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Deficiency Records for Hope Springs at Minnetonka
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.
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? |
|---|---|---|---|---|
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-16 | 2024-07-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-16 | 2024-07-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-16 | 2024-07-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-05-16 | 2024-06-30 | 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 | 2024-05-16 | 2024-06-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-16 | 2024-06-30 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-05-16 | 2024-06-30 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-05-16 | 2024-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-16 | 2024-06-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-16 | 2024-06-30 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-05-16 | 2024-06-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-16 | 2024-06-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-16 | 2024-06-30 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-05-16 | 2024-06-19 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-05-16 | 2024-06-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-05-14 | 2024-06-17 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-05-16 | 2024-06-12 | N |
| Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2024-05-16 | 2024-06-10 | 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 | 2024-05-16 | 2024-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-16 | 2024-06-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-05-14 | 2024-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-14 | 2024-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-14 | 2024-06-10 | N |
| 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 |
| 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 |
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