Edenbrook of Edina

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess for safe self-administration and storage of medications and failed to obtain a physician order for 2 of 3 residents (R24 and R50) reviewed for self-administration of medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the skilled nursing facility Advanced Beneficiary Notice (SNFABN-10055) was provided to 1 or 3 residents (R59) reviewed for Beneficiary notifications.

Inspectors wroteBased on record review and interview, the facility failed to ensure ordered as needed (PRN) psychotropic medications were limited to a 14-day time period for 1 or 5 residents (R34) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to follow physician orders for 1 of 2 residents (R3) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement a fall management program which included development and implementation of care plans, comprehensive fall analysis for root causes, and implementation of appropriate fall interventions to prevent and/or reduce the likelihood of future falls for 5 of 5 residents (R1 had one unwitnessed fall with major injury, R6 who had four unwitnessed falls one with major injury, R2 had 8 unwitnessed falls, R3 had 4 unwitnessed falls, and R4 had 10 unwitnessed falls) who had an identified risk for falls. This resulted in actual harm for R6 who suffered a left tibial fracture and hospitalization and actual harm for R1 when she sustained a spinal fracture and hospitalization.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to increase in resident falls by developing and implementing action plans for process improvement. This had the potential to affect all 60 residents that resident in the facility.

Inspectors wroteBased on interview and document review, the facility failed to timely report to State Agency (SA) falls with serious injury for 2 of 2 residents (R1, R6) who had falls without implementation of appropriate fall interventions to prevent/mitigate risk of recurrent falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the care plan for 2 of 5 residents (R4. R6) who were reviewed for accidents/falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment for 2 of 3 residents assessed (R1 and R3). R1's room was observed having the bed made over a urine-soiled facility bath blanket. R3's room was cluttered with facility supplies covering up furniture and clean supplies found on the floor.

Inspectors wroteBased on interview and document review the facility failed to ensure the comprehensive care plan was developed to implement cares and services for a leg prosthetic for 1 of 1 resident (R3) reviewed. R3's care plan did not have any person-centered details for R3's prosthetic placement or use. In addition, R3's comprehensive assessment did not indicate R3 had a leg prosthetic.

Inspectors wroteBased on interview and record review the facility failed to meet a resident needs and choices to perform activities of daily living of toileting for 1 of 3 residents (R3) reviewed when R3 wore an incontinent brief for toileting. R3 had a below the knee leg prosthesis and was unable to use his preferred method of toileting due to staff not able to apply the prosthesis in a timely manner to transfer R3 to the toilet or commode chair (a portable toilet chair) as indicated on R3's care plan.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment and a physician's order was completed to allow a resident to safely administer their own medication for 3 of 4 residents (R263, R15, R54) observed with unattended medication.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for 1 of 1 resident (R27) reviewed who had an unclean tube feeding pole.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide treatment to a skin tear and documented it had been completed for 1 of 4 residents (R3) reviewed for wound care. In addition, the facility falsely documented wound care was being provided for 2 of 4 residents (R4, R5) reviewed for wound care whose wounds had been resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize enhanced barrier precautions (EBP) for 2 of 5 residents (R3) observed for personal cares and wound care treatments.

Inspectors wroteBased on observation, interview and document review, the facility failed to protect a resident while an allegation of abuse was being investigated for 1 of 3 (R1) residents reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to awake staff on the overnight shift to provide adequate supervision and care of residents for 1 of 3 residents (R1) when R1 called 911 due to pain and the need to use the bathroom.

Inspectors wroteBased on interview and document review, the facility failed to have a designated charge nurse for each shift.

Inspectors wroteBased on interview and record review, the facility failed to report alleged violations of abuse was reported immediately, but no later than 2 hours after the allegation is made State Agency for one of one resident (R1) reviewed when a police officer visited the facility to investigate an allegation of abuse. for reporting of alleged violations of mistreatment, exploitation, neglect, or abuse. Law enforcement visited R1 due to allegations of maltreatment and stated to the Director of Nursing (DON) they were there for allegations of maltreatment and the facility did not report the allegations of maltreatment.

Inspectors wroteBased on interview and record review, the facility failed to investigate a report of abuse for one of one resident (R1) reviewed for response to allegations of abuse when a police officer visited the facility to investigate an allegation of abuse.

Inspectors wroteBased on interviews and record review the facility failed to ensure R1 was allowed to exercise rights consistent with the comprehensive assessment and plan of care for 1 of 3 residents (R1) reviewed. R1 was her own representative who wanted to leave the facility after having smoking privileges revoked, was not an elopement risk, did not have dementia, and was not given assistance getting her needs met with her desire to leave. In addition, her smoking privileges were revoked without assistance to manage a safe smoking plan at the facility or assistance with smoking cessation tools.

Inspectors wroteBased on interview and record review, the facility failed to maintain respect and dignity for personal possessions for 1 of 3 resident's (R1) reviewed who had her room searched and items removed without consent.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident was assessed to self-administer medications (SAM) for 1 of 1 resident (R171) reviewed whose medications were left in the resident room during medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine bathing and hair washing was offered or provided to promote good hygiene for 2 of 3 residents (R13, R172), and failed to ensure oral cares were offered or provided for 1 of 3 residents (R46) reviewed for activities of daily living (ADLs) and who were dependent on staff for their cares.

Inspectors wroteBased on interview and document review, the facility failed to monitor weights as ordered for 1 of 1 residents (R13) reviewed for weight loss.

Inspectors wroteBased on interview and document review, the facility failed to provide the necessary services for the behavioral health needs for 1 of 1 resident (R186) reviewed for mood and behavior. Findings Include: R171's admission Minimum Data Set (MDS) dated [DATE], identified R171 was cognitively intact. R171's diagnoses included anxiety, depression, agoraphobia with panic disorder (fear of and avoids places or situations that might cause panic and feelings of being trapped, helpless or embarrassed), alcohol use with alcohol induced disorder and toxic effect of unspecified substance. R171's care plan (CP) dated 12/18/23, identified R171 had potential psychosocial well-being related to diagnoses of depression and alcohol abuse and instructed staff to consult with pastoral care, social services, and psych services. [...]

Inspectors wroteBased on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 1 of 5 residents (R46) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure orders were entered appropriately and carried out for a urinary analysis and culture (UA/UC) for processing in a timely manner for 1 of 2 residents (R169) reviewed for urinary tract infections (UTI).

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 (R46) reviewed for dental concerns, who had broken/chipped teeth in poor condition.