Lake Minnetonka Shores

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Apr 25, 2024

  Based on interview and document review, the facility failed to ensure resident advanced directives were accurately documented in the electronic medical record (EMR) and physician orders to ensure their wishes would be followed in the event of a cardiac arrest for 1 of 24 residents (R158) reviewed for advanced directives. The immediate jeopardy (IJ) began on [DATE] when R158 completed an updated Physician's Orders For Life Sustaining Treatment (POLST) to change code status to Do Not Resuscitate (DNR) and was identified on [DATE]. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 12:18 p.m. on [DATE]. […]

• Actual harm, isolatedF689Aug 16, 2022

  Based on observation, interview, and document review, the facility failed to comprehensively assess resident equipment to ensure appropriateness and safety when using a shower chair for 1 of 1 resident (R1) who had a fall while receiving a shower. This resulted in actual harm for R1 who was hospitalized , and was diagnosed with compression fractures of L4-L5 and impacted transverse fracture of the proximal tibial shaft extending into the tibial plateaus reviewed for accidents. Findings include: R1's diagnoses included [CONDITION(S)] (RA), other chronic pain, contractures of the right and left knees, and arthritis obtained from the annual Minimum Data Set (MDS) dated [DATE]. […]

• Actual harm, isolatedF697Aug 16, 2022

  Based on interview, and document review, the facility failed to ensure complaints of worsening acute generalized pain were comprehensively assessed and treated in a timely manner to provide comfort and reduce risk of complications for 1 of 1 residents (R1) who voiced concerns about pain following a fall. This resulted in actual harm when after a fall R1 experienced increasing, ongoing pain with decreased mobility and was subsequently hosptialized for fractures. Findings include: R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based on observation, interview and document review, the facility failed to follow food safety guidelines to thaw raw chicken to prevent the spread of cross-contamination. Furthermore, the facility failed to ensure appropriate hand hygiene was performed for 1 of 1 staff observed preparing food in the kitchen. These deficient practices had the potential to affect all 57 residents who ate in the facility. Findings include: During a kitchen observation on 4/25/24 at 11:55 a.m., cook-A stated chicken was being thawed for supper. Cook-A was working at a two-compartment stainless steel prep sink, and the right-side sink compartment was approximately 75% full of cloudy, pink-gray water, with cold water running from the faucet into the cloudy water, and the contents of the sink were not visible. […]

• No harm, potential for more than minimal, patternF689Feb 25, 2021

  Based on observation, interview, and document review, the facility failed to ensure potentially unsafe, escalating wandering behaviors were comprehensively assessed and interventions were developed to provide adequate supervision for 1 of 1 male resident (R39) identified to wander into female resident rooms. This had potential to affect 7 of 7 female residents identified on the Lafayette Bay Unit. In addition, the facility failed to assess and ensure adequate supervision with cleaning supplies, medications, heating pad and alcohol consumption for 2 of 2 residents (R4, R7) reviewed who had these items accessible. […]