Hope Springs at Minnetonka

Inspectors wroteBased on interview and document review the facility failed to submit accurate data for staffing information, including agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 1 2026) to the centers for Medicare and Medicaid (CMS) according to specifications established by CMS. This had the potential to affect all 21 residents living in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure Quality Assurance Performance Improvement (QAPI) meetings were held on a quarterly basis. This had the potential to affect all 21 residents residing at the facility.

Inspectors wroteBased on record review and interviews, the facility failed to obtain informed consents including risk and benefit for 1 of 5 residents (R11) reviewed for psychotropic medications.

Inspectors wroteBased on record review and interviews, the facility failed to obtain diagnostic testing related to recommendations from a speech language pathology (SLP) evaluation for 1 of 1 resident (R11) reviewed for SLP recommendations.

Inspectors wroteBased on record review and interview, the facility failed to report a COVID-19 outbreak in their facility. This had the potential to affect all 21 residents in the facility, staff, and visitors.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day. This deficient practice had the potential to affect all 21 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure cups were completely dry before storing and stacked bowls stayed dry to prevent bacterial growth. In addition, the facility failed to ensure food items were properly labeled and dated, failed to ensure staff covered their hair, assess food temperature during food prep, and to ensure staff followed appropriate infection control technique during food service. This had potential to affect all 21 residents who were served food from the kitchen.

Inspectors wroteBased on interview and document review the facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven quality assurance and performance improvement (QAPI) program. These findings had potential to affect all 21 residents residing within the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance (QA) committee identified and implement performance improvement projects to address any identified concerns. These findings had potential to affect all 21 residents residing within the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance (QA) committee consisted of the minimum required members. These findings had potential to affect all 21 residents residing within the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure completed Minimum Data Set (MDS) assessments were accurately coded to reflect correct medication use for 5 of 5 residents (R1, R3, R6, R9, and R15).

Inspectors wroteBased on observation, interview and document review the facility failed to ensure residents who self-administered topical medications creams were assessed for safe and appropriate use for 2 of 3 residents (R11 and R15) reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food preferences were honored for 1 of 1 resident (R4) reviewed for choices related to food.

Inspectors wroteBased on interview and document review, the facility failed to ensure provider orders code status [e.g. full code or do not resuscitate (DNR)] were updated, consistent, and accurate throughout the resident's medical record for 1 of 4 residents (R4) reviewed for advance directives.

Inspectors wroteBased on interview and document review the facility failed to ensure a process for missing clothing was followed and residents received appropriate follow up after reporting concerns of missing clothing for 3 of 5 residents (R1, R4, and R9) reviewed for personal property.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess and monitor skin alterations for 1 of 2 residents (R8) reviewed for skin integrity. Furthermore, the facility failed to follow up with urology after several urinary tract infection and failed to comprehensively monitor and assess (i.e bladder scanning to assess for urine retention, proactive UTI assessments or assessing if R3 required more assistance with toileting or bathing) to timely treat, if needed, and prevent hospitalization for 1 of 1 resident (R3) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident who wished to smoke off facility grounds was properly assessed for safety, and risks of unsupervised smoking were discussed for 1 of 1 resident (R5) reviewed for smoking. The facility further failed to ensure residents at risk for falls were assessed for a root cause and new interventions were put in place to prevent falls for 2 of 3 residents (R10 and R8) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess pain and attempt non-pharmacological pain interventions for 1 of 1 resident (R11) receiving multiple medications for pain.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure alternate interventions were assessed and/or attempted, risks and benefits of bed assist devices were reviewed, and consent was obtained for 1 of 2 residents (R9) reviewed for bed assist devices. Furthermore, the facility failed to remove a bed assist device or re-evaluate its use after an assessment indicated the bed assist device was not needed for 1 of 2 residents (R14) reviewed for bed assist devices.

Inspectors wroteBased on interview and document review the facility failed to ensure orthostatic hypotension (characterized by a sudden drop in blood pressure that may lead to dizziness, lightheadedness, or fainting) was communicated the physician to ensure psychotropic medications (which can commonly cause orthostatic hypotension due to their effect on the body's blood vessels) did not need to be reduced to prevent falls, over sedation or complications for 1 of 5 residents (R3) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the appropriate, modified diet was given, and risks versus benefits of refusing a modified diet were discussed with 1 of 2 residents (R18) who had difficulty swallowing and recent coughing episodes after meals.

Inspectors wroteBased on observation and interview the facility failed to ensure mail was delivered to residents on Saturdays and also failed to ensure mail was delivered unopened to residents. This had the potential to affect all residents in the facility who received personal mail, including but not limited to 2 of 12 residents (R5, R6) at the resident council meeting who verbally confirmed not receiving mail on Saturdays and that their personal mail was opened by the facility. Findings Include: During interview on 5/13/24 at 1:26 p.m., R5 stated staff were opening her mail and reading them and had been receiving her mail opened before it was delivered to her ongoing. R5 verbalized she did not like that her mail was being opened by the facility and had communicated to the facility that she wanted her mail delivered unopened. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours per day. This deficient practice had the potential to affect all 20 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure frozen, refrigerated, and dry food items were properly stored, labeled, and dated and disposed of after expiration date. Furthermore, the facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of foodborne illness. This had potential to affect all residents and staff who eat from the main kitchen.

Inspectors wroteBased on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Q1), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.

Inspectors wroteBased on interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement, and failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 20 residents which resided in the facility.

Inspectors wroteBased on interview and record review the facility failed to develop an infection prevention control program that included written standards, policies and procedures that included when and to whom possible incidents of communicable disease or infections should be reported, when and how transmission-based precautions (TBP) and enhanced barrier precautions (EBP) should be implemented to prevent infections, hand hygiene procedures to be followed by staff involved in direct resident care and a process fpr surveillance and monitoring of infection control practices were implemented by staff. Furthermore, the facility failed to ensure the antibiotic stewardship protocol included a system to monitor antibiotic use. This had the potential to affect all 20 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure staff were educated to standards, policies, and procedures of their infection control program. This had the potential to impact all 20 residents who reside in the facility.

Inspectors wroteBased on interview and document review, the facility failed to assist the resident council in setting up regular meetings. This had the potential to affect 12 of 12 residents (R1, R2, R5, R6, R7, R9, R10, R12, R14, R17, R19, R20) who met to discuss resident council. Findings Include: Resident Council (RC) notes documentation indicated the following documented meetings: 4/5/24, 10/27/23, and 7/24/23, were the only meeting notes documented after 6/2023. During interview on 5/14/24 at 11:23 a.m., activity director (AD)- stated they was in charge of setting up resident council meetings but was on a medical leave from 11/2023, and returned in 3/2024, with no one else setting up and arranging resident council meetings in her absence. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure residents had access to petty cash, including on weekends, for 3 of 3 residents (R6, R10, R12) who had personal funds deposited with the facility. This had the potential to affect all 20 residents who utilized a personal funds account.

Inspectors wroteBased on observation, interview and document review, the facility failed to develop a comprehensive care plan that included resident-specific interventions for 2 of 2 residents (R11, R19) reviewed for care planning.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance and coordination of services to ensure timely referral and treatment for prosthetic fit for 1 of 1 resident (R17) reviewed who needed a prosthesis.

Inspectors wroteBased on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 2 of 5 residents (R11, R15) reviewed for unnecessary medications. Furthermore, the consulting pharmacist failed to address duplicative medication orders for 1 of 5 residents (R9) reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure duplicative medications were not prescribed for 1 of 5 residents (R9) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dental status was accurately assessed and routine dental services were provided for 1 of 2 residents (R6) reviewed for dental concerns.

Inspectors wroteBased on interview and record review the facility failed to ensure influenza immunization were offered to 2 of 5 (R20, R11) residents reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure survey results were posted in a location visible and easily accessible to residents and visitors. This had the potential to affect all 20 residents residing in the facility and their visitors.