Hope Springs at Minnetonka

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Have a plan that describes the process for conducting QAPI and QAA activities.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

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.

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.

Provide safe, appropriate pain management for a resident who requires such services.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure each resident receives an accurate assessment.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Allow residents to self-administer drugs if determined clinically appropriate.

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Provide and implement an infection prevention and control program.

Have a plan that describes the process for conducting QAPI and QAA activities.

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Provide routine and 24-hour emergency dental care for each resident.

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

Provide appropriate care/assistance for a resident with a prosthesis.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Ensure residents have reasonable access to and privacy in their use of communication methods.

Honor the resident's right to manage his or her financial affairs.

Honor the resident's right to organize and participate in resident/family groups in the facility.