Hope Springs at Minnetonka

In the surveyor’s words

From the most serious findings on record at Hope Springs at Minnetonka, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Oct 21, 2021

  Based on observation, interview, and document review, the facility failed to ensure a residents cardiopulmonary resuscitation (CPR) status was accurately reflected for 1 of 1 resident (R10) who wished to receive chest compressions in the event of a cardiopulmonary arrest (cessation of pulse and respirations). The resulted in an immediate jeopardy (IJ) situation for R10 who would not had received CPR in the event of cardiopulmonary arrest and was at risk for death. The IJ began on [DATE], at 10:54 a.m. when R10's door had a red rectangle beside her name which indicated do-not-resuscitate (DNR). R10's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator was notified of the IJ on [DATE], at 3:15 p.m. The IJ was removed on [DATE], at 7:48 p.m. […]

• Immediate jeopardy, isolatedF689Jul 31, 2021

  Based on interview and document review, the facility failed to prevent an elopement and provide safety for 1 of 3 residents (R1) identified at risk for elopement. R1 successfully eloped from the building, undetected, and was found by a citizen about five blocks away. This deficient practice resulted in immediate jeopardy (IJ) for R1. The IJ began on 7/24/21, when R1, who was on 15 minute checks, successfully eloped from the facility through two alarmed doors, went off the facility grounds, and was found five blocks away by a community member. The facility was unaware R1 was gone from the building and the police brought R1 back to the facility. On 7/28/21, the director of nursing (DON) was notified of the immediate jeopardy for R1. The IJ was removed on 7/31/21, at 11:30 a.m. […]

• Immediate jeopardy, isolatedF689Jul 15, 2021

  Based on interview and document review, the facility failed to prevent an elopement and provide safety for 1 of 3 residents (R1) identified at risk for elopement who successfully eloped from the building, undetected, and was found a block and a half away approximately twenty minutes later. This deficient practice resulted in immediate jeopardy for R1. The elopement immediate jeopardy (IJ) began on 6/30/21, when R1 successfully eloped from the facility, through two alarmed doors and went off the facility grounds. The facility did not know R1 had left. On 7/13/21, at 4:14 p.m. the director of nursing (DON) was notified of the IJ for R1. The DON was notified that the immediate jeopardy was removed on 7/15/21, at 12:30 p.m. […]

• Immediate jeopardy, isolatedF689Jun 18, 2021

  Based on observation, interview and document review, the facility failed to assess safety risk for 1 of 3 residents (R5) who were allowed to go into the community unsupervised, which placed R5 at risk for serious injury, impairment or death. R5 returned to the facility, which was located a block and half from a lake, wet from the chest down, had a [CONDITION(S)] which required emergency room care for staples, and was missing his shoes. In addition to the resident in immediate jeopardy, the facility failed to ensure the porch and deck area were free of potential accident hazards for 3 of 3 (R12, R5 and R2) who were on the deck area while decking boards were being removed which had the potential for harm that is not immediate jeopardy. […]

• Actual harm, isolatedF760Jun 10, 2021

  Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) was free from significant medication errors. This resulted in actual harm for R1 when R1 was administered another resident's medications, experienced adverse medication reactions and received IV fluids and was observed at the hospital overnight with [CONDITION(S)] (altered brain function) and [CONDITION(S)]. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], included, cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was independent with activities of daily living (ADL's). […]