Heritage Haven

Summary: MDH found the licensee failed to post a menu a week in advance that was made available to all residents.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to post a menu a week in advance that was made available to all residents. This had the potential to affect all 25 residents. [...]”

Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

Summary: MDH found the licensee failed to post the required information related to the grievance procedure.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure. This had the potential to affect all current residents, staff, and visitors. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to display the original current license at the main entrance of the assisted living facility as required.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to display the original current license at the main entrance of the assisted living facility as required. This had the potential to affect all of the licensee's current residents, staff and visitors. [...]”

Rule cited: “The original current license must be displayed at the main entrance of each assisted living facility. The facility must provide a copy of the license to any person who requests it.”

Summary: MDH found the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of quality management activity appropriate to the size and relevant to the type of services provided by the assisted living. This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R6) who had incidents of elopement and for one of one resident (R1) who had a significant injury with a fall. [...]”

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

Summary: MDH found the licensee failed to post the required content in common areas including: posting the 911 emergency number and contact information for Minnesota Adult Abuse Reporting Center (MAARC) in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required content in common areas including: posting the 911 emergency number and contact information for Minnesota Adult Abuse Reporting Center (MAARC) in common areas and near telephones provided by the assisted living facility. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

Summary: MDH found the licensee failed to ensure two of five employee records (clinical nurse supervisor (CNS)-B, licensed practical nurse (LPN)-C) contained a current job description.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of five employee records (clinical nurse supervisor (CNS)-B, licensed practical nurse (LPN)-C) contained a current job description. [...]”

Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

Summary: MDH found the licensee failed to develop and post a written emergency preparedness plan (EPP) with all the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and post a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents, staff, and visitors of the facility. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

Summary: MDH found the licensee failed provide interconnected smoke alarms in each sleeping room and outside in immediate vicinity of the sleeping rooms.

MDH’s finding, as written: “Based on observation and interview, the licensee failed provide interconnected smoke alarms in each sleeping room and outside in immediate vicinity of the sleeping rooms. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

Summary: MDH found the licensee failed to provide portable fire extinguishers that were readily accessible and had no more than 75-foot travel distance within the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide portable fire extinguishers that were readily accessible and had no more than 75-foot travel distance within the facility. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the facility's physical environment in a continuous state of good repair and operation regarding the health, safety, and well-being of the residents. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

MDH’s finding, as written: “Based on record review and interview, the licensee failed to maintain the facility's fire safety and evacuation plan with required elements. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to provide facilities that were not a distinct hazard to life.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide facilities that were not a distinct hazard to life. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “(g) Existing construction or elements, including assisted living facilities that were registered as housing with services establishments under chapter 144D prior to August 1, 2021, shall be permitted to continue in use provided such use does not constitute a [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of [...]”

Rule cited: “(a) The contract must include in a conspicuous place and manner on the contract the legal name and the health facility identification of the facility. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of [...]”

Rule cited: “(d) The contract must include a description of the facility's complaint resolution process available to residents, including the name and contact information of the person representing the facility who is designated to handle and resolve complaints. [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of [...]”

Rule cited: “(5) a description of the facility's policies related to medical assistance waivers under chapter 256S and section 256B.49 and the housing support program under chapter 256I, including: (i) whether the facility is enrolled with the commissioner of human [...]”

Summary: MDH found the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to execute a written contract with the required content for three of three residents (R1, R4, R6). This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the resident and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to provide written notice with required content to the resident, legal representative, and designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide written notice with required content to the resident, legal representative, and designated representative, and failed to provide the notification to the Office of Ombudsman for Long-Term Care (OOLTC) when the resident did not return from the emergency relocation within four days for one of one resident (R5). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure a background study was affiliated with the assisted living with dementia care license for four of six employees (licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-G, ULP-H, cook (C)-I).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a background study was affiliated with the assisted living with dementia care license for four of six employees (licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-G, ULP-H, cook (C)-I). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

Summary: MDH found the licensee failed to ensure three of three unlicensed personnel (ULP)-E, ULP-G, ULP-H) received the required training.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure three of three unlicensed personnel (ULP)-E, ULP-G, ULP-H) received the required training. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

Summary: MDH found the licensee failed to ensure orientation to assisted living statutes including all required content for four of five employees (licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-E, ULP-G. ULP-H).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure orientation to assisted living statutes including all required content for four of five employees (licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-E, ULP-G. ULP-H). [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure an employee received all required annual training content for each 12 months of employment for four of four employees (clinical nurse supervisor(CNS)-B,

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an employee received all required annual training content for each 12 months of employment for four of four employees (clinical nurse supervisor(CNS)-B, licensed practical nurse(LPN)-C, unlicensed personnel(ULP)-G, ULP-H). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure five of five employees (clinical nurse supervisor (CNS)-B, licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-E, ULP-G, ULP-H) received the required amount of dementia care training in the required time frame.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure five of five employees (clinical nurse supervisor (CNS)-B, licensed practical nurse (LPN)-C, unlicensed personnel (ULP)-E, ULP-G, ULP-H) received the required amount of dementia care training in the required time frame. [...]”

Rule cited: “(3) for assisted living facilities with dementia care, direct-care employees must have completed at least eight hours of initial training on topics specified under paragraph (b) within 80 working hours of the employment start date. [...]”

Summary: MDH found the licensee failed to ensure employees not providing direct care received at least two hours of annual dementia training for one of one employee (cook(C)-I).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees not providing direct care received at least two hours of annual dementia training for one of one employee (cook(C)-I). [...]”

Rule cited: “(4) staff who do not provide direct care, including maintenance, housekeeping, and food service staff, must have at least four hours of initial training on topics specified under paragraph (b) within 160 working hours of the employment start date, and must [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) reassessed one of one resident (R1) with repeated falls and the use of sensor motion alarms and for one of one resident (R6) who had incidents of elopement.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse (RN) reassessed one of one resident (R1) with repeated falls and the use of sensor motion alarms and for one of one resident (R6) who had incidents of elopement. In addition, the licensee failed to ensure the RN completed a comprehensive reassessment using the uniform assessment tool on day 90 for one of one resident (R4). [...]”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

Summary: MDH found the licensee failed to ensure one of one resident's (R4) service plan included all required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of one resident's (R4) service plan included all required content. 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 an isolated scope (when one or a limited number of residents are affected or one or a limited [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure one of three unlicensed personnel (ULP)-E received training by the registered nurse (RN) and demonstrated competency to the RN prior to administering medications to residents.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure one of three unlicensed personnel (ULP)-E received training by the registered nurse (RN) and demonstrated competency to the RN prior to administering medications to residents. [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure the effectiveness of PRN (as necessary) medications were documented for two of two residents (R1, R4) and failed to ensure medications were administered as ordered for two of two residents (R1, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the effectiveness of PRN (as necessary) medications were documented for two of two residents (R1, R4) and failed to ensure medications were administered as ordered for two of two residents (R1, R4). [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to ensure documentation of medication setup included all required content for two of two residents (R1, R8).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication setup included all required content for two of two residents (R1, R8). [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for four of four medication refrigerators.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure refrigerated medications were maintained at manufacturer recommended temperatures by failing to monitor and document medication refrigerator temperatures for four of four medication refrigerators. In addition, the licensee failed to ensure medications were secure and permitted access to only authorized personnel for three of four refrigerators being used to store medications. [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications and failed to monitor for expired medications for three of three medication storage carts.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were maintained bearing the original prescription label with legible information including the expiration date for time sensitive medications and failed to monitor for expired medications for three of three medication storage carts. [...]”

Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of one

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of one resident (R4) who had treatments managed by the facility. [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to ensure treatment or therapies were administered as directed and failed to document the reason they were not administered, and any follow up procedures provided to meet the resident's needs for one of one resident (R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment or therapies were administered as directed and failed to document the reason they were not administered, and any follow up procedures provided to meet the resident's needs for one of one resident (R4). [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

MDH’s finding, as written: “Based on record review and interview, the licensee failed to provide a hazard vulnerability assessment or safety risk assessment of the physical environment on and around the property. This deficient practice had the ability to affect all staff, residents, and visitors. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

Summary: MDH found the licensee failed to ensure the designated person overseeing staff training in the care of individuals with dementia (clinical nurse supervisor (CNS)-B), had documented evidence of competency or knowledge test required by the commissioner.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the designated person overseeing staff training in the care of individuals with dementia (clinical nurse supervisor (CNS)-B), had documented evidence of competency or knowledge test required by the commissioner. This had the potential to affect all residents and staff of the facility. [...]”

Rule cited: “Persons providing or overseeing staff training must have experience and knowledge in the care of individuals with dementia, including: (1) two years of work experience related to Alzheimer's disease or other dementias, or in health care, gerontology, or [...]”

Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for three of three residents (R1, R2, R3) who utilized bed rails.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to provide care and services according to acceptable health care, medical or nursing standards for three of three residents (R1, R2, R3) who utilized bed rails. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R6) who had incidents of elopement and for one of one resident (R1) who had a significant injury with a fall.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R6) who had incidents of elopement and for one of one resident (R1) who had a significant injury with a fall. [...]”

Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

Summary: MDH found the licensee failed to ensure signage was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all residents, staff, and visitors of the licensee.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure signage was posted at the main entryway of the establishment to display statutory language to disclose electronic monitoring activity, potentially affecting all residents, staff, and visitors of the licensee. [...]”

Rule cited: “(a) A facility must post a sign at each facility entrance accessible to visitors that states: "Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities." (b) The facility is responsible for [...]”