Vitacare Living

Summary: MDH found the licensee failed to maintain documentation of quality management activity.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain documentation of quality management activity. This had the potential to affect all 11 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. [...]”

Summary: MDH found the licensee failed to post the required information to include: (1) Posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and (2) Posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information to include: (1) Posting the 911 emergency number in common areas and near telephones provided by the assisted living facility; and (2) Posting information and the reporting number for the Minnesota Adult Abuse Reporting Center (MAARC) to report suspected maltreatment of a vulnerable adult under section 626.557. This had the potential to affect all current 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 maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). Additionally, the licensee failed to ensure it completed a facility TB risk assessment or identify a person in charge of the TB infection control program. [...]”

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 [...]”

Summary: MDH found the licensee failed to have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have a written emergency preparedness plan with all the required content and post an emergency preparedness plan prominently. This had the potential to affect all 11 residents receiving services under the assisted living with dementia care license. [...]”

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 to ensure a resident record included a discharge summary for one of one discharged resident (R3) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a resident record included a discharge summary for one of one discharged resident (R3) with record reviewed. [...]”

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, [...]”

Summary: MDH found the licensee failed to provide working required smoke alarms in the hallways near resident room #4 and the office.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide working required smoke alarms in the hallways near resident room #4 and the office. This has the potential to directly affect residents, staff, and visitors. [...]”

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 maintain portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2).

MDH’s finding, as written: “Based on observation, record review, and interview, the licensee failed to maintain portable fire extinguishers in accordance with the State Fire Code as required by MN Statute 144G.45 Subd(a)(2). This had the potential to directly affect all residents and staff. [...]”

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 physical environment of the facility in a continuous state of good repair and operation.

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

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 [...]”

Summary: MDH found the licensee failed to provide all required content on

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide all required content on the fire safety and evacuation plan, required training, and the minimum number of evacuation drills. This has the potential to directly affect the safety of all residents receiving care, 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 ensure insulin was administered per the manufacturer's instructions for one of one resident (R2) observed during insulin administration and failed to ensure as needed (PRN) medications had documentation of effectiveness after administration for one of one resident (R1) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure insulin was administered per the manufacturer's instructions for one of one resident (R2) observed during insulin administration and failed to ensure as needed (PRN) medications had documentation of effectiveness after administration for one of one resident (R1) with records reviewed. [...]”

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 provide a hazard vulnerability or safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect the residents from potential harm.

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment plan to identify hazard vulnerabilities and mitigations on and around the property to protect the residents from potential harm. This has the potential to directly affect all memory care residents receiving assisted living services and staff. [...]”

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 [...]”

MDH’s finding, as written: “Based on interview and record review, licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were provided to each resident and/or the residents legal/designated representative at the time of move-in. This had the potential to affect all residents with dementia care, staff and visitors. [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to have an evaluation for an activity plan for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to have an evaluation for an activity plan for two of two residents (R1, R2) with records reviewed. 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 [...]”

Rule cited: “(b) Each resident must be evaluated for activities according to the licensing rules of the facility. [...]”