Editorial Independence

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StarlynnCare
Minnesota · Duluth

Heritage Haven Inc.

Heritage Haven Inc is Grade C−, ranked in the bottom 49% of Minnesota memory care with 1 MDH citation on record; last inspected Sep 2023.

ALF · Memory Care33 licensed beds · mediumDementia-trained staff
3042 Morris Thomas Road · Duluth, MN 55811LIC# ALRC:245
Limited Inspection History · fewer than 4 records in 3 years
Facility · Duluth
Heritage Haven Inc
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A 33-bed ALF · Memory Care with one citation on file (Oct 2024).
Last inspection · Sep 2023 · citedSource · MDH
Licensed beds
33
Memory care
✓ Yes
Last inspection
Sep 2023
Last citation
Oct 2024
Operated by
Phone
§ 01 · Snapshot

A medium home, reviewed on public record.

§ 02 · Peer Comparison

Ranked against 187 Minnesota facilities.

ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.

Severity rank
20th
Weighted citations per bed.
peer median
0
100
Repeat rank
100th
Repeat deficiencies as share of total.
peer median
0
100
Frequency rank
28th
Deficiencies per inspection.
peer median
0
100

FACILITY WATCH · BETA

Heritage Haven Inc has 1 citation on record. Know the moment anything changes.

New findings, complaint investigations, or status changes — emailed to you free.

§ 03 · The Record

Citation history, plotted month by month.

1 deficiencie on record. Each bar is a month with a citation.

10weighted score · 24 mo
Last citation: OCT 2024. Compared against peer median (dashed).
peer median
OCT 2024
Jun 2024May 2026

Finding distribution

1 total · 36 months

Scope × Severity (CMS A–L)

Isolated
Pattern
Widespread
Sev 4 · IJ
J
K
L
Sev 3
G1
H
I
Sev 2
D
E
F
Sev 1
A
B
C
§ 05 · Tour Prep

Questions to ask before you visit.

A short pre-tour checklist tailored to Heritage Haven Inc's record and state requirements.

01 /

MDH records show 2 complaints filed against Heritage Haven — can you share what those complaints were about, whether they were substantiated, and what corrective action plans the facility implemented in response?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

02 /

The most recent inspection on September 1, 2023 resulted in zero deficiencies — can you walk us through how the facility prepares for state surveys and what internal quality assurance processes are in place to maintain compliance with Minnesota Stat. ch. 144G dementia care requirements?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

03 /

Heritage Haven holds an Assisted Living Facility with Dementia Care license under ch. 144G — can you provide a copy of the facility's written dementia care program and explain how staff competency in dementia care is documented and assessed?

Ask the operator on tour. Take notes and compare answers across facilities you visit.

§ 06 · Full Inspection Record

Every MDH visit, verbatim.

3 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.

3
reports on file
1
total deficiencies
2024-10-30
Complaint Investigation
1 · Substantiated Finding

Plain-language summary

A staff member at this facility was found to have financially exploited a resident by making unauthorized charges totaling $8,401.97 from the resident's bank account to purchase cosmetics for personal use and resale on social media. The investigation was substantiated based on bank records, law enforcement findings, and interviews; the staff member denied the charges but evidence showed orders were shipped to her home address using her contact information. The facility issued a correction order, the staff member was terminated, and the facility offered to secure the resident's banking materials going forward.

Substantiated FindingMinn. Stat. §MN-SUBST
Verbatim citation text · Minn. Stat. §MN-SUBST

MDH substantiated maltreatment or licensing violation finding

Full inspector notes

Finding: Substantiated, individual responsibility 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), a staff member, financially exploited the resident when the AP made unauthorized and fraudulent charges from the resident’s bank account. Investigative Findings and Conclusion: The Minnesota Department of Health determined financial exploitation was substantiated. The AP was responsible for the maltreatment. The AP made unauthorized charges from the resident’s bank account for a total of $8,401.97 to an on-line cosmetic company for the AP’s personal use. The investigator conducted interviews with facility staff members, including administrative staff and the AP. The investigation included review of the resident records, facility internal investigation, personnel file, law enforcement report, and related facility policy and procedures. Also, the investigator toured the facility. The resident resided in an assisted living facility. The resident’s diagnoses included diabetes. The resident’s service plan included assistance with medication management, transfers using a mechanical lift, dressing, grooming, and repositioning. The resident was alert, oriented, and managed her own finances independently. The internal investigation indicated the resident reported to the facility she had fraud charges occurring on her bank account. Unauthorized purchases were made to an on-line cosmetic company that she had not ordered. The investigation established the AP was selling the same cosmetic from the same company identified on the resident’s bank statement, on the AP’s social medica (Facebook) marketplace page. The law enforcement report indicated there was a total of $8,401.97 worth of cosmetic purchases made using the resident’s card. All orders were shipped to the AP’s home address, in the AP’s name using her cell phone number, the AP’s email address, and the AP also had been selling some of the items on the AP’s social media marketplace page. During an interview, the resident stated there were purchases made for cosmetics on her bank account. The resident stated she did not make the purchases. During an interview, the AP denied making charges and ordering the cosmetics using the resident’s account. The AP stated her family member ordered her a trial pack of the cosmetics that she did not use so she put that gift up for sale on social media. During an interview, leadership stated the resident said she did not make any purchases to the on-line cosmetic company. Leadership stated the AP sold the cosmetics on the AP’s social media marketplace page, from the same company identified in the resident’s bank statements. Leadership stated the AP had received training on resident rights and property. In conclusion, the Minnesota Department of Health determined financial exploitation was substantiated. Substantiated: Minnesota Statutes, section 626.5572, Subdivision 19. “Substantiated” means a preponderance of evidence shows that an act that meets the definition of maltreatment occurred. Financial exploitation: Minnesota Statutes, section 626.5572, subdivision 9 "Financial exploitation" means: (b) In the absence of legal authority, a person: (1) willfully uses, withholds, or disposes of funds or property of a vulnerable adult; (2) obtains for the actor or another the performance of services by a third person for the wrongful profit or advantage of the actor or another to the detriment of the vulnerable adult; (3) acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud; or (4) forces, compels, coerces, or entices a vulnerable adult against the vulnerable adult's will to perform services for the profit or advantage of another Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: No, responsible for self. Alleged Perpetrator interviewed: Yes. the Action taken by facility: The facility conducted an internal investigation and contacted law enforcement. The facility offered to store the resident’s banking cards and materials in a safe. The AP is no longer employed by the facility. Action taken by the Minnesota Department of Health: The facility was issued a correction order regarding the vulnerable adult’s right to be free from maltreatment. You may also call 651-201-4200 to receive a copy via mail or email. The responsible party will be notified of their right to appeal the maltreatment finding. If the maltreatment is substantiated against an identified employee, this report will be submitted to the nurse aide registry for possible inclusion of the finding on the abuse registry and/or to the Minnesota Department of Human Services for possible disqualification in accordance with the provisions of the background study requirements under Minnesota 245C. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities Saint Louis County Attorney Duluth City Attorney Duluth Police Department PRINTED: 10/30/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25455 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3042 MORRIS THOMAS ROAD HERITAGE HAVEN INC DULUTH, MN 55811 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****** ASSISTED LIVING PROVIDER CORRECTION ORDER In accordance with Minnesota Statutes, section 144G.08 to 144G.95, these correction orders are issued pursuant to a complaint investigation. Determination of whether a violation is corrected requires compliance with all requirements provided at the statute number indicated below. When a Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: #HL254555466C/#HL254554442M On September 24, 2024, the Minnesota Department of Health conducted a complaint investigation at the above provider, and the following correction orders are issued. At the time of the complaint investigation, there were 29 residents receiving services under the provider's Assisted Living with Dementia Care license. The following correction order is issued for #HL254555466C/#HL254554442M, tag identification 2360. 02360 144G.91 Subd. 8 Freedom from maltreatment 02360 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 X58X11 If continuation sheet 1 of 2 PRINTED: 10/30/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25455 09/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3042 MORRIS THOMAS ROAD HERITAGE HAVEN INC DULUTH, MN 55811 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) 02360 Continued From page 1 02360 This MN Requirement is not met as evidenced by: 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. STATE FORM 6899 X58X11 If continuation sheet 2 of 2

2024-01-04
Complaint Investigation
No findings

Plain-language summary

A complaint alleged the facility neglected a resident by failing to assess her for injuries after a fall, but the Minnesota Department of Health determined the allegation was not substantiated after investigating medical records, staff interviews, and family statements that showed the resident was assessed by a nurse immediately after the fall with no apparent injuries found. The resident was hospitalized four days later with back pain and other conditions, was admitted to hospice for end-stage kidney disease, and died eight days after the fall from natural causes related to her kidney disease. No violations were cited and no further action was taken.

Full inspector notes

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 resident was neglected when the facility failed to assess the resident for injuries after a fall when the resident complained of pain. The resident died eight days later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. The residents plan of care was being followed at the time of the fall and the resident was assessed and had no apparent injuries when the nurse assessed the resident following the fall. Four days later, the resident was admitted to the hospital with back pain, elevated blood pressure, and increased confusion. The resident was discharged back to the facility the following day on end-of-life cares. The resident died 8 days later due to kidney disease. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted the resident’s family. The investigation included review of resident records including assessments, care plan, service plan, An equal opportunity employer. service delivery of care record, fall incident reports/post fall assessment, hospital after visit summaries (AVS), progress notes, staff communication, medication administration records, provider communication/orders, and facility policies and procedures. Also, the investigator observed resident’s and staff interactions at the facility. The resident resided in an assisted living dementia care facility with diagnoses including end stage renal disease, type II Diabetes Meletus, dementia, and hypertension. The resident’s assessment and care plan identified she was at a high risk for falls related to a history of falls, below the knee amputation, visual impairment, poor decision-making ability, and history of self-transferring. The assessment and care plan included various interventions to reduce the occurrence of falls. An incident report indicated one day the resident had an unwitnessed fall. The resident stated she was looking at things on her bookshelf and fell out of her chair. The staff immediately reported the incident to the nurse. The nurse assessed the resident had no change in range of motion or mobility after the fall. The incident report indicated the resident had a bruise on her left eyebrow, and neurologic assessments were completed, with no concerns identified. The resident’s progress notes indicated after the fall the resident had full range of motion but reported pain when moving her left leg. A follow up progress note indicated when the nurse assessed the resident for injuries, the resident had full range of motion and slight tenderness in the opposite leg. When the nurse assessed the resident after the incident there was no indication the resident had pain in her left leg. A faxed communication to the resident’s provider the following day indicated the facility reported the resident had hip and back pain, with orders for a transdermal lidocaine patch received. Three days later a hospital note indicated the resident was admitted to the hospital with back pain, hypertension, and increased confusion. The resident record indicated while hospitalized, the resident was admitted to hospice for end-of-life care related to end stage renal disease, and hemodialysis was discontinued. The resident was readmitted to the facility the following day. The resident died at the facility 8 days later. The resident’s record of death indicated the resident died of natural causes related to end stage renal disease. When interviewed facility staff stated the resident was assessed for injuries after the fall occurred and no injuries were noted. When interviewed the resident’s family member stated she had no concerns with actions taken by the facility to help prevent the resident’s falls, or the care and services provided. The family member stated the resident was assessed for injuries after the fall occurred, and the resident’s hospice admission and subsequent death were not related to the fall that occurred at the facility. 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, deceased. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: N/A. the Action taken by facility: No action taken. 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: 01/09/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 25455 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3042 MORRIS THOMAS ROAD HERITAGE HAVEN INC DULUTH, MN 55811 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 December 13, 2023, the Minnesota Department of Health initiated an investigation of complaint #HL254558286M/#HL254555465C. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 E63M11 If continuation sheet 1 of 1

2023-09-01
Annual Compliance Visit
No findings

Plain-language summary

A follow-up survey on December 13, 2023 found that the facility had not corrected all state correction orders from a prior September 1, 2023 inspection, including violations related to reporting requirements, disaster planning, fire protection, and physical environment standards. The facility was assessed a total fine of $1,500.00 and issued new correction orders for additional violations in reporting requirements and contract documentation. The facility is required to document actions taken to comply with these correction orders within the timeframe specified and has the right to request reconsideration or a hearing.

Full inspector notes

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. Furthermore, the follow-up survey determined your facility had not corrected all of the state correction orders issued pursuant to the September 1, 2023, initial survey. In accordance with Minn. Stat. § 144G.31, Subd. 4 (a), state correction orders issued pursuant to the last survey completed on September 1, 2023, found not corrected at the time of the follow-up survey follow-up survey and/or subject to a penalty assessment are as follows: 0620-Compliance With Requirements For Reporting Ma-144g.42 Subd. 6 (a) / 626.557, Subd. 3 0680-Disaster Planning And Emergency Preparedness-144g.42 Subd. 10 -$500.00 0780-Fire Protection And Physical Environment-144g.45 Subd. 2 (a) (1) - $500.00 0810-Fire Protection And Physical Environment-144g.45 Subd. 2 (b)-(f) - $500.00 The details of the violations noted at the time of this follow-up survey completed on December 13, 2023 (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. An equal opportunity employer. Letter ID: 292I_Revised 04/14/2023 Heritage Haven Inc December 20, 2023 Page 2 Also, at the time of this follow-up survey completed on December 13, 2023, we identified the following violation(s): 0630-Compliance With Requirements For Reporting Ma-144g.42 Subd. 6 (b) 0900-Contract Required-144g.50 Subdivision 1 The details of the violation(s) noted at the time of this follow-up survey are delineated on the attached State Form. Only the ID Prefix Tag in the left hand column without brackets will identify these state correction orders. It is not necessary to develop a plan of correction. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $1,500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY Per 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). IMPOSITION OF FINES: 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. 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 the MDH within 15 calendar days of the correction order receipt date. Heritage Haven Inc December 20, 2023 Page 3 To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRD-Appeals-Form 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 MDH 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 h ttps://forms.web.health.state.mn.us/form/HRD-Appeals-Form. 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 the website listed above. 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. Sincerely, Maria King, RN Division Director HHH PRINTED: 12/20/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 25455 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3042 MORRIS THOMAS ROAD HERITAGE HAVEN INC DULUTH, MN 55811 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 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 this correction order(s) has appears in the far left column entitled "ID been issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether a violation has been out of compliance is listed in the corrected requires compliance with all "Summary Statement of Deficiencies" requirements provided at the Statute number column. This column also includes the indicated below. When Minnesota Statute findings which are in violation of the state contains several items, failure to comply with any requirement after the statement, "This of the items will be considered lack of Minnesota requirement is not met as compliance. evidenced by." Following the surveyors' findings is the Time Period for Correction. INITIAL COMMENTS: Project SL25455015-1 PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH On December 12, 2023, through December 13, STATES,"PROVIDER'S PLAN OF 2023, the Minnesota Department of Health CORRECTION." THIS APPLIES TO conducted a revisit at the above provider to FEDERAL DEFICIENCIES ONLY. THIS follow-up on orders issued pursuant to a survey WILL APPEAR ON EACH PAGE. completed on December 13, 2023. At the time of the survey, there were 28 residents receiving THERE IS NO REQUIREMENT TO services under the Assisted Living with Dementia SUBMIT A PLAN OF CORRECTION FOR care license. As a result of the revisit, the VIOLATIONS OF MINNESOTA STATE following orders were reissued and issued. 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. {0 620} 144G.42 Subd. 6 (a) / 626.557, Subd. 3 {0 620} SS=D Compliance with requirements for reporting ma (a) The assisted living facility must comply with LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 ZJ8M12 If continuation sheet 1 of 17 PRINTED: 12/20/2023 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 25455 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3042 MORRIS THOMAS ROAD HERITAGE HAVEN INC DULUTH, MN 55811 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) {0 620} Continued From page 1 {0 620} the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. The facility must establish and implement a written procedure to ensure that all cases of suspected maltreatment are reported. The requirement in Minnesota Statute section 626.557, Subd.

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