on May 29, 2015. The client is now on Hospice and has PRN pain medications available. Client C1's record indicated the LPN completed the "Nursing Evaluation Post Incident" and the "Fall Risk Assessment" on January 25, 2015, and May 7, 2015. The RN failed to evaluate the client after the falls to assess for causative factors so If continuation sheet 5 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 5 possible interventions could be implemented to decrease the risk of further falls and injury. On June 15, and 16, 2015, client C1 was observed lying in bed. Employee CA (unlicensed personnel/ulp) stated since the client had returned from the hospital she had required total assistance with all activities of daily living (ADL's). In addition, employee CA stated since the client's return, her hip was dislocated, and she had remained on bed rest, and was receiving medication for the pain. Client C1's record lacked evidence the RN had re-evaluated the clients change in condition upon return from the hospital. On June 15, 2015, employee C (RN) stated the LPN evaluated the client after the falls, and with changes in condition because the LPN was at housing with services C all the time. Employee C confirmed that she had not assessed the client since her return from the hospital, and had not evaluated the client after the falls to assess for causative factors so interventions could be implemented to decrease the risk of further falls. 0 265 CLIENT A2 - FALLS Client A2 had five falls between January 5, 2015, and May 11, 2015. The RN failed to evaluate the client's falls to assess for causative factors so interventions could be implemented in an attempt to decrease the risk of further falls and injury. Client A2 sustained a hip fracture (serious injury) after a fall on May 11, 2015, and was hospitalized. The client was discharged from the facility on May 31, 2015. In addition, the client had increased pain after falls on April 9, 2015, and May 11, 2015, and was not re-assessed by the If continuation sheet 6 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 6 RN. Client A2's diagnoses included hip joint replacement, glaucoma, anxiety, and depression. Client A2's "Mobility/Falls Risk Criteria" form completed by the RN dated October 14, 2014, indicated the client was at risk for falls related to being a new admission; a history of past falls with injuries; ambulation/gait issues; the use of an assistive device for ambulation; impaired sensory awareness; and medications that could increase fall risk. Client A2's service plans dated October 24, 2014, and updated April 16, 2015, (mailed to representative, but not signed per employee C - RN) indicated the client required assistance with most ADL's; was incontinent of bladder; used a walker for ambulation; and used a wheelchair for long distances due to a previous hip fracture. The plans indicated the client had a previous hip and clavicle fracture; would forget to call for help; and was at high risk for falls. Interventions included a TAB alarm when sitting; a pressure alarm in bed (alarms sound when the client attempts to stand); a call pendant; assistance of one staff with transfers; frequent checks by staff; and reminders to call for help. A "Resident Assessment" dated December 12, 2014, indicated the client did not use her call pendant for transfers and would self-transfer. The client had alarms, but would often take them off. The assessment further indicated the client had a history of bilateral hip fractures and a scapula fracture from previous falls (prior to admission). 0 265 Review of "Incident Details, Incident Reports, On-Call Triage Documentation, Progress Notes, Fax Orders, ER records, Medication If continuation sheet 7 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 7 Administration Records (MAR's), and a Head Injury Observation Form" noted the following: - January 5, 2015, at 5:00 a.m. was found on the floor in her apartment next to a chair with no apparent injuries. The triage RN was notified and instructed to check vital signs every two hours for 24 hours, and notify with any changes. A "Nursing Evaluation" and a "Progress Note" completed by the RN dated January 5, 2015, indicated the client's medical/physical condition was evaluated. - April 3, 2015, at 7:00 p.m. was found in her apartment on the floor with no apparent injuries. The triage RN was notified and instructed to check vital signs for 24 hours, and notify with any changes. A "Nursing Evaluation" and a "Progress Note" completed by the RN dated April 4, 2015, indicated the client's medical/physical condition was evaluated. The "Nurse Section" noted the client had many previous falls; would take off her own alarm; and did not wait for staff. Interventions included to remind to use call pendant; keep the alarm out of reach; and complete frequent checks. 0 265 - April 9, 2015, at 1:30 p.m. was found on the floor in her apartment in front of her dresser after taking off her alarm and self-transferring. The client complained of lower back pain. A "Nursing Evaluation" and a "Progress Note" completed by the LPN dated April 9, 2015, indicated the client had a bruise to the right elbow with mild elbow pain. The "Nurse Section" completed by the RN on April 9, 2015, noted the client had many previous falls and was impulsive, and takes off her own alarm. Interventions included to make sure the alarm was on and out of reach, and ask if the client needed anything before leaving. The triage RN was notified by the LPN on April 10, If continuation sheet 8 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 8 2015, at 11:44 p.m. due to increased back pain. Instructions were given to offer to send the client to the ER, and if she declined the ER visit to place her on her side with a pillow and an ice pack as tolerated. The client had received scheduled Tylenol for pain at 8:00 p.m. The client had on-going pain and developed a low grade fever so a urinalysis was completed (was negative). Due to increased pain, the client was sent to the ER on April 11, 2015, and returned the same day with prescriber's orders for ibuprofen (anti-inflammatory) 400 milligrams (mg) twice a day for one week for back strain. - April 14, 2015, at 9:00 p.m. was found on the floor in her apartment between the chair and the wall with no apparent injuries. The client stated she was reaching for something and slipped out of the chair. The triage RN was notified and instructed to check vital signs for 24 hours, and notify with any changes. The "Nursing Evaluation," a "Progress Note," and the "Nurse Section" dated April 15, 2015, were completed by the LPN, and identified no injuries. 0 265 - May 11, 2015, at 11:00 a.m. was found on the floor in her apartment by the bathroom door. The client's right fingers were swollen and bruised; the pinky finger had a 1 centimeter scrape; and she complained of lower back pain. Tylenol and ice packs were provided. The "On-Call Triage Documentation" dated May 13, 2015, had the date crossed off and was re-dated May 11, 2015, (no name or title or date of who changed it), indicated the client had gotten up to use the bathroom and turned to shut off her alarm, and fell. The triage RN instructed to check vital signs for 24 hours, and notify with any changes. The "Nursing Evaluation" completed by the LPN dated May 12, 2015, indicated the client had a 1/4 inch If continuation sheet 9 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 9 scratch to the left pinky finger and a dime sized red mark on the right hip. The client complained of mild pain in the right hip upon ambulation only. Review of the "Head Injury Observation Form" completed by the ULP dated from May 11, to May 12, 2015, indicated the client complained of on-going pain in the hips and legs. Review of the client's "Medication Administration Record" for May 2015, indicated the client received as needed (PRN) Tylenol 1000 mg on May 12, 2015, at 2:34 a.m. for a pain level of eight out of 10, and on May 13, 2015, the client received PRN Tramadol 50 mg at 6:39 a.m. for a pain level of 10 out of 10. After administration of the Tylenol the client's pain level was five, and after the administration of the Tramadol the client's pain level was eight. The client had not received any other doses of the PRN medications in May. A "Progress Note" by the LPN dated May 13, 2015, indicated the client had made suicidal comments during the previous night (May 12, 2015), and 15 minute checks would be completed. A "Progress Note" by the LPN dated 5/13/15, indicated the client was out with family for an eye appointment and the family member noted the client had increased pain in her hip. The family member transported the client to the ER. A "Progress Note" by the RN dated May 13, 2015, indicated the client had a right femur fracture. 0 265 Although the RN had evaluated the client's medical/physical condition after most of the falls, client A2's records lacked evidence an RN had evaluated the client after the falls to assess for causative factors so interventions could be implemented in an attempt to decrease the risk of further falls and injury, and there was no evidence an RN had re-assessed and monitored the clients pain after the April 9, 2015, and May 11, 2015, falls. If continuation sheet 10 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 10 0 265 On June 16, 2015, employee C (RN) confirmed there were no evaluations completed by the RN after falls to assess for causal factors, and verified the client's pain after the April 9, 2015, and May 11, 2015, falls had not been re-assessed by the RN. The licensee's "Initial and On-Going Nursing Assessment of Resident" policy and procedure dated September 2, 2014, indicated whenever a client had returned from a hospital or nursing home stay, had a change in condition or experienced an incident, such as a fall, the RN would reassess the client and the service plan would be updated. INFECTION CONTROL Employee BA (unlicensed personnel/ulp) did not follow appropriate infection control technique after completing a blood glucose check, and after the administration of insulin to decrease the risk of possible cross-contamination. On June 16, 2015, during an observation of medication administration and a blood glucose check by employee BA for client B3, the following was noted: - Employee BA washed her hands and obtained the client's 8:00 a.m. medications, "Breeze 2" blood glucose meter, and blood glucose testing supplies from the medication cart (disposable lancets, alcohol wipes). - The employee entered the client's room and administered the client's oral medications; applied gloves and administered one eye drop in each If continuation sheet 11 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 11 eye. - The employee discarded the gloves and applied new gloves, and after wiping the client's right middle finger with alcohol, poked the client's finger with the disposable lancet, and obtained the blood glucose level. - After completing the blood glucose check, the employee discarded the gloves, and without washing her hands, left the client's room. - The employee returned to the room with a sharps container and stated she had obtained the container from a locked cupboard in the nursing office. - The employee discarded the client's disposable lancet into the sharps container, and immediately, without washing her hands, left the room. - The employee opened the medication cart drawer and obtained the client's Lantus and Novolog insulin pens from the cart, and prepared the dosages to be administered. - The employee entered the client's room; applied gloves; wiped the injection sites with alcohol (left and right abdomen); and administered the insulin. - After administering the client's insulin, the employee discarded the gloves, and without washing her hands, exited the client's room. - The employee replaced the sharps container in the locked cupboard in the nursing office, and placed the client's blood glucose meter back into the medication cart drawer, and then washed her hands. The surveyor questioned the employee regarding washing her hands after completing the the client's blood glucose check and administering his insulin. Employee B confirmed she had not washed her hands, and stated she should have. 0 265 On June 16, 2015, employee C (RN) verified employee BA should have washed her hands If continuation sheet 12 of 58

ENTIFICATION NUMBER: SUMMARY 0 265 Continued From page 12 after completing the blood glucose check and insulin administration for client B3. The licensee's "Handwashing" policy and procedure dated June 7, 2014, indicated hands should be washed or decontaminated before and after direct contact with clients, after contact with environmental surfaces or equipment in the immediate vicinity of the client, and after removing gloves. TIME PERIOD FOR CORRECTION: Seven (7) days 0 265 0 805 144A.479, Subd. 6(a) Reporting Maltrx of Vulnerable Adults/Minors 0 805 This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure an evaluation of an injury of unknown source was completed to determine if the incident should be reported to the Common Entry Point (CEP) for one of one client (C1) who sustained a dislocated hip. 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). Client C1 sustained a dislocation of the right hip (serious injury) after readmission by the licensee following surgery on May 19, 2015, for a right hip fracture. The injury was not evaluated to If continuation sheet 13 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 13 determine if the incident should be reported to the CEP. 0 805 TIME PERIOD FOR CORRECTION: Seven (7) days If continuation sheet 14 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 14 0 805 If continuation sheet 15 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 15 0 805 If continuation sheet 16 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 16 0 805 If continuation sheet 17 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 17 0 805 CLIENT C1 Client C1 sustained a dislocation of the right hip after re-admitted by the licensee following surgery on May 19, 2015, for a right hip fracture. The significant injury was not evaluated by the RN to determine if the incident should be reported to the CEP. Client C1's diagnoses included dementia, osteoporosis, history of urinary tract infections (UTI's), and hip fracture. Review of client C1's " Incident Details for Resident" revealed the following: On May 18, 2015, at 7:50 p.m., client C1 was found on the floor in her apartment. The client stated she could not move and her "right top of leg" really hurt. The client's leg was also swollen, and she was transported to the hospital. The client was diagnosed with a right hip fracture and required surgical repair. Client C1's hospital discharge instructions dated May 29, 2015, indicated the client could be up as tolerated and bear weight as tolerated. If continuation sheet 18 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 18 Review of client C1's "Progress Notes" (all entries written by a licensed practical nurse/lpn)revealed the following: On May 29, 2015, client C1 returned to the housing with services (HWS) and required two staff and/or Hoyer lift (mechanical lift) for transfers. On June 12, 2015, client C1's right hip looked "out of place. Her knee is turned in. Hospice will be here to x-ray." On June 13, 2015, client C1 continued to appear to be in pain and the client's hip "appears out of place." Called Hospice to see what they would like us to do about the client's hip. On June 14, 2015, the final x-ray report was received at the HWS. The x-ray report indicated the client's right hip was dislocated, and Hospice was notified. On June 15, 2015, employee C (RN) stated the family had decided to not do further surgery on the client's right hip and to keep her comfortable. In addition, employee C stated client C1 was able to be up as tolerated and the client often tried to get up without assistance. Client C1's record lacked evidence to indicate the registered nurse (RN) had re-assessed the client after the dislocation of the right hip, and there was no evidence the licensee had reported the significant injury to the CEP. In addition, the client's record lacked documentation pertaining to the client transferring without assistance. This was verified by employee C (RN) on June 16, 2015. 0 805 On June 16, 2015, employee E (LPN) stated she questioned staff as to what might have caused the dislocation, and staff reported that the client often attempted to get up without assistance. A If continuation sheet 19 of 58

ENTIFICATION NUMBER: SUMMARY 0 805 Continued From page 19 progress note was added to the client C1's "Progress Notes" dated June 16, 2015, after the surveyor questioned staff regarding the client's dislocated hip. The licensee's "Reporting, Documenting and Reviewing Incidents Involving Residents" policy and procedure dated June 7, 2014, indicated whenever there was an incident involving a client, the staff should immediately contact the nurse in charge. The staff present would take any emergency actions and complete an incident report. If the incident must be reported to the CEP, the RN would make the report as soon as possible and no later than 24 hours after the incident, consistent with the vulnerable adult reporting policy. If it was a reportable incident, the RN would immediately begin an investigation. The nurse would document in the client's chart the details of any incident involving the client and would document the follow-up actions that were taken. The licensee's "Vulnerable Adult Reporting and Investigation" policy and procedure dated June 7, 2014, indicated if staff observed an unexplained physical injury they should immediately notify the RN, who would conduct and internal investigation to determine whether the injury was unexplained and whether a report to the CEP was required. If the injury was not reasonably explained, a report to the CEP would be required. TIME PERIOD FOR CORRECTION: Seven (7) days 0 805 0 810 144A.479, Subd. 6(b) Individual Abuse Prevention Plan 0 810 If continuation sheet 20 of 58

ENTIFICATION NUMBER: SUMMARY 0 810 Continued From page 20 (b) Each home care provider must develop and implement an individual abuse prevention plan for each vulnerable minor or adult for whom home care services are provided by a home care provider. The plan shall contain an individualized review or assessment of the person's susceptibility to abuse by another individual, including other vulnerable adults or minors; the person's risk of abusing other vulnerable adults or minors; and statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults or minors. For purposes of the abuse prevention plan, the term abuse includes self-abuse. 0 810 This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure an individual abuse prevention plan was developed, that included the person's susceptibility to abuse by other individuals, including other vulnerable adults, the person's risk of abusing other vulnerable adults, and statements of the specific measures to be taken to minimize the risk of abuse to that person and other vulnerable adults for four of four clients (A1, C1, C3, and B1) 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 a pattern scope (when more than a limited number If continuation sheet 21 of 58

ENTIFICATION NUMBER: SUMMARY 0 810 Continued From page 21 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 A1 Client A1's "Client Vulnerability" form dated July 1, 2015, did not identify falls as a risk for self-injury and did not include a statement of specific measures to be taken to minimize the risk of abuse for the identified vulnerabilities. Client A1's diagnoses included Parkinsons Disease and history off falls. Client A1 "Client Vulnerability" form dated July 1, 2015 indicated the client was vulnerable in teh following areas; orientations to time, place and person, ability to give accurate information consistently, able to ambulate with/without assistve devices, range of motion and endurance. Review of the licsenee's "Incident Details for Residents" indicated client A1 fell 15 times between January 5, 2015 and June 6, 2015. On May 15, 2015, employee C (registered nurse/rn) verified client A1's "Client Vulnerability" did not include the risk of falls and behaviors. In addition, employee C verified the client's "Client Vulnerability" did not include a statement of specific measures to be taken to minimize the risk of abuse. CLIENT C1 Client C1's "Client Vulnerability" was not updated following changes in the client's condition, did not identify falls as a risk for self-injury, or the behaviors the client exhibited, and did not include a statement of specific measures to be taken to minimize the risk of abuse. 0 810 If continuation sheet 22 of 58

ENTIFICATION NUMBER: SUMMARY 0 810 Continued From page 22 Client C1, resided on the memory care unit, and had diagnoses of dementia, osteoporosis, history of urinary tract infections (UTI's), and hip fracture. Client C1's "Client Vulnerability" form dated May 12, 2014, indicated the client was oriented to time, place, and person, able to follow directions, and able to report abuse or neglect. The "Client Vulnerability" identified ability to give accurate information consistently, and ability to ambulate safely as vulnerabilities. Client C1's "Resident Assessment" dated November 18, 2014, indicated the client had short term memory loss and was forgetful. In addition, the assessment indicated the client exhibited agitation, and wandered into other client rooms. Client C1's "Progress Notes" included several entries indicating the client exhibited the following behaviors: agitation, hitting, kicking and screaming. Review of "Incident Details" report indicated client C1 had five falls between January 24, 2015, and May 18, 2015. The fall on May 18, 2015, resulted in a hip fracture. On June 16, 2015, client C1 was observed laying in bed being fed by employee CA (unlicensed personnel/ulp). On June 15, 2015, employee CA stated client C1 was confused and required total care at this time. In addition, employee CA stated the client no longer ambulated and was on bed rest because of a dislocated hip. 0 810 If continuation sheet 23 of 58

ENTIFICATION NUMBER: SUMMARY 0 810 Continued From page 23 On May 15, 2015, employee C (registered nurse/rn) verified client C1's "Client Vulnerability" had not been updated upon change of condition, and did not include the risk of falls and behaviors. In addition, employee C verified the client's "Client Vulnerability" did not include a statement of specific measures to be taken to minimize the risk of abuse. 0 810 CLIENT C3 Client C3's "Client Vulnerability" plan did not include interventions in the other identified vulnerable areas to decrease the risk of abuse to the client, or the client's risk of abusing other vulnerable adults. Client C3's "Client Vulnerability" dated May 30, 2015, indicated the client was vulnerable in the following areas: orientation, ability to give accurate information consistently, ambulation, and ability to report abuse or neglect. Client C3's "Client Vulnerability" did not include a statement of specific measures to be taken to minimize the risk of abuse for identified vulnerabilities. On May 16, 2015, employee C verified client C3's "Client Vulnerability" did not include a statement of specific measures to be taken to minimize the risk of abuse for the identified vulnerabilities. CLIENT B1 Client B1's abuse prevention plan was not updated, and did not identify assistance with transferring, ambulation, and falls as a vulnerability. In addition, the plan did not include If continuation sheet 24 of 58

ENTIFICATION NUMBER: SUMMARY 0 810 Continued From page 24 interventions in the other identified vulnerable areas to decrease the risk of abuse to the client, or the client's risk of abusing other vulnerable adults. Client B1, resided on the memory care unit, and had diagnoses which included dementia secondary to anoxic brain injury, rheumatoid arthritis, history of a fractured left hand, defibrillator implantation, coronary artery disease (CAD), progressive mental illness with behaviors, and anxiety. Client B1's "Assessment for Client Vulnerability, Safety, and Risk to Others" dated May 7, 2015, identified the following areas as vulnerabilities: - cognitive impairment - inability to give accurate information consistently - inability to use the telephone - inability to follow directions consistently - inability to report abuse or neglect On June 15, 2015, client B1 was observed sitting in a wheelchair in the dining room. The client was unable to be interviewed due to severe cognitive impairment. 0 810 On June 15, 2015, employee BB and AB (unlicensed personnel/ulp) were observed to transfer client B1 from the wheelchair using a transfer belt onto the toilet in the client's bathroom. The client required extensive assistance of both staff to transfer and adjust himself to sit onto the toilet. Employee BB stated the client required the assistance of two staff with all ADL's, including ambulation. Employee BB added, the client used to get up and ambulate on his own with a walker at times; however, he had been placed on Hospice a few months prior, and had required more assistance with transfers and If continuation sheet 25 of 58

ENTIFICATION NUMBER: SUMMARY 0 810 Continued From page 25 ambulation. Review of "Incident Details" from January 5, 2015, to June 4, 2015, indicated client B1 had 13 falls. Seven of the falls resulted in minor injuries. Client B1's "Assessment for Client Vulnerability, Safety, and Risk to Others" dated May 7, 2015, was not updated, and did not identify assistance with transfers, ambulation and falls, as a vulnerability. The assessment also lacked specific interventions related to the other identified vulnerabilities, and did not include the client's susceptibility to abuse by other individuals, including other vulnerable adults, and the client's risk of abusing other vulnerable adults. On June 16, 2015, employee C (RN) confirmed client B1 had severe cognitive impairment, and required the assistance of staff with transferring, ambulation, and had falls. Employee C verified client B1's abuse prevention plan did not include the information, and confirmed interventions were lacking in the other identified vulnerabilities. Employee C confirmed the client's susceptibility to abuse by other individuals, including other vulnerable adults, and the client's risk of abusing other vulnerable adults was not on the assessment. A policy and procedure regarding client abuse prevention plans was not provided. 0 810 TIME PERIOD FOR CORRECTION: Twenty-one (21) days If continuation sheet 26 of 58

ENTIFICATION NUMBER: SUMMARY 0 860 Continued From page 26 0 860 144A.4791, Subd. 8 Comprehensive Assessment and Monitoring 0 860 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 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) completed a re-assessment for one of one client (C1) with a dislocated hip; for three of three of three clients (C1, A2, B1) with a history of falls; for one of one If continuation sheet 27 of 58

ENTIFICATION NUMBER: SUMMARY 0 860 Continued From page 27 client (C1) with changes in behavior; and for two of two clients (C1, B2) with a change in condition. 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, 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: DISLOCATED HIP Client C1's record lacked evidence that the RN completed a re-assessment of the client's dislocated hip following surgery on May 19, 2015, for a right hip fracture. Client C1's diagnosis included dementia, osteoporosis, history of urinary tract infections, and hip fracture. Review of client C1's "Progress Notes" revealed the following: (all entries written by a Licensed Practical Nurse/LPN) On May 29, 2015, client C1 returned to the housing with services (HWS) and required a two people and or Hoyer lift (mechanical lift) for transfers. On June 12, 2015, client C1's right hip looks "out of place". "Her knee is turned in". Hospice will be here to x-ray. On June 13, 2015, client C1 continued to appear to be in pain and the client's hip "appears out of place". Called Hospice to see what they would like us to do about the client's hip. On June 14, 2015, the final x-ray report was received at the HWS. The x-ray report indicated the client's right hip was dislocated. Hospice was notified. 0 860 If continuation sheet 28 of 58

ENTIFICATION NUMBER: SUMMARY 0 860 Continued From page 28 Client C1's record lacked evidence that the RN completed a re-assessment of the client's dislocated hip and increased pain. June 15, 2015, employee C (RN) confirmed that the RN had not completed a re-assessment of the client's dislocated hip and increased pain. 0 860 CLIENT C1 - FALLS Client C1 had five falls from January 24, 2015, to May 18, 2015, and was not re-assessed by the RN after the falls in an attempt to identify potential causative factors to determine individualized interventions to reduce the clients risk for further falls and injury. Client C1 had diagnoses which included dementia, osteoporosis, history of urinary tract infections, and hip fracture. On June 15, 2015, client C1 was observed laying in bed. Employee CA (unlicensed personnel/ulp) indicated the client required total care since the client returned from the hospital and remains on bed rest because of the dislocated hip. Review of "Incident Detail" reports from January 24, 2015 to May 18, 2015, indicated client C1 had five falls. The reports indicated during one fall the client fell and fractured her right hip. Client C1's "Resident Assessment" dated November 18, 2014, indicated the client had one fall in the last three months and the client was independent with mobility. Client C1's record lacked evidence the RN had assess the client after the falls in an attempt to identify causative factors to determine individualized interventions to reduce the client risk of injury. If continuation sheet 29 of 58

ENTIFICATION NUMBER: SUMMARY 0 860 Continued From page 29 CLIENT C1 - CHANGE OF CONDITION Client's C1 record lacked evidence of a re-assessment by the RN pertaining to the changes in the clients cognition and difficulty swallowing. Client C1's "Progress Notes" (all entries written by the licensed practical nurse/lpn) indicated the following: May 3, 2015, client C1 is more lethargic and is having difficulty swallowing pills. A fax was sent to the client's physician for a "crush order". May 7, 2015, client C1 is having difficulty swallowing her pills. Faxed the client's prescriber for a crush order and a swallow evaluation. The client continues to show decline. May 10, 2015, client C1 was started on Cipro (antibiotic) on May 8, 2015, for UTI (urinary tract infection). May 14, 2015, client C1's physician did order a swallowing evaluation. May 14, 2015, client C1 son came to visit the client yesterday and filled out "Notice of Change Alert". The notices states the client had more limited mobility, is confused, and has little communication and recognition. This writer will fax the prescriber in regards to the change in status. Family and "DOW" (Director of Wellness) "on board for hospice. Will ask for an order. May 20, 2015, client C1 had a witnessed fall on May 18, 2015, and was sent to the hospital. The client has a diagnosis of a broken hip. Client C1's record lacked evidence that a RN had completed a re-assessment of the changes in the client's condition. On May 16, 2015, employee C (RN) confirmed that a RN had not completed a re-assessment of the changes in the client condition. 0 860 CLIENT C1 - BEHAVIORS/PSYCHOTROPIC MEDICATION If continuation sheet 30 of 58

ENTIFICATION NUMBER: SUMMARY 0 860 Continued From page 30 Client C1's record lacked documentation that an re-assessment by the RN pertaining to the changes in the clients behaviors. Client C1's record contained the following physician's orders: December 18, 2014, Seroquel (antipsycotic)25 mg (milligrams by mouth twice a day. January 25, 2015, increase Seroquel to 50 mg twice a day and stop the lorazepam (anti anxiety). January 29, 2015, start risperidone (antipsycotic) 0.5 mg twice a day. February 18, 2015, increase risperidone to 1 mg twice a day. Client C1's "Progress Notes" indicate the following: (progress notes written by a LPN) January 26, 2015, the physician increase the client's Seroquel to 50 mg twice a day and stopped the lorazepam. February 20, 2015, the physician ordered Risperdol 1 mg twice a day February 24, 2015, client C1's behaviors continue to increase and the scheduled behavior medications do not seem to be effective. The staff continue to try and redirect. February 26, 2016, client C1 continues to exhibit behaviors of agitation. The client hits, kicks, and screams. Faxed the physician for a PRN (as needed). February 28, 2015, client C1 was aggressive last night. March 3, 2015, client C1 continues to exhibit al lot of aggressive behaviors. April 19, 2105, client C1 was angry and hit staff. 0 860 Client C1's record lacked evidence that a RN had completed a re-assessment of the changes in the client's behaviors resulting in changes to the client's medication regime. On June 16, 2015, employee C confirmed a RN had not completed a re-assessment of the If continuation sheet 31 of 58

ENTIFICATION NUMBER: SUMMARY 0 860 Continued From page 31 changes in the client's behaviors. 0 860 CLIENT A2 - FALLS Client A2 had five falls from January 5, 2015, to May 11, 2015, and was not re-assessed by the RN after the falls in an attempt to identify potential causative factors to determine individualized interventions to reduce the clients risk for further falls and injury. In addition, the client had increased pain after falls on April 9, 2015, and May 11, 2015, and was not re-assessed by the RN. The client was discharged on May 31, 2015. Client A2's diagnoses included hip joint replacement, glaucoma, anxiety, and depression. Client A2's "Mobility/Falls Risk Criteria" form completed by the RN dated October 14, 2014, indicated the client was at risk for falls related to being a new admission; a history of past falls with injuries; ambulation/gait issues; the use of an assistive device for ambulation; impaired sensory awareness; and medications that could increase fall risk. Client A2's service plans dated October 24, 2014, and updated April 16, 2015, (mailed to representative, but not signed per employee C - RN) indicated the client required assistance with most ADL's; was incontinent of bladder; used a walker for ambulation; and used a wheelchair for If continuation sheet 32 of 58