The Pillars of Prospect Park

Survey completed July 13, 2023: 17 correction orders

• Tag 100: 144G.10 Subdivision 1 License required Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to obtain accurate licensure to include application and approval for an innovation variance as defined in 144G.33 prior to the licensee advertising and offering intergenerational (student) housing.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to obtain accurate licensure to include application and approval for an innovation variance as defined in 144G.33 prior to the licensee advertising and offering intergenerational (student) housing. [...]”

  Rule cited: “(a) (1)?Beginning August 1, 2021, no assisted living facility may operate in Minnesota unless it is licensed under this chapter. [...]”

• 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 and served 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 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 [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

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

  Summary: MDH found the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical and nursing standards for infection control for one of five employees (unlicensed personnel (ULP)-K) observed to provide personal cares.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical and nursing standards for infection control for one of five employees (unlicensed personnel (ULP)-K) observed to provide personal cares. [...]”

  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 660: 144G.42 Subd. 9 Tuberculosis prevention and control Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure tuberculosis (TB) testing was completed at the time of hire, or

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure tuberculosis (TB) testing was completed at the time of hire, or within 90-days prior to the date of hire, for 11 student resident volunteers. [...]”

  Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, pattern scope, scope/level letter E · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to document services were provided as identified in the service plan for three of five residents (R5, R6, R9).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document services were provided as identified in the service plan for three of five residents (R5, R6, R9). [...]”

  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Total fines assessed, as printed in the letter: $6,500.00.

Allegation, as written: “The alleged perpetrator (AP) abused a resident when the AP sexually assaulted the resident during cares.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. The resident reported the AP raped her. The AP denied he raped the resident. The DNA swab did not detect any male DNA. The physical exam findings could not determine any definitive signs of sexual assault. It could not be determined if the AP sexually assaulted the resident.”

Action taken by facility: “The facility reported to authorities and made a report to the Minnesota Adult-Abuse Reporting Center (MAARC).”

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

Survey completed September 3, 2024: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP) abused the resident when the AP tied the resident's legs with a bed sheet resulting in a blood clot in the left leg.”

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

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

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. Due to incomplete and conflicting accounts of the incident, it could not be determined if maltreatment occurred. In addition, there was no evidence to support that the blood clot was directly related to the incident.”

Action taken by facility: “The facility investigated the incident and suspended AP #1 for two days.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed July 2, 2024: 2 correction orders

• Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) Days
  Details

  Summary: MDH found the licensee failed to comply with statute requirements to ensure cases of suspected maltreatment were reported for one of one resident (R1).

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to comply with statute requirements to ensure cases of suspected maltreatment were reported for one of one resident (R1). Facility staff did not report an allegation of suspected maltreatment unitl seven days after the initial report and after completion of an internal investigation into the incident. [...]”

  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 2320: 144G.91 Subd. 4 (b) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7) Days
  Details

  Summary: MDH found the licensee failed to ensure appropriate care and services were provided when staff failed to adhere to the steps outlined in the procedure of immediate action required following a report of suspected maltreatment and an alleged perpetrators (AP) of maltreatment remained working at the facility during investigation of the incident and failed to implement additional measures to reduce the risk of further occurrence.

  MDH’s finding, as written: “Based on interview and document review, the licensee failed to ensure appropriate care and services were provided when staff failed to adhere to the steps outlined in the procedure of immediate action required following a report of suspected maltreatment and an alleged perpetrators (AP) of maltreatment remained working at the facility during investigation of the incident and failed to implement additional measures to reduce the risk of further occurrence. [...]”

  Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Allegation, as written: “The facility neglected the resident when facility staff failed to provide adequate supervision. As a result, the resident barricaded himself in the bathroom drank shampoo and hand soap in attempts to harm himself. The resident required hospitalization.”

“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. The resident had a history of suicidal ideation, and the facility had interventions in place. The day the resident admitted to the memory care unit; the resident barricaded himself in his bathroom. The resident told staff he drank shampoo and hand soap in attempts to harm himself. During the shift prior to the incident, the resident did not verbalize any suicidal ideation. In addition, the resident did not have history of drinking shampoo or hand soap in attempts to self-harm. The facility staff called EMS (emergency medical services) and the resident transferred to the hospital.”

Action taken by facility: “When the resident expressed suicidal ideation, facility staff contacted EMS.”

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

Survey completed November 5, 2025: no correction orders issued.