Edenbrook Omro

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R1) of 4 sampled residents. R1 was on enhanced barrier precautions (EBP) due to a suprapubic catheter. On 4/1/26, staff did not wear gowns while providing personal care for R1.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a fall intervention was in place and post-falls assessments were accurately completed for 3 residents (R) (R1, R2, and R3) of 3 sampled residents. R1 had multiple falls since admission. R1's care plan contained an intervention for 2 body pillows when in bed. The intervention was not consistently implemented. In addition, R1's post fall assessments were not completed per policy. R2 had a fall on 10/1/25. R2's post fall assessments were not completed per policy. R3 had a fall on 10/5/25. R3's post fall assessments were not completed per policy.

Inspectors wroteBased on observation, resident and staff interview, the facility did not ensure staffing was sufficient to meet care needs of residents. This had the potential to affect all 37 residents. Schedules were compared with daily census as well as the Facility Assessment and there were days staffing did not meet the needs of the daily census. Interviewed residents and family members indicated they waited a long time for call lights and call lights were observed to be turned off prior to the resident need being met. Interviews revealed weekends were more challenging because there was no office staff to assist as needed. Interviewed staff which revealed that the facility has many 2 person assist transfers and high acuity residents which affects care needs being met as well as meal times. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) document was accurate for 1 resident (R) (R1) of 14 sampled residents. R1's POAHC document was not in accordance with R1's wishes. The facility did not review the document with R1 to ensure accuracy.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure assistance for activities of daily living (ADLs) was provided in a timely and consistent manner for 2 residents (R) (R3 and R1) of 3 sampled residents. R3's plan of care indicated R3 should receive a weekly shower on the Thursday PM shift. R1's plan of care was not consistently followed. R1's plan of care indicated R1 should receive 2 full bed baths weekly. R1's plan of care was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was observed unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 10/16/24, the 100 wing medication cart was left unlocked and unattended during medication administration for 3 residents (R) (R6, R7, and R4).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 6 residents (R) (R6, R8, R9, R10, R11, and R4) of 12 sampled residents observed during medication administration. On 10/16/24, Licensed Practical Nurse (LPN)-D did not complete hand hygiene during medication administration for R6, R8, R9, and R10. On 10/16/24, Registered Nurse (RN)-E did not sanitize the blood pressure cuff between use for R11 and R4.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 3 residents (R) (R6, R7, and R4) of 12 sampled residents were assessed as able to safely and accurately self-administer medication. On 10/16/24, Surveyor observed Licensed Practical Nurse (LPN)-D leave a cup with medication on R6's bedside table. R6 did not have a physician's order or an assessment that indicated R6 could self-administer medication. On 10/6/24, Surveyor observed Registered Nurse (RN)-E leave a cup with medication on R7's table for R7 to self-administer. R7 did not have a physician's order or an assessment that indicated R7 could self-administer medication. On 10/16/24, Surveyor observed RN-E leave cups with medication R4's table for R4 to self-administer. R4 did not have a physician's order or an assessment that indicated R4 could self-administer medication.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R3) of 4 sampled residents had a call light within reach. On 10/16/24, R3 was observed in R3's room without a call light within reach.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure an allergy was conveyed prior to a medication order for 1 resident (R) (R1) of 12 sampled residents. R1 had an allergy to Zofran which was documented in R1's hospital discharge summary and the facility's admission orders. R1 was administered Zofran on 9/6/24 and 9/7/24.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R9 and R434) of 4 sampled residents received the necessary care and services to prevent and/or monitor weight loss. R9 had an order to be weighed 3 times per week. R9's weights were not completed in accordance with the physician's order. In addition, R9 experienced a significant weight loss of 14.29% from 3/22/24 to 7/2/24. R434 was admitted to the facility on [DATE] and had an order for weights to be completed for the first 7 days after admission and one time a day every Monday, Wednesday, and Friday. R434's weights were not completed in accordance with the physician's order. Findings Include: The facility's Resident Height and Weight policy, with a revision date 7/7/23, indicates: [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene for 1 resident (R) (R2) of 3 residents observed during the provision of care. Registered Nurse (RN)-C did not perform appropriate hand hygiene during care for R2 on 7/22/24.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure necessary care and services were provided to prevent pressure injuries from developing or worsening and/or promote healing for 2 Residents (R) (R10 and R30) of 4 sampled residents. R10 was admitted to the facility following a fall that resulted in a right hip fracture. R10 was assessed to be at risk for the development of pressure injuries. Interventions to elevate and protect R10's heels were not initiated until R10 developed suspected deep tissue injuries (DTIs) (areas of soft tissue damage due to pressure or shear which are anticipated to evolve into a deep PI, but have not yet done so. The affected skin is discolored purple or maroon, may be painful, firm, mushy, boggy, and warmer or cooler than adjacent skin. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 36 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella - Identify acceptable ranges of control limits and corrective actions when control limits are not met

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified of a change in weight for 1 Resident (R) (R30) of 2 residents reviewed for nutrition. R30's weight decreased 7.5 pounds from 5/31/23 through 6/9/23. R30 lost 5.34% of R30's body weight in a nine-day period. R30's physician was not notified of the weight loss.

Inspectors wroteBased on staff interview and record review, the facility did not provide care and services to maintain acceptable parameters of nutritional status for 1 Resident (R) (R30) of 2 residents reviewed for nutrition. R30's weight decreased 7.5 pounds from 5/31/23 through 6/9/23. R30 lost 5.34 % of R30's body weight in a nine-day period. R30's nutrition plan was not revised to add supplements after R30 lost weight and developed a pressure injury.

Inspectors wroteBased on staff interview and record review, the facility did not ensure pharmacy recommendations were addressed by a physician for 2 Residents (R) (R3 and R6) of 5 residents reviewed. Two out of three pharmacy recommendations for R3 did not contain a response from R3's physician. Two out of six pharmacy recommendations for R6 did not contain a response from R6's physician.