Edenbrook of Rochester

Inspectors wroteBased on interview and document review, the facility failed to monitor, assess, implement physician orders and notify the physician of worsening hypoxia for 1 of 3 residents (R1) reviewed for change in condition. This resulted in actual harm for R1 when as a result of the delay in care, R1 experienced respiratory distress without necessary and appropriate medical intervention for over two and a half hours before emergency medical staff arrived.

Inspectors wroteBased on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for change in condition.

Inspectors wroteBased on interview and document review, the facility failed to provide necessary respiratory care consistent with professional standards of practice, physician orders, standing orders, the resident's care plan, goals and preferences for 1 of 3 residents (R1) reviewed for change in condition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a cable cord face plate was fixed and secured for 1 of 1 resident (R1) reviewed for a safe and homelike environment. Further, the facility failed to remove discarded cigarette butts from the ground at the back entrance of the facility. This had the potential to affect all 56 residents, staff and visitors.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 2 (R30, R2) residents who utilized a urinary catheter (tube from bladder to a bag outside the body) and 4 of 4 (R17, R25, R49, R52) residents who required assistance in the dining room.

Inspectors wroteBased on interview and document review, the facility failed to follow-up from resident council complaints and grievances after a determination was made by the facility. This had the potential to affect all residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) for 1 of 1 resident (R11) reviewed for accuracy of assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards of practice were followed for accurate charting of dialysis assessments including vital signs and weights for 1 of 1 resident (R52) reviewed for dialysis assessment.

Inspectors wroteBased on observation, interviews and document review the facility failed to have an appropriately trained staff member assist a resident with meals. This affected 1 of 4 (R24) residents reviewed for dining services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to address clothing burns for 1 of 1 resident (R31) reviewed for smoking safety.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the risk of infection for 2 of 3 (R30, R2) residents reviewed for infection control when it was identified the catheter bags were dragging on the floor. Additionally, the facility failed to implement enhanced barrier precautions (EBP) when caring for indwelling medical device for 1 of 1 (R52) resident reviewed for infection prevention.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were properly labeled with open dates, expired medications were removed and disposed of properly and discharged and/or expired residents' medications were removed from the cart in a timely manner to decrease the potential for drug diversion for 2 of 2 medication carts reviewed for medication storage. This deficient practice had the potential to affect all residents receiving medications from these medications' carts.

Inspectors wroteBased on observation and interview the facility failed to ensure a mechanical transfer lift was cleaned after resident use for 1 of 1 resident (R14), observed for infection control practices. Findings Include: R14's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R14 was cognitively intact, dependent on staff for toileting, required substantial/maximal assistance with transfers, personal hygiene, and dressing and used a wheelchair for mobility. R14's care plan dated 4/30/24, indicated R14 required the use of a standup lift (EZ stand) for transfers. During observation on 4/30/25 at 7:38 a.m., nursing assistant (NA)-A entered R14's room to answer his call light. NA-A went out of room and retrieved the EZ stand from the hall and brought into R14's room. The EZ stand had debris of a white flaky substance on it. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 1 of 1 residents (R20) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident equipment was kept in a clean and in a sanitary manner to promote resident well-being for 1 of 1 resident (R31) observed for wheelchair cleanliness. In addition, the facility failed to provide comfortable sound levels for 1 of 1 resident (R44) observed for uncomfortable noise levels. Findings Include: R31 R31's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 is unable to speak and uses an iPad for communication needs. R31 has impaired vision requiring glasses, adequate hearing, and understands himself and others. R31's had intact cognition. R31 had functional impairment of both lower extremities requiring an electric wheelchair and functional limitations of both upper extremities requiring supervision and intermittently assistance for feeding task. [...]

Inspectors wroteR20 R20's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R20 admitted on [DATE], was cognitively intact, had no behaviors, did not refuse cares and had the following pertinent diagnoses: A-fib (irregular heartbeat), congestive heart failure (the heart does not pump enough to adequately supply the body with blood or oxygen), and high blood pressure. R20's order summary indicated the following cardiac related orders: -Apply gradient compression garments to lower extremities-on during the day and off at night -CHF monitoring: monitor respiratory status (i.e. Orthopnea and dyspnea), edema, (i.e. leg or abdominal swelling), fatigue, change in mental status every shift and document findings in PCC (Point Click Care). Update provider with any signs/symptoms of worsening CHF. [...]

Inspectors wroteBased on document review and interview, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to identify, investigate, analyze, and respond to medication errors by developing and implementing action plans for process improvement. This had the potential to affect all 50 residents who resided in the facility.

Inspectors wroteBased on observation interview and document review the facility failed to ensure their Facility Assessment (FA) included resident diagnoses of organ transplant recipients who currently resided in the facility. In addition, the facility assessment failed to identify education on specific care or practices necessary to meet identified care needs regarding organ transplant recipients which had the potential to affect 1 of 1 resident (R1) and all future organ transplant residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP)-(an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were implemented for management of an indwelling catheter to reduce the risk of infection to others for 1 of 1 resident (R1) reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a system to provide the correct physician ordered textured diet for 1 of 1 resident (R1) who was at risk for choking and history of aspiration pneumonia. This resulted in a immediate jeopardy for R1 and has the likelihood to effect current and future residents who required changes to textured diets to prevent choking/aspiration. The immediate Jeopardy (IJ) began on 1/3/25, when R1 returned from the hospital with new diet texture orders and received a regular textured diet through 1/9/25 related to facility system failure when dietary orders are changed. The administrator and director of nursing (DON) were notified of the IJ on 1/9/25 at 5:49 p.m. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to assess and monitor non-pressure related skin injuries (bruises) for changes until resolved for 1 of 3 residents (R1), reviewed for injury of unknown origin.

Inspectors wroteBased on interview and document review the facility failed to identify, comprehensively assess, monitor surgical wound changes for 1 of 1 resident (R5). This resulted in harm when the physician was not notified of R5's fall that caused R5's wound to dehisce which delayed healing because of required surgical intervention.

Inspectors wroteBased on interview, and document review, the facility failed to ensure residents were treated with dignity and respect for 3 of 3 residents (R2, R3, R4) who required assistance with activities of daily living (ADLs) and reported concerns about a staff member.

Inspectors wroteBased on observation, interview, and document review the facility failed to notify the physician of an injury after a fall for 1 of 3 residents (R5) who fell from the wheelchair and landed on a freshly healed below knee amputation causing bleeding and dehiscence to the healed site which resulted in surgery and facility failed to notify the physician of the inability to procure and administer an emergent medication for 1 of 3 residents (R1) which resulted in a visit to the emergency department to lower potassium level.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure personal privacy and confidentiality was provided for 1 of 1 resident (R2) noted to have a facility video monitoring recording device with a view that included the interior of a resident room without resident knowledge or consent.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine grooming and personal hygiene care (i.e. nail care) was provided for 1 of 1 resident (R2) reviewed for activities of daily living (ADLs) and who was dependent on staff for such care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and administer medications and failed to have a system in place to identify, record, and report omitted medications as medication errors for 3 of 3 (R1, R2, R3) residents reviewed for medication errors.

Inspectors wroteBased on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 2 of 3 residents (R1, R2) reviewed for medical record accuracy.

Inspectors wroteBased on interview and document review, the facility failed to protect a resident's right to privacy during a routine skin observation/assessment, making a resident feel their personal privacy was violated for 1 of 1 resident (R2) reviewed for resident rights.

Inspectors wroteBased on interview and document review the facility failed to safely discharge 1 of 1 resident (R4), who was discharged from the facility without a source or a plan to obtain supplemental oxygen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure assessed and care-planned interventions for preventative skin care were consistently implemented; and failed to comprehensively reassess and, if needed, develop interventions after a change (i.e., increase) in pressure ulcer risk for 1 of 2 residents (R11) reviewed for pressure ulcer care. This resulted in actual harm for R11 who developed an avoidable stage III (i.e., full-thickness tissue loss) pressure injury on their heel.

Inspectors wroteBased on observation, interview, and document review, the facility failed to perform adequate testing to ensure proper sanitization of dishware used for meal preparation and meal service when using a low-temperature dishwashing machine. This had the protentional to affect all 48 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure potential constipation was identified and, if needed, comprehensively assessed for proactive bowel management interventions for 1 of 2 residents (R11); and failed to ensure an area of developed bruising was evaluated or monitored to promote healing and reduce the risk of complication (i.e., worsening) despite the application of a medical device for 1 of 1 resident (R32) observed to have dark-colored bruising on their hand.

Inspectors wroteBased on interview and document review, the facility failed to ensure as-needed (PRN) antipsychotic medications were limited to 14 days of use or re-evaluated by the medical provider to ensure necessity and reduce the risk of complication for 1 of 6 residents (R45) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 2 of 5 residents (R10, R37) reviewed for immunizations.

Inspectors wroteBased on observation, interviews and record review the facility failed to follow implementation of transmission-based precautions for 1 of 1 resident (R3) diagnosed with clostridium difficile colitis, (C. Diff.), an inflammation of the colon caused by bacteria, easily spread from person-to-person through infected spore and use appropriate hand hygiene for C.Diff. In addition, the facility failed to disinfect reusable medical equipment between use.