Brookview Cottage Inc.

correction orders issued pursuant to the June 25, 2025 survey. In accordance with Minn. Stat. § 144G3. 1 Subd .4 (a), state correction orders issued pursuant to the last survey, completed on June 25, 2025, found not corrected at the time of the Septembe r11, 2025, follow-up survey and/or subject to penalty assessmen at re as follows: 0775-Fire Protection And Physica lEnvironment-144g.45 Subd. 2. (a) - $500.00 The details of the violations noted at the time of this follow-up survey completed on Septembe r11, 2025 (listed above), are on the attached State Form. Brackets around the ID Prefix Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Therefore ,in accordance with Minn. Stat. §§ 144G0. 1 to 144G9. 999, the total amount you are assesse dis $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATIO ONF ACTION TO COMPLY In accordance with Minn. Stat. § 144G3. 0, Subd .5(c), the licensee must document actions taken to comply with the correction orders outlined on the state form; however, plans of correction are not required to be submitted for approval. IMPOSITION OF FINES In accordance with Minn. Stat. § 144G3. 1, 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: Leve l1: no fines or enforcement; Leve l2: a fine of $500 per violation, in addition to any enforcemen tmechanism authorized in § 144G2. 0; Leve l3: a fine of $1,000 per incident, in addition to any enforcemen tmechanism authorized in § 144G2. 0; Leve l4: a fine of $3,000 per incident, in addition to any enforcemen tmechanism authorized in § 144G2. 0; An equal opportunity employer . Letter ID: 8GKP Revised 04/14/2023 Brookview Cottage Inc October 17, 2025 Page 2 Leve l5: a fine of $5,000 per violation, in addition to any enforcemen tmechanism authorized in § 144G2. 0. CORRECTIO ONRDER RECONSIDERATI OPRNOCESS In accordance with Minn. Stat. § 144G3. 2, Subd .2, you may challenge the correction order(s) issued ,including the level and scope ,and any fine assesse dthrough 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 REQUESTIN AG HEARING Alternatively ,in accordance with Minn. Stat. § 144G3. 1, Subd .5(d), an assisted living provider that has been assesse da fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuan tto Minn. Stat. § 144G2. 0, 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 appea lfines via reconsideration ,please follow the procedure outlined above. Please note that you may request a reconsideration or 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 the website listed above. We urge you to review these orders carefully. If you have questions ,please contact Benjamin J. Zwart at You are encouraged to retain this document for your records . It is your responsibility to share the information contained in the letter and/or state form with your organizations’ Governing Body. Sincerely, Benjamin J. Zwart, Supervisor State Engineering Service sSection Email :BenjaminZ. wart@state.mn.us Telephone :651-201-3715 Fax :1-866-890-9290 CLN PRINTED: 10/20/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31392 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2808 BROOKVIEW DRIVE BROOKVIEW COTTAGE INC BURNSVILLE, MN 55337 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX 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 Correction Orders ASSISTED LIVING PROVIDER FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE-ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL31392016-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On 9-10-25, the Minnesota Department of Health corresponding text of the state Statute out conducted a follow-up survey at the above of compliance is listed in the "Summary provider to follow-up on orders issued pursuant Statement of Deficiencies" column. This to a survey completed on 6-24-25. As a result of column also includes the findings which the follow-up survey, the following orders were are in violation of the state requirement reissued. after the statement, "This Minnesota requirement is not met as evidenced by." Following the evaluators ' findings is the Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'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. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. {0 775} 144G.45 Subd. 2. (a) Fire protection and physical {0 775} SS=E environment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 MDUZ12 If continuation sheet 1 of 8 PRINTED: 10/20/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 31392 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2808 BROOKVIEW DRIVE BROOKVIEW COTTAGE INC BURNSVILLE, MN 55337 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE PREFIX PREFIX REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) {0 775} Continued From page 1 {0 775} Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: This MN Requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with the current Minnesota Fire Code Provisions. This had the potential to directly affect all residents, staff, and visitors. 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 was issued at a pattern scope (when more than a limited number of residents are affected, 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: On September 10, 2025, the surveyor initiated a follow-up for the initial survey conducted on June 6, 2025. Housing manager (HM)-C met the surveyor and explained that the windows in resident rooms one and two had not been replaced. HM-C stated they had hired a contractor, but the contractor canceled before the work had been completed. HM-C stated that a new contractor had just came to the facility to measure the windows. On September 10, 2025, at 12:06 p.m. the surveyor and HM-C entered unoccupied resident rooms one and two. HM-C verified that the windows were the same as during the initial STATE FORM 6899 MDUZ12 If continuation sheet 2 of 8 PRINTED: 10/20/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B.