Hope Springs At Minnetonka

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), dated 10/2024, indicated medications are to be indicated as taken by a resident based on pharmacological classification, not how it is used. The RAI Manual further indicated herbal and alternative medicine products are considered to be dietary supplements by the Food and Drug Administration (FDA). These products are not regulated by the FDA (e.g., they are not reviewed for safety and effectiveness like medications) and their composition is not standardized (e.g., the composition varies among manufacturers). Therefore, they should not be counted as medications (e.g., melatonin). R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the care facility 7/24/23 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R11: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was admitted to the care facility on 4/6/23 and was cognitively intact. R11's Orders, indicated R11 had an order for Betamethasone Valerate External Cream 0.1% (a steroid cream used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions), apply to affected skin as needed for rash unsupervised self-administration. Apply to affected skin twice daily PRN [as needed] for rash up to five days a month and two times a day for rash for two weeks. R11's care plan, dated 6/26/24, indicated for staff to provide medications as ordered, including Betamethasone cream PRN for rash outbreaks. R11's electronic medical record (EMR) indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had intact cognition, disorganized thinking, verbal behavioral symptoms directed towards others, and did not reject cares. R4 required supervision or touching assistance with eating and was independent with most activities of daily living. R4 had diagnoses of orthostatic hypotension (condition where blood pressure drops when standing up from a sitting or lying position), dementia and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). R4's oral intake care plan revised 12/13/24, indicated R4 had potential for inadequate oral intakes related to history of varying appetite secondary to mental health and had been hospitalized for not eating and weight loss. Care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was admitted to the care facility on [DATE]. The MDS indicated R4 had intact cognition, disorganized thinking, verbal behavioral symptoms directed toward others, and diagnoses including orthostatic hypotension (condition where blood pressure drops when standing up from a sitting or lying position), dementia and schizophrenia (chronic mental illness characterized by disruptions in through process, perceptions, emotions, and social interactions). R4's care plan dated [DATE], lacked documentation of code status. R4's Health Care Directive dated [DATE], indicated they did not want CPR (cardiopulmonary resuscitation; emergency procedure which combined chest…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the care facility 7/24/23 and was cognitively intact. During an interview on 2/11/25 at 8:41 a.m., R1 stated missing clothing was a common occurrence in the facility and she was currently missing a blue hoody. R1 confirmed she had let the facility nursing assistants (NA) know but had not received any follow up. R5: R5's quarterly MDS dated [DATE], indicated R5 was admitted to the care facility 10/1/24 and was cognitively intact. During an interview on 2/12/25 at 8:54 a.m., R5 stated she had not been getting all of her clothing back after getting it washed and was currently missing a pair of jeans, socks, and underwear. R5 stated she had told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was cognitively intact and was independent with most activities of daily living and required set up assistance with bathing. R3's progress notes dated 8/6/24 - 2/12/25, indicated R3 had three UTIs in the past six months resulting in two hospitalizations and was displaying current UTI symptoms. On 8/6/24 it was documented R3 had complaints of strong smelling/cloudy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. The MDS further indicated R5 utilized a walker for locomotion and was independent with most activities of daily living (ADLs) except bathing. R5's progress note, dated 1/6/25, indicated R5 asked staff if it was okay for her to go outside and walk down the trail. Staff assured R5 it was okay as long as staff knew where she was. That afternoon R5 came back to facility smelling of smoke. R5 confirmed she was aware the care facility was a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R11's quarterly Minimum Data Set (MDS), dated [DATE], indicated R11 was cognitively intact and had pain almost constantly that frequently effected sleep and day to day activities. The MDS further indicated R11 had received pain medication during the look back period however had not received any non-pharmacological pain interventions. R11's Orders, printed on 2/13/25, indicated R11 received several medications for pain including Ajovy (used to prevent migraine headaches) 225 milligram (mg)/1.5 milliliters (ml) inject subcutaneously once a month for intractable migraines, alpha-lipoic acid (used in alternative medicine to aide treating nerve pain) 300mg by mouth two times a day for polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R9 R9's quarterly minimum data set (MDS) dated [DATE], indicated R9 had moderately impaired cognition, inattention, disorganized thinking, hallucinations, delusions, verbal and other behaviors, and rejected cares. R9 had no upper or lower extremity impairments and used a walker. R9 required partial and/or moderate assistance for dressing and supervision for footwear application and removal, toileting, personal and oral hygiene, and ambulation. The MDS indicated R9 had arthritis (general term for conditions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was admitted to the care facility on 9/21/09 and was cognitively intact. R3's Diagnoses, printed 2/13/25, indicated R3 had several medical and mental health diagnoses including bipolar disorder, major depressive disorder and anxiety disorder. R3's Orders indicated R3 was receiving several medications including Venlafaxine (an antidepressant medication which may cause orthostatic hypotension) 225 milligrams (mg) by mouth one time a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R18's quarterly [NAME] Data Set (MDS), dated [DATE], indicated R18 was admitted to the care facility on 11/8/23, and was cognitively intact. The MDS further indicated R18 had coughing/choking episodes during meals. R18's Diagnoses, dated 11/7/23, indicated R18 had several medical diagnoses including dysphagia (difficulty swallowing) and moderate protein-calorie malnutrition. R18's Orders, dated 7/15/24, indicated an order for mechanical soft texture, regular consistency, easy to chew texture. R18's Care Plan, dated 11/24/23, and revised on 2/10/25, indicated R18 was able to feed himself and staff was to provide soft food and ground meat, indicating at times R18 would ask that his meat not be ground. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. During interview on 5/15/24 at 2:30 p.m., R6 stated her personal mail was being delivered opened by the facility and that she had asked the facility not to open her mail however, this practice remained ongoing. During interview on 5/15/24 at 10:11 a.m., the administrative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Finding include: Review of the facility PBJ (Payroll Based Journal) Staffing Data Report dated 10/1/23 - 12/31/23, identified the facility failed to have RN coverage for the dates of: 10/1/23, 10/14/23, 10/15/23, 10/16/23, 10/18/23, 10/19/23, 10/20/23, 10/21/23, 10/22/23, 10/24/23, 10/28/23, 11/04/23, 11/5/23, 11/11/23, 11/19/23, 11/23/23, 11/25/23, 11/26/23, 11/27/23, 11/29/23, 11/30/23, 12/1/23, 12/4/23, 12/6/23, 12/9/23, 12/10/23, 12/22/23, and 12/23/23. The undated, facility payroll sheets confirmed the facility did not have RN coverage for the dates of: 10/18/23, 10/19/23, 10/20/23, 10/21/23, 10/22/23, 11/4/23, 11/5/23, 11/19/23, 11/23/23, 11/29/23, 11/30/23, 12/1/23, 12/4/23, 12/6/23, 12/23/23. During interview on 5/14/24 at 11:26 a.m., RN-A stated the facility was required to have at least one RN on site every day, including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Food storage During the initial kitchen observation on 5/13/24 at 12:46 p.m., the refrigerators in the main kitchen contained the following: - opened 2% [NAME] select white milk and skim vitamin a and d white milk with no opened date. - slices of circular meat wrapped in plastic wrap with no opened date or label identifying what the item was. - Hormel roast beef was opened and in a Ziplock bag. The Hormel bag read 5/23/24 as the prepare by or freeze date but did not have an open date. - an unopened tight sealed package of meat was thawing in a serving container with typed label of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility PBJ Staffing Data Report dated 10/1/23 - 12/31/23 (Q1), identified the facility failed to have RN coverage for the dates of: 10/1/23, 10/14/23, 10/15/23, 10/16/23, 10/18/23, 10/19/23, 10/20/23, 10/21/23, 10/22/23, 10/24/23, 10/28/23, 11/04/23, 11/5/23, 11/11/23, 11/19/23, 11/23/23, 11/25/23, 11/26/23, 11/27/23, 11/29/23, 11/30/23, 12/1/23, 12/4/23, 12/6/23, 12/9/23, 12/10/23, 12/22/23, and 12/23/23. The report also indicated the facility failed to have licensed nursing coverage 24 hours per day on the following dates: 10/12/23, 10/17/23, 11/4/23, 11/19/23, 12/23/23, and 12/29/23. In addition, the report identified the facility was triggered for low weekend staffing. Review of the facilities undated payroll sheets indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The facility's QAPI meeting minutes, attendance, and evidence of the facility's ongoing performance improvement projects (PIPs) was requested, however not received. During interview with director of nursing and administrator on 5/16/24 at 2:30 p.m., the administrator stated the facility held quarterly QAPI meetings but had not developed any performance improvement projects and did not have any formal documentation relating to the correction of previous and repeated quality…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: The facility's policy titled Infection Control revised 6/2023, directed staff to follow to utilize infection control procedures related to standard precautions and droplet and airborne TBP. However, the policy lacked direction or procedure for EBP, contact precautions and enteric…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Staff education for infection control was requested however wasn't received. When interviewed on 5/15/24 at 12:32 p.m., licensed practical nurse (LPN)-A stated if a resident had any signs of infection or change, they would alert the Director of Nursing (DON) and the provider. The provider would determine next steps. LPN-A stated there was not a specific way to monitor residents when they have an infection or when an antibiotic was used. LPN-A stated use of TBP would depend on how the infection spreads. LPN-A further stated when the DON was notified about the signs of an infection, she would direct us if any TBP were required and what should be done. LPN-A stated there had been an in-service on enhanced barrier precautions (EBP) recently and wasn't sure about education about the policies and procedures. When interviewed on 5/15/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. AD explained did not think about arranging RC meeting coverage in her absence but should have had someone else take the responsibility of setting up RC meetings monthly. AD- also verified RC meetings were not consistently being held monthly. During resident council (RC) meeting with surveyor on 5/15/24 at 2:30 p.m., R1, R2, R5, R6, R7, R9, R10, R12, R14, R17,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: During interview on 5/13/24 at 2:40 p.m., R10 verified she had a personal account with the facility and stated the facility had allocated every Wednesday as money pass day and could only have access to personal funds during money pass on Wednesdays. R10 further stated she could not get money on the weekends or other days of the week. During interview on 5/13/24 at 4:33 p.m., R12 verified she had a personal account with the facility but that she only had access to the money on Wednesdays which was assigned by the facility as money pass day. R12 stated she could not access personal account funds on the weekends or other days of the week besides Wednesdays, when the facility would distribute money from resident account for the week as they needed. During interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact, had diagnoses of chronic pain, constipation, bladder dysfunction, anxiety, depression, post-traumatic stress disorder, and schizophrenia. R11's Care Areas Assessment (CAA) dated 7/31/23, identified the following triggered concerns: Visual function Communication Indwelling catheter Psychosocial well-being Mood Activities Falls Nutritional status Dehydration/Fluid maintenance Pressure ulcer/injury Psychotropic drug use Pain Acitivies of daily living (ADL) functional/rehabilitation potential R11's care plan printed 5/15/24, lacked desired goals and person-centered interventions for visual function, communication, indwelling catheter, activities, dehydration/fluid maintenance, pressure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, used a wheelchair for mobility, and had diagnoses of vascular disease, diabetes, malnutrition, and right lower leg amputation. R17's admission Orders included R17 could walk with a walker up to 100 feet with modified independent and an order to remind R17 to put on right leg prosthesis between 10:00 a.m., and 11:30 a.m., daily. R17's provider Nursing Home Visit note dated 11/16/23, included, Per RN, patient has not been utilizing the R (right) leg prosthesis due to complaints of itchy/skin irritation. In addition, discussed with RN to follow up with prosthetic company regarding reassessing patient for prosthesis exchange. R17's New admission Appointment Referral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact, had diagnoses of chronic pain, anxiety, depression, post-traumatic stress disorder, and schizophrenia, and did not take an opioid medication. R11's care plan dated 5/15/24, lacked identification of pain focus and opioid medication. R11's Order Summary Report dated 5/15/24, included an order for hydromorphone HCl (an opioid pain medication) 2 milligrams (mg) every three hours as needed for pain starting 11/17/23. R11's Medication Administration Records (MARs) for 1/1/24 - 5/15/24, indicated R11 had not taken any doses of hydromorphone during that time. R11's progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], indicated R9 was cognitively intact and had diagnoses of schizoaffective disorder and chronic pain. A review of R9's provider orders indicated R9 had the following orders: -on 1/19/24, acetaminophen (non-narcotic pain medication) 325 milligrams (mg) give every for hours as needed (PRN)for pain was prescribed. There were no parameters for when to administer this dose. -on 1/19/24, acetaminophen 650mg give every 4 hours PRN for pain was prescribed. There were no parameters for this dose. -on 3/7/24, Tylenol (acetaminophen) 1000mg three times a day for chronic pain was prescribed. R9's medication administration record for 3/2024-5/13/24, indicated R9 had been currently using all Tylenol orders prescribed. When interviewed on 5/15/24 at 5:37 p.m., licensed practical nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, had diagnoses of renal insufficiency or failure, diabetes mellitus, hemiplegia (a severe or complete loss of strength or paralysis on one side of the body), and hemiparesis (a mild loss of strength on one side of the body), The MDS indicated R6 was independent with oral hygiene and did not reject cares. R6's annual MDS dated [DATE], indicated R6 had no natural teeth and did not indicate loosely fitting dentures. R6's dental care area assessment was triggered but not provided. R6's care plan dated revised 4/9/24, indicated R6 was independent after set-up with oral hygiene and did not mention dentures. During interview on 5/13/24 at 7:08 p.m., R6 stated they told the facility they wanted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure influenza immunization were offered to 2 of 5 (R20, R11) residents reviewed for immunizations. Findings include: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 was cognitively intact and had diagnoses of bipolar disorder and depression. Furthermore, R20's MDS indicated no influenza vaccination was given this season and the influenza vaccine was not offered. R20's Minnesota Immunization Information Connection Report (MIIC) dated 1/11/24, indicated R20 had not received the influenza vaccine for the 2023-2024 season. R20's medical record lacked indication R20 had been offered, received or declined the influenza vaccination. R20's declination of influenza vaccination was requested however was not received. R11's MDS dated [DATE], indicated R11 was cognitively intact and had diagnoses of schizoaffective disorder and depression. Furthermore, R11's MDS indicated R11 had been offered and refused the influenza vaccination. R11's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.