The Pillars of Lakeville.

correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. The Department of Health documents state correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Home Care Providers. 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 . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the violations; h owever, no immediate fines are assessed for this survey of your facility. DOCUMENTATION OF ACTION TO COMPLY Per Minn. Stat. § 144G.30, Subd. 5(c), t he 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. An equal opportunity employer. Letter ID: 9GJX Revise d04/20/2023 The Pillars of Lakeville April 26, 2024 Page 2 Identify how the area(s) of noncompliance was corrected for all of the provider’s residents/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 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 the Department of Health within 15 calendar days of the correction order receipt date. A state correction order under Minn. Stat. § 144G.91, Subd. 8, Free from Maltreatment is associated with a maltreatment determination by the Office of Health Facility Complaints. If maltreatment is substantiated, you will receive a separate letter with the reconsideration process under Minn. Stat. § 626.557. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm 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. 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 organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state.mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 HHH PRINTED: 04/26/2024 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 _____________________________ 39503 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 17701 GLACIER WAY THE PILLARS OF LAKEVILLE LAKEVILLE, MN 55044 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 Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER(S) been assigned to Minnesota State Statutes for Assisted Living License 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' findings is the Time Period for Correction. INITIAL COMMENTS: PLEASE DISREGARD THE HEADING OF SL39503015-0 THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF On April 1, 2024, through April 3, 2024, the CORRECTION." THIS APPLIES TO survey at the above provider, and the following WILL APPEAR ON EACH PAGE. correction orders are issued. At the time of the survey, there were 82 residents; 46 receiving THERE IS NO REQUIREMENT TO services under the provider's Assisted Living with SUBMIT A PLAN OF CORRECTION FOR Dementia Care license. 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 subd. 1, 2, and 3. 0 480 144G.41 Subd 1 (13) (i) (B) Minimum 0 480 SS=F requirements (13) offer to provide or make available at least the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 18OV11 If continuation sheet 1 of 20 PRINTED: 04/26/2024 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 _____________________________ 39503 04/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 17701 GLACIER WAY THE PILLARS OF LAKEVILLE LAKEVILLE, MN 55044 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) 0 480 Continued From page 1 0 480 following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and This MN Requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. 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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the residents). The findings include: Please refer to the document titled, Food and Beverage Establishment Inspection Report (FBEIR) dated April 1, 2024, for the specific Minnesota Food Code violations. The Inspection Report was provided to the licensee within 24 hours of the inspection. TIME PERIOD FOR CORRECTION: Please refer to the FBEIR for any compliance dates. 0 800 144G.45 Subd. 2 (a) (4) Fire protection and 0 800 SS=F physical environment (4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of STATE FORM 6899 18OV11 If continuation sheet 2 of 20 PRINTED: 04/26/2024 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.