Vitacare Living

Summary: MDH found the licensee failed to ensure the staffing plan was developed and posted as required, potentially affecting all 19 residents in the assisted living with dementia care facility, staff, and any visitors of the licensee.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the staffing plan was developed and posted as required, potentially affecting all 19 residents in the assisted living with dementia care facility, staff, and any visitors of the licensee. [...]”

Rule cited: “(11) develop and implement a staffing plan for determining its staffing level that: (i) includes an evaluation, to be conducted at least twice a year, of the appropriateness of staffing levels in the facility; (ii) ensures sufficient staffing at all times to [...]”

Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota

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: (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 ensure that a registered nurse was available on-call 24 hours a day, seven days per week.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure that a registered nurse was available on-call 24 hours a day, seven days per week. This had the potential to affect all 21 residents and staff of the facility. This resulted in an immediate correction order on December 6, 2022, at 1:45 p.m. [...]”

Rule cited: “(14) provide staff access to an on-call registered nurse 24 hours per day, seven days per week.”

Summary: MDH found the licensee failed to ensure infection control standards were followed for one of two unlicensed personnel (ULP-G) during personal cares for R12.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure infection control standards were followed for one of two unlicensed personnel (ULP-G) during personal cares for R12. [...]”

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. [...]”

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. [...]”

Summary: MDH found the licensee failed to ensure two of two employees' (unlicensed personnel (ULP)-E and ULP-G) records included the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure two of two employees' (unlicensed personnel (ULP)-E and ULP-G) records included the required content. [...]”

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 establish and maintain a TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines and the Minnesota Department of Health (MDH).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to establish and maintain a TB (tuberculosis) prevention and control program based on the most current guidelines issued by the centers for Disease Control and Prevention (CDC) guidelines and the Minnesota Department of Health (MDH). [...]”

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 develop an emergency preparedness plan (EP) with all required content or practice and document testing of it's plan at least twice annually as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop an emergency preparedness plan (EP) with all required content or practice and document testing of it's plan at least twice annually as required. 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 to provide the physical environment in a continuous state of good repair and operation with regard to the health, safety, and well-being of the residents.

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

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to provide the required plans, training, and drills for fire safety and evacuation. This had the potential to directly affect all residents and staff. [...]”

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

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property of a resident. This had the potential to affect all 19 residents living within the assisted living facility. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations included all the required training for one of two unlicensed personnel (ULP-G).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of two unlicensed personnel (ULP-G). [...]”

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 training and

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure training and competency evaluations included all the required training for one of two unlicensed personnel (ULP-G). [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure direct supervision of one of two unlicensed personnel (ULP-G) performing delegated tasks was completed by the registered nurse (RN).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure direct supervision of one of two unlicensed personnel (ULP-G) performing delegated tasks was completed by the registered nurse (RN). [...]”

Rule cited: “(a) Staff who perform delegated nursing or therapy tasks must be supervised by an appropriate licensed health professional or a registered nurse according to the assisted living facility's policy where the services are being provided to verify that the work [...]”

Summary: MDH found the licensee failed to ensure one of two employees (unlicensed personnel (ULP)-E) completed 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 one of two employees (unlicensed personnel (ULP)-E) completed 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 a registered nurse (RN) conducted an initial assessment for one of three residents (R3) as required.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted an initial assessment for one of three residents (R3) as required. [...]”

Rule cited: “(a) Residents who are not receiving any services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment on day 14 and day 90 for two of three residents (R2, R4) as required.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) completed a comprehensive reassessment on day 14 and day 90 for two of three residents (R2, R4) as required. [...]”

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 the service plan included the required content for three of three residents (R2, R3, R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan included the required content for three of three residents (R2, R3, R4). [...]”

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 develop and maintain a current individualized medication management plan for three of three residents (R2, R3, R4) to include all required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain a current individualized medication management plan for three of three residents (R2, R3, R4) to include all required content. [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure prescriptions were renewed at least every 12 months for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for one of one resident (R2). 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 [...]”

Rule cited: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to provide a hazard vulnerability or safety risk assessment that had been completed on and around the property.

MDH’s finding, as written: “Based on document review and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that had been completed on and around the property. This had the potential to directly affect all residents 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 [...]”

Summary: MDH found the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure policies and procedures required in the licensing of assisted living facilities with dementia care were developed or implemented, and provided to each resident and/or the residents legal and designated representative at the time of move-in. This had the potential to affect all dementia care residents, 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 conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan with required content based on the evaluation, for three of three residents (R3, R4, R5) who received services under an assisted living with dementia care license.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to conduct an evaluation for activities that addressed all provisions and failed to develop an individualized activity plan with required content based on the evaluation, for three of three residents (R3, R4, R5) who received services under an assisted living with dementia care license. [...]”

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

Summary: MDH found the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for three of three residents (R5, R6, R7) with bedrails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for three of three residents (R5, R6, R7) with bedrails. This resulted in an immediate correction order on December 6, 2022, at approximately 9:45 a.m. [...]”

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.”