Edenbrook Rochester West

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet resident needs for 2 of 3 residents (R3 and R2), resulting in a pattern of delayed toileting assistance and care needs.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure physician orders were in place to provide treatment and monitoring for an ostomy (ileostomy) (opening to allow waste to exit the body and be collected in a pouch) for 1 of 1 resident (R5) reviewed for ostomy care. The facilities failure resulted in harm for R5 who continued to exhibit symptoms of redness, severe pain, excoriation (abrasion, breakdown) and infection requiring two courses of antibiotics.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure direct-care nursing staff were appropriately trained and competent in the assessment and care of ostomies for 1 of 1 (R5) resident reviewed for ostomy care.

Inspectors wroteBased on interview and document review the facility failed to ensure all staff working in the dietary department had training on use of equipment, safe temperatures to ensure food safety and sanitation processes. This had the potential to affect all 29 residents in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure infection control practices were maintained by wearing a hair net and beard cover while in the kitchen. Additionally, the facility failed to ensure a commercial dishwasher was adequately monitored (i.e., every shift). Last, the facility failed to ensure food stored in the refrigerators and freezers were labeled, dated and discarded properly. These deficient practices had the potential to affect all 29 residents, staff and visitors who received food from facility kitchen. During the initial kitchen tour on 11/17/25 at 10:58 a.m., dietary (D)-C greeted surveyor inside the kitchen; after introductions D-C exited the kitchen with surveyor and applied a hairnet, returning to stove side to finish cooking lunch vegetables. D-C stated he should have put his hairnet on before coming into the kitchen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate information was communicated to the receiving facility, and obtain provider orders prior to discharge for 1 of 1 residents (R37) reviewed for discharge.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and initiate a plan of care for 1 of 1 (R5) resident who was reviewed for ostomy care.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide professional standards of practice when staff completed treatments and later entered orders in the medical administration record without verification from a physician for 1 of 1 resident (R5) reviewed for ostomy cares.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident had physician orders for the care and treatment for 1 of 1 (R5) resident reviewed for ostomy care.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 1 of 5 residents (R5) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure respiratory equipment was properly maintained for 2 of 2 residents (R27 and R2) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the nurse staffing data sheet was posted in a place readily accessible to residents, families, and visitors. This had the potential to affect all 29 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to identify, assess, monitor, and follow physicians' orders for signs and symptoms of hypoglycemia (low blood sugar) for 1 of 3 residents (R1) who had diagnosis of diabetes. This resulted in an immediate jeopardy (IJ) situation for R1 who had continuous low blood sugars without treatment that resulted in hospitalization with hypoglycemia. The IJ began on 8/29/25 at 4:00 p.m., when interventions were not implemented to prevent hypoglycemia. The facility did not notify the provider and R1's blood sugars continued to drop until he was sent to the ED on 8/30/25 at 1:20 a.m. The administrator, director of nursing (DON), assistant director of nursing ADON), regional nurse consultant (RNC), activity director (D), health unit coordinator (HUC), and licensed social worker (LSW) were notified of the IJ on 9/4/25 at 5:14 p.m. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure food preferences were comprehensively assessed, a physician ordered nutritional supplement was available for administration and further failed to obtain physician ordered daily weights for 1 of 3 residents (R1) with impaired nutrition to help maintain adequate nutritional status that was consistent with the residents nutritional assessment, reviewed for weight loss.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure food temperatures were monitored consistently prior to serving to prevent risk of food born illness. The facility further failed to maintain a clean refrigerator and freezer for food storage. This had the potential to affect all 28 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess for broken/missing teeth and difficulty chewing for 1 of 1 (R24) resident.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure an insulin FlexPen was appropriately primed prior to insulin administration for 1 of 2 residents (R14) who received sliding scale (SS) insulin.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure utilization of proper personal protective equipment (PPE) with cares for 1 of 2 residents (R8) evaluated for enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview and document review the facility failed to ensure waking times were honored for 1 of 1 residents (R2) for choices.

Inspectors wroteBased on observation, interview and document review the facility failed to complete a comprehensive assessment for food preferences for 1 of 1 residents (R2) who preferred foods consistent with R2's culture.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) was appropriately managed based on professional standards of practice and in accordance with physician orders for 1 of 1 resident (R2) reviewed for intravenous (IV) medications.

Inspectors wroteBased on observation, interview and document review the facility failed to accurately transcribe and administer an intravenous (IV) antibiotic, cefazolin (an antibiotic to treat moderate to severe bacterial infections) for seven days and omitted four doses of an injectable medication, Retacrit (an injectable medication used to treat anemia due to chronic kidney disease to decrease the need for a blood transfusion) per provider orders for 1 of 3 residents (R2) reviewed for medication administration.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed Quarter 3, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on interview and document review, the facility failed to have a comprehensive infection control surveillance program to include tracking resident illnesses through to resolution and identify when employees would be able to return to work after illness, dependent upon their symptoms. The facility further failed to ensure 1 of 1 discontinued hydrocollator was drained and maintained in a sanitary manner to prevent mold-like buildup and prohibit a potential Legionella source of infection and failed to ensure staff had not stored personal items in 1 of 1 occupational therapy (OT) refridgerator and 1 of 1 family room fridge was maintained in a clean and sanitary manner, and staff food was not stored within. Additionally, the facility failed to ensure 2 of 2 mechanical stand lifts were maintained in a clean manner with washable surfaces. This had the ability to affect all 34 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 hall (200 wing) multi-resident bathroom ceiling, 1 of 1 dining room tiles and ceiling, 1 of 1 wing (200 wing) shower tile, 1 of 1 resident (R1) room wall, 4 of 4 hallway walls which were scuffed had been painted, 2 of 2 mechanical stand-lifts were maintained to have cleanable surfaces, and 1 of 1 entryway tiles was maintained to promote a safe, sanitary, and homelike environment.

Inspectors wroteBased on observation, interview and document review, the facility failed to to ensure 1 of 2 shower room wall ties were repaired to prevent potential injury for 14 of 34 residents (R1, R4, R5, R9, R10, R12, R15, R17, R19, R22, R24, R29, R334, and R335) who resided on the 200 wing and used that shower.

Inspectors wroteR185's 10/18/23, admission, Minimum Data Set (MDS) assessment identified R185's cognition was moderately impaired, he had diagnosis of irregular heartbeat, recent stroke, heart failure, and weakness. R185 required staff assistance with toileting, dressing and bed mobility, and transfers. Review of R185's diagnosis list identified additional diagnosis of muscle weakness, lack of coordination, unsteady gait, chronic respiratory failure with low oxygen levels, poor vision. Interview on 10/30/23 at 2:19 p.m., with R185 identified staff do not wash me up or brush my teeth in the morning or at bedtime unless he requests them to. Interview on 10/31/23 at 2:30 p.m., family member (FM)-A reported R185 told her staff do not assist him with personal hygiene. [...]

Inspectors wroteBased on observation, interview, and document review, facility failed to ensure 5 of 5 sampled nurse aids (NA-A, NA-B, NA-C, NA-D, and NA-E) were deemed competent upon hire or yearly thereafter to provide care to residents.

Inspectors wroteBased on observation, and interview, the facility failed to have a method in place for timely removal of discarded medications in 3 of 3 medication containers from the facility.

Inspectors wroteBased on interview and document review, the facility failed to complete a thorough investigation to identify potential diversion for 1 of 1 resident (R134) whose Fentanyl narcotic pain patch was missing.

Inspectors wroteBased on interview and record review, the facility failed to appropriately discharge 1 of 1 resident (R136) with known dementia with behaviors. The facility also failed to ensure policies related to discharge and transfers were reviewed yearly for appropriateness and accuracy.

Inspectors wroteBased on interview and document review the facility failed to ensure a level II Pre-admission Screening and Resident Review (PASARR) was completed for 1 of 1 resident who was admitted with a diagnosis of Schizoaffective disorder.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed in a timely manner for 1 of 2 residents (R26) reviewed for respiratory care.

Inspectors wroteBased on interview and document review, the facility failed to individualize the care plan to include target behaviors for psychotropic medication use for 1 of 1 (R12) resident. Additionally, the facility failed to have appropriate diagnoses for antipsychotic medication for 2 of 2 (R23 and R185) residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide an ordered therapeutic diet for 1 of 1 resident (R138) reviewed for provision of therapeutic diets.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 (R8, R12) resident were appropriately vaccinated against pneumococcal disease upon admission and/or offered updated vaccination per Centers for Disease Control (CDC) vaccination recommendations.

Inspectors wroteBased on observation, interview, and document review the facility failed to administer the right prescribed medications to right residents for 1 of 3 residents (R1). R1 had developed hypotension (low blood pressure) and bradycardia (low heart rate) that required emergency medical treatment and admitted to the hospital ICU (intensive care unit) to stabilize R1's condition which resulted in an immediate jeopardy (IJ). The immediate jeopardy (IJ) began on 10/9/23, when registered nurse (RN)-A failed to identity R1 prior to the administration of prescribed medications. The director of nursing (DON) and vice president of success (VPOS) were notified of the IJ on 10/24/23, at 6:30 p.m. The facility immediately implemented corrective action on 10/9/23, the deficient practice was corrected on 10/9/23, prior to the start of the survey and was therefore issued at Past Noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper hand hygiene was performed during a medication pass between 2 of 6 residents (R3 and R4) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess and determine safety for self-administration of medications (SAM) for 2 of 6 residents (R3 and R4) reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure insulin was administered in accordance with manufacturer recommendations for 1 of 1 resident (R4) reviewed for insulin administration.