A list of the most recent deficiencies for Hope Springs at Minnetonka. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-27 | 2023-06-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-27 | 2023-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-27 | 2023-06-12 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-04-27 | 2023-06-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-27 | 2023-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-27 | 2023-06-12 | N |
| Report COVID19 data to residents and families. | Health | 2023-04-27 | 2023-06-12 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-04-27 | 2023-06-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-27 | 2023-06-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-27 | 2023-06-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-27 | 2023-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-06-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-23 | 2023-03-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-21 | 2021-12-31 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-21 | 2021-12-31 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-10-21 | 2021-12-31 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-21 | 2021-12-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2021-12-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-21 | 2021-12-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-10-21 | 2021-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-21 | 2021-12-31 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-10-21 | 2021-12-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-21 | 2021-12-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-21 | 2021-12-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-10-21 | 2021-12-31 | N |
| Develop a communication plan. | Fire Safety | 2021-10-21 | 2021-12-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-21 | 2021-12-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-25 | 2021-12-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-15 | 2021-08-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-15 | 2021-08-31 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-07-15 | 2021-08-31 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-07-15 | 2021-08-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-31 | 2021-08-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-06 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-06-18 | 2021-08-06 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-06-18 | 2021-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-18 | 2021-07-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-10 | 2021-06-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-10 | 2021-06-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-04-19 | 2019-05-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-19 | 2019-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-19 | 2019-05-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-19 | 2019-05-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-19 | 2019-05-29 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-19 | 2019-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-19 | 2019-05-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-04-19 | 2019-05-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-19 | 2019-05-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-04-19 | 2019-05-29 | N |
| Develop a communication plan. | Fire Safety | 2019-04-19 | 2019-05-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-04-19 | 2019-05-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-10-21 | Not Fixed | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-25 | Not Fixed | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-10-25 | Not Fixed | N |
