Urbana Place Senior Living.

Finding: Inconclusive Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): 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. Investigative Findings and Conclusion: 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. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted resident #1 and resident #2’s family members and resident #2’s case manager. The investigation included review of resident records, hospital records, facility internal investigation, facility incident reports, personnel files, staff schedules, and related facility policy and procedures. Also, the investigator observed staff and resident interactions and cares. Resident #1 resided in an assisted living memory care unit. Resident #1’s diagnoses included early onset Alzheimer’s disease. Resident #1’s service plan included assistance with toileting, escorts, medications, meals, personal cares, and safety checks. Resident #1’s assessment indicated resident #1 was not oriented to person, place, or time, was unable to express her needs, exhibited poor judgement with impaired decision making. Resident #1 was unable to report abuse or neglect. Resident #1 walked independently and wandered. Resident #2 resided in an assisted living memory care unit. Resident #2’s diagnoses included dementia. Resident #2’s service plan included assistance with toileting, escorts, medications, meals, and personal cares. Resident #2 received three scheduled safety checks at 3:00 a.m., 6:00 a.m., and 11:30 p.m. Resident #2 was forgetful, confused with poor/impaired decision making, and memory loss. Resident #2 was prescribed an antipsychotic medication scheduled three times a day for his agitation and anxiety. Resident #2’s apartment door was kept locked from the outside to prevent other residents from wandering into resident #2’s room. Resident #2 was able to leave his room independently. Resident #2 had impaired short-term memory and was unable to recall events. Resident #2 was unable to report abuse or neglect. Resident #2 used a walker for mobility and a wheelchair for longer distances. Resident #1’s progress note indicated one evening staff documented resident #1 experienced an unwitnessed fall in another resident’s bathroom. Resident #1 was unable to tell staff what happened. Staff found resident #1 in the common area bleeding from head wounds to the top and back of her head; blood dripped down her face and neck. Skin tears and cuts were noted on resident #1’s forearms and fingers and resident #1’s left pointer finger was discolored and swollen. Later, staff reviewed the facility’s recorded video. After review of the video, facility staff notified the on-call triage nurse to report the video showed resident #1 entering resident #2’s room. The on-call triage nurse advised the nurse to complete an incident report, place a door alarm on resident #2’s room door, obtain vitals, and see if resident #2 needed to be evaluated at a hospital if he became a risk to himself. The on-call nurse contacted resident #2’s primary provider about the incident and requested a change in resident #2’ s antipsychotic medications. Resident #2’s progress note indicated the day of the incident, at an unknown time, the resident exhibited increased confusion when he stated he needed to get to the third floor because “Someone is coming to get me.” Resident #2 was unable to be redirected and adamantly refused any assistance with his bedtime routine but took his medication without concern and went to bed. The facility’s internal investigation report indicated the day of the incident, at 7:44 p.m., resident #1 was seen on facility camera footage entering resident #2’s apartment. An hour later, resident #2 left his apartment and four minutes later resident #1 was seen exiting resident #2’s apartment. A few minutes later facility staff found resident #1 in the hallway with blood on her clothes and hair. Resident #1’s family members arrived and transported the resident to the hospital for evaluation. After the incident, staff activated door alarms on resident #1 and resident #2’s room doors. Resident #2’s antipsychotic medication dose was increased with an additional as needed dose. Staff education included ensuring resident #2’s door was locked when leaving his apartment, conducting safety checks according to the resident’s service plans, and frequent staff rounding in the memory care unit. Causative factors contributing to the incident included resident #1 was able to enter resident #2’s unlocked room door. Resident #1’s hospital record indicated resident #1 injuries included: a significant hematoma (swelling or lump caused by a collection of blood due to trauma or injury) to the occipital (back) of her head as well as superficial lacerations (cuts), abrasions (friction rubbing of skin) to her front chest and arms, scratch marks from a hand over her left shoulder, and bruising on her body. X-rays of her left hand indicated her left pointer finger was fractured. Due to resident #1’s impaired cognition, the head wound was repaired using minimally invasive procedures. Resident #1 was discharged back to the facility. Review of the facility staff schedule indicated three unlicensed personnel were scheduled to work the memory care unit for the evening shift instead of the normal schedule of four unlicensed personnel. During an interview, an unlicensed personnel stated between 7:00 p.m. and 7:30 p.m. she provided resident #2’s cares then locked his door and went to resident #1’s apartment to prepare the resident for bed. The unlicensed personnel stated resident #1 frequently wandered and was “so” fast, stating after putting her to bed, resident #1 was able to leave her room and enter resident #2’s apartment unnoticed. The unlicensed personnel stated although they were short staffed she and other unlicensed personnel worked together to provide services for the residents. During an interview, a facility nurse stated resident #2 felt comfortable and safe inside his apartment, was sometimes quiet and not a problem, but other times could be easily angered, yell, and aggressive around dinnertime. The facility nurse stated after the incident they were able to remove most of the blood from of resident #1 and keep her calm, stating resident #1 seemed okay and her vital signs were normal. The nurse stated she asked the three unlicensed personnel who worked in the memory care unit where they were when the incident happened, stating one unlicensed personnel was performing cares and giving medications to other residents and the other two unlicensed staff were completing two resident showers. During an interview, leadership stated she immediately reviewed camera footage after the incident and saw resident #1 wandering the hall looking for an unlocked apartment door. Leadership stated staff were in the hallway walking by resident #1 but stated resident #1 was not trying to enter a resident’s apartment. Leadership stated as soon as staff walked down another hallway resident #1 walked over to resident #2’s apartment door and opened it. Leadership stated after resident #2 and resident #1 left resident #2’s apartment, within minutes of each other, they crossed paths in the hallway. Resident #1 did not appear afraid and resident #2 showed no signs of aggression. Leadership stated after the incident they put door alarms on both residents’ doors to alert staff when the residents left their apartments, increased monitoring of facility camera footage, and increased resident #2’s behavior medication. During an interview, resident #1’s family member stated she complained to leadership about staffing issues and having staff in the common area while other staff prepare other residents for bed. During an interview, resident #2’s family member stated Resident #2 did not recall the incident stating staff reported resident #2 did not appear injured but was “out of it.” Resident #2’s family member stated she recognized even though the residents were on frequent safety checks something could still happen. In conclusion, the Minnesota Department of Health determined neglect was inconclusive Inconclusive: Minnesota Statutes, section 626.5572, Subdivision 11. "Inconclusive" means there is less than a preponderance of evidence to show that maltreatment did or did not occur. Neglect: Minnesota Statutes, section 626.

CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are 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 . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Urbana Place Senior Living December 13, 2024 Page 2 St - 0 - 2310 - 144g.91 Subd. 4 (a) - Appropriate Care And Services - $3,000.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $3,000.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at Urbana Place Senior Living December 13, 2024 Page 3 the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Casey DeVries, Supervisor State Evaluation Team Email: Casey.DeVries@state.mn.us Telephone: 651-201-5917 Fax: 1-866-890-9290 HHH PRINTED: 12/13/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 35230 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5601 94TH AVENUE NORTH URBANA PLACE SENIOR LIVING BROOKLYN PARK, MN 55443 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Licensing ASSISTED LIVING PROVIDER LICENSING Correction Orders using federal software. CORRECTION ORDER(S) Tag numbers have been assigned to Minnesota State Statutes for Home Care In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G.08 to 144G.95, these correction orders are appears in the far-left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL35230016-0 PLEASE DISREGARD THE HEADING OF On November 4, 2024, through November 7, THE FOURTH COLUMN WHICH 2024, the Minnesota Department of Health STATES,"PROVIDER'S PLAN OF conducted a full survey at the above provider, and CORRECTION." THIS APPLIES TO the following correction are issued. At the time of FEDERAL DEFICIENCIES ONLY. THIS the survey there were 104 residents residing at WILL APPEAR ON EACH PAGE. the facility, 90 of those residents received assisted living services. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR An immediate correction order was identified on VIOLATIONS OF MINNESOTA STATE October 21, 2024, issued for SL36204016-0, tag STATUTES. identification 2310. The licensee took action to mitigate the immediate risk, however, THE LETTER IN THE LEFT COLUMN IS noncompliance remained, and the scope and USED FOR TRACKING PURPOSES AND level remained unchanged. REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144A.474 SUBDIVISION 11 (b)(1)(2). 0 470 144G.41 Subdivision 1 Minimum requirements 0 470 SS=F (11) develop and implement a staffing plan for LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 NJSR11 If continuation sheet 1 of 39 PRINTED: 12/13/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The alleged perpetrator (AP) neglected a resident when the AP witnessed the resident fall and hit her head. Additionally, the facility neglected the resident when staff failed to provide services within her plan of care. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The resident leaned forward while toileting and hit her head on a grab bar. The resident did not fall. Staff responded and assisted the resident. Staff followed the resident’s service plan. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of grievances, incidents, policies including vulnerable adult, assessments, toileting, transfers, and pendants. The investigation also included review of the resident’s medical record. Also, the investigator observed lunch service, toileting, and staff interactions with residents. An equal opportunity employer. The resident resided in an assisted living facility. The resident’s diagnoses included cancer. The resident’s service plan included assistance with toileting three times daily, meal delivery daily, and safety checks daily. The resident’s assessment indicated the resident was on hospice and had at least three falls within the three months prior. The resident’s service delivery record indicated the resident received meal delivery twice daily and toileting three to eight times every day of the month during which the concerns occurred. An incident report indicated the resident became lightheaded in the bathroom while on the toilet and fell forward, hitting her head on the grab bar. The resident did not fall to the floor. The resident’s vitals signs were taken and were within normal limits. The report indicated the unlicensed personnel (ULP) assisted the resident with toileting and helped her back into her wheelchair. The resident sustained a small bruise to the upper right part of the forehead. The ULP notified the lead ULP of the incident. During an interview, a nurse stated the resident got lightheaded on the toilet, went forward, and hit her head on the grab bar. The nurse stated she did not fall to the ground. During an interview, the ULP stated staff responded to residents any time they pushed their pendant. Regarding meals, staff took meals directly from the kitchen to the resident’s room. If in a wheelchair, the staff would bring the resident to the table to eat. Regarding the resident, the ULP stated she frequently used her call light pendant to use the bathroom throughout the shift, and the staff would answer it each time. During an interview, the resident’s family member stated she should have received a call since the resident hit her head. The family member stated the resident’s meals would arrive late if they were delivered at all. One time, the resident had to wait over an hour to use the bathroom. Additionally, the resident had been told on multiple occasions she could not use her call pendant. The family member also stated she thought staff needed better training. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 Neglect means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No; the vulnerable adult is deceased Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable Action taken by facility: The facility completed an incident report. The nurse investigated concerns of lengthy call light times. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 06/12/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 35230 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5601 94TH AVENUE NORTH URBANA PLACE SENIOR LIVING BROOKLYN PARK, MN 55443 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On March 15, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL352304967C/#HL352303044M and HL352308595C/#HL352305003M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 EGUJ11 If continuation sheet 1 of 1