Urbana Place Senior Living

Survey completed June 1, 2022: 7 correction orders

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action required.”

  Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

• Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment (re-issued) scope/level letter D
  Details

  MDH’s finding, as written: “No further action required.”

  Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

• Tag 800: 144G.45 Subd. 2 (a) (4) Fire protection and physical environment (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action required.”

  Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment (re-issued) scope/level letter F
  Details

  MDH’s finding, as written: “No further action required.”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

• Tag 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring (re-issued) Level 3, isolated scope, scope/level letter G · correction period: Immediate
  Details

  Summary: MDH found the licensee failed to complete a change of condition reassessment when a resident presented with new or changed symptom for one of one resident (R14) with record reviewed.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to complete a change of condition reassessment when a resident presented with new or changed symptom for one of one resident (R14) with record reviewed. [...]”

  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

• Tag 1650: 144G.70 Subd. 4 (f) Service plan, implementation and revisions to (re-issued) Level 2, widespread scope, scope/level letter F
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to ensure the service plan contained all required content for one of one resident (R15) with record reviewed. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and is issued at a widespread scope (when problems are pervasive or represent a systemic [...]”

  Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

• Tag 1940: 144G.72 Subd. 3 Individualized treatment or therapy managemen (re-issued) Level 2, widespread scope, scope/level letter F
  Details

  Summary: MDH found the licensee failed to develop a treatment management plan to include all required content for one of one resident (R15) who received treatments with record reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a treatment management plan to include all required content for one of one resident (R15) who received treatments with record reviewed. [...]”

  Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Survey completed March 16, 2022: 16 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure food was prepared according to the Minnesota Food Code. This had the potential to affect all residents. [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to establish and maintain an effective infection control program to comply with accepted health care, medical, and nursing standards for infection control and current recommendations for COVID-19. This practice had the potential to affect the licensee's residents, staff and visitors. [...]”

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 630: 144G.42 Subd. 6 Compliance with requirements for reporting ma Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include statements of the specific measures to be taken to minimize the risk of abuse for 4 of 5 residents (R1, R2, R3, R4) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure an individual abuse prevention plan (IAPP) was developed to include statements of the specific measures to be taken to minimize the risk of abuse for 4 of 5 residents (R1, R2, R3, R4) with records reviewed. [...]”

  Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to have a written emergency disaster plan with all required content and post an emergency disaster plan prominently.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency disaster plan with all required content and post an emergency disaster plan prominently. In addition, the licensee failed to provide the minimum frequency of inspection, maintenance and load test requirements for the emergency power generator as outlined under NFPA 110, (referenced under the Code of Federal Regulations, title 42, section 483.73). This had the potential to affect all 67 residents. [...]”

  Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

• Tag 780: 144G.45 Subd. 2 (a) (1) Fire protection and physical environment Level 2, isolated scope, scope/level letter D · correction period: Two (2) days
  Details

  Summary: MDH found the licensee failed to maintain proper functioning of the smoke alarm in resident room #2 of the memory care unit as required by Minnesota Statutes, 144G.45, Subd. 2.

  MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain proper functioning of the smoke alarm in resident room #2 of the memory care unit as required by Minnesota Statutes, 144G.45, Subd. 2. This has the potential to directly affect all assisted living residents, visitors, and staff. [...]”

  Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

From MDH’s letter: the letter says the facility is in substantial compliance.

Total fines assessed, as printed in the letter: $4,000.00.

Total fines assessed, as printed in the letter: $500.00.

Allegation, as written: “The facility neglected two residents (resident #1, resident #2) when they failed to provide adequate supervision. As a result, resident #2 assaulted resident #1 causing multiple injuries.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the memory care unit was short one staff that evening, facility staff provided care to resident #1 and resident #2 according to their care plan. It could not be determined if the incident could have been prevented with one additional staff.”

Action taken by facility: “The facility conducted an internal investigation. After the incident, both residents received increased safety checks and door alarms, and Resident #2's antipsychotic medication was adjusted.”

Action taken by MDH: “No further action taken at this time.”

Survey completed March 13, 2025: 2 correction orders

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to ensure a facility licensed practical nurse (LPN)-A, reported a pressure sore to one of one resident (R1)'s medical provider to initiate orders for home health management of R1's wound.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a facility licensed practical nurse (LPN)-A, reported a pressure sore to one of one resident (R1)'s medical provider to initiate orders for home health management of R1's wound. LPN-A was instructed twice by licensed assisted living director (LALD)-C and registered nurse (RN)-B to evaluate and update R1's medical provider. [...]”

  Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual person was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

Allegation, as written: “The facility neglected the resident when the facility failed to follow up with the provider after notifying them of symptoms the resident displayed. Subsequently, the resident admitted to the hospital with blood clots in the right lower leg and lungs.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident developed blood clots in the leg, the subsequent hospital admission and blood clots in the lungs could not be directly caused by the lack of action from nursing based on the available evidence. Unlicensed staff members were unable to recall events or details during interviews. Additionally, the provider declined to interview due to inability to recall events.”

Action taken by facility: “The facility completed an investigation and instructed nursing to check the electronic portal at least daily.”

Action taken by MDH: “No further action taken at this time.”

Survey completed March 15, 2023: no correction orders issued.

Allegation, as written: “Two facility staff members/alleged perpetrators (AP) #1 and AP #2, neglected the resident when they failed to ensure the resident's safety while undressing the resident. AP#1 and AP#2 roughly removed the resident's clothing causing the resident to fall on the bathroom floor and sustain deep bruising and rib cage damage. In addition, AP#1 and AP#2 lacked knowledge on how to use a full mechanical sling lift (Hoyer) to assist the resident off the floor after he fell. The resident remained on the floor for a while until the fire department arrived and assisted the resident off the floor.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Cares were provided in accordance with the resident's service plan. During the facility's internal investigation both AP#1 and AP#2's stories remained consistent. AP#1 and AP#2 followed facility procedure by not immediately getting the resident off the floor until he was assessed by a facility nurse. Although the resident fell, his injuries did not require an evaluation at a hospital.”

Action taken by facility: “The facility conducted an internal investigation and updated the resident's service plan to include more staff assistance when toileting.”

Action taken by MDH: “No further action taken at this time.”

Survey completed March 13, 2025: 2 correction orders

• Tag 2310: 144G.91 Subd. 4 (a) Appropriate care and services Level 3, isolated scope, scope/level letter G
  Details

  Summary: MDH found the licensee failed to ensure a facility licensed practical nurse (LPN)-A, reported a pressure sore to one of one resident (R1)'s medical provider to initiate orders for home health management of R1's wound.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a facility licensed practical nurse (LPN)-A, reported a pressure sore to one of one resident (R1)'s medical provider to initiate orders for home health management of R1's wound. LPN-A was instructed twice by licensed assisted living director (LALD)-C and registered nurse (RN)-B to evaluate and update R1's medical provider. [...]”

  Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one resident reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of one resident reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual person was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”