Edenbrook Of Rochester

grievances after a determination was made by the facility.

This had the potential to affect all

five different residents vocalized concerns related to food.

They indicated it has been mentioned at each of the meetings.

The residents indicated they have not heard back from the facility staff or an rationale as to why no response.

During an interview on 2/10/26 at 4:51 p.m., the life enrichment director ([NAME]) stated food was a big grievance mentioned at resident council meetings.

There were a few other items brought up recently but could not remember what they were.

After the meeting, the grievances would be taken to the appropriate department to handle from that point. [NAME] indicated they would follow up with the departments prior to the next resident council meetings and if there was anything to bring forward they would be brought to resident council at that time. [NAME] indicated they have notes about everything talked about in resident council but have not inputted the information in the new form yet.On 2/10/26 at 4:51 p.m., a copy of the [NAME]'s resident council notes was requested although not received.Facility Resident Council Meeting Minutes for 10/25 through 1/26 were reviewed, the following grievances were reported:- on 12/17/25, grievances related to can foods used to often and artificial sweeteners used was filed.No other grievances were filled out from resident council meetings.The minutes lacked documented responses and rationales of the concerns resident council brought forward.

During an interview on 2/10/26 at 5:11 p.m., the administrator stated the resident council staff spokesperson, who was [NAME], would bring all grievances to the appropriate departments to handle.

The facility would deal with grievances on a more personal level, instead of taking them back to the resident council.During a follow up interview on 2/10/26 at 5: 22 p.m., the administrator stated the [NAME]'s notes had been reviewed and lacked any proof follow-through with the resident council members had occurred related to grievances and complaints filed in resident council.

245409 02/12/2026

Edenbrook of Rochester 1875 19th Street Northwest Rochester, MN 55901

During an interview on 2/11/26 at 11:00 a.m., director of nursing (DON) stated she was not aware of the hole in R1's wall with cable protruding.

The DON stated this could be a safety issue and should be fixed.

During an interview on 2/11/26 at 2:33 p.m., maintenance (M)-A stated he was aware the cable in R1's room was protruding out of the wall. On 1/6/26 at 12:44 p.m. a maintenance request was submitted to fix the cable in R1's room. He stated after the cable ends were replaced, the faceplate was not reattached.

The maintenance report had been marked as completed on 1/7/26 at 7:18 a.m. M-A stated the maintenance report should not have been marked completed until the face plate had been replaced. He understood why the hole in the wall might bother R1. M-A stated it is important to replace lost or missing items so that residents have a homey feel to their surroundings.

During an interview on 2/11/26 at 2:39 p.m., administrator stated when residents let facility staff know about a building concern, this should be fixed as soon as possible.

The administrator stated he was not aware of the hole in the wall, and this could be fixed as soon as possible.

The administrator stated it is important for residents to feel like this is their home.Cigarette ButtsDuring interview on 2/10/26 at 09:16 a.m., family member (FM)-A stated she does not like to enter the facility through the back door. FM-A stated the back entrance area was littered with dirty, old cigarette butts. FM-A stated she was disgusted by the facility for not removing the cigarette butts.During observation on 2/10/26 at 9:48 a.m., the facility's back entrance was littered with dozens of cigarette butts.During observation and interview on 2/10/26 at 10:58 a.m., the administrator confirmed the cigarette butts lined the facility wall at the facility's back entrance.

Further, cigarette butts lined the driveway extending towards the designated smoking area.

Additionally, cigarette butts were found in the garden planter next to the designated smoking area.

The administrator acknowledged the discarded cigarette butts were unpleasing to the eye. A facility policy titled Preventative Maintenance dated 4/6/23, routine facility inspections promote safety.A facility policy titled Preventative Maintenance dated 4/6/23, maintenance includes part replacements that is performed specifically to prevent faults from occurring.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

245409 02/12/2026

Edenbrook of Rochester 1875 19th Street Northwest Rochester, MN 55901

for 1 of 1 resident (R11) reviewed for accuracy of assessments.

Findings include:R11's quarterly MDS

Parkinson's disease. R11 received Invasive Mechanical Ventilator (must have a tube or other item placed in the airway and connected to a ventilator machine to assist breathing).R11's care plan dated 2/28/25, indicated R11 used a continuous positive airway pressure (CPAP) machine at night.

The CPAP machine has a mask that fits over the mouth to assist in keeping the airway open when sleeping.

During an interview on 2/10/26 at 2:26 p.m., the MDS coordinator (MDSC) reviewed R11's MDS report from 11/19/25 and confirmed an invasive mechanical ventilator was marked in error and should be for a CPAP which was noninvasive mechanical ventilation.

During an interview on 1/29/26 at 2:33 p.m., the director of nursing (DON) stated MDS accuracy was important as it is part of their payment.

245409 02/12/2026

Edenbrook of Rochester 1875 19th Street Northwest Rochester, MN 55901

time of completion or at the end of shift. It can be difficult to adjust cardiac medications when she is

entry when they chart at end of shift.

Accurate daily weights are another charting issue she struggles

them as collected after their shift ends in the afternoon.

Ultimately, the NP expected the charted time to be the time the task was completed, not the end of shift charting time.

During an interview on 2/12/26 at 10:37 a.m., the administrator confirmed accurate charting was an issue the facility knows about.

Administrator confirmed the charting should reflect the actual time of completion not the time of charting at the end of the shift.A facility policy titled Charting and Documentation dated 11/13/24, a treatment administration record shall be maintained which records the resident care procedures and/or treatments ordered by the physician that is performed and by whom the procedure/treatment was performed.

245409 02/12/2026

Edenbrook of Rochester 1875 19th Street Northwest Rochester, MN 55901

During an interview on 2/11/26 at 8:33 a.m., C-A confirmed she had assisted R24 with the meal on 2/9/26 and 2/11/26. C-A stated she was not a nurse assistant in the state of Minnesota.

During an interview on 2/11/26 at 8:40 a.m., the culinary director (CD) confirmed C-A was a cook in the facility.

The CD stated the facility did not use any paid feeding assistants and was sure the only people allowed to assist with feeding residents were nursing staff or people trained to feed the residents.

During an interview on 2/12/26 at 9:18 a.m., the director of nursing (DON) stated the only staff that should feed residents are the clinical staff or somebody trained to assist with meals dietary staff should not assist residents with their meals.

245409 02/12/2026

Edenbrook of Rochester 1875 19th Street Northwest Rochester, MN 55901

During observation on 2/10/26 at 9:48 a.m., R31's coat had two burn holes on the right forearm. R31 stated the burn holes happened right after she got her new coat a couple months ago. R31 stated she was right-handed and was having difficulty lighting her cigarette with her left hand because she didn't have much movement in her right hand due to the contracture.

R31 stated she was upset about the burn holes because her jacket was brand new and it already had holes in it. R31 stated other than the two burns holes, she feels mostly safe smoking outside alone.

During an interview on 2/10/26 at 10:39 a.m., nurse manager (NM)-B stated the process to complete a smoking assessment included reviewing the facility smoking process, staff assessed resident ability to go out to smoke independently and safely, provide smoking education, and provide safety equipment if needed (apron, blanket, etc.). NM-B stated R31 did not have any smoking safety equipment. NM-B stated if staff observed burn holes in the clothing; they would assess the resident for wounds and conduct another smoking assessment to ensure resident was safe to continue smoking independently. NM-B stated she was not aware of burn holes in R31's jacket.

During an interview on 2/10/26 at 10:47 a.m., director of nursing (DON) stated the process to assess a resident for safety while smoking included review facility smoking policy, smoking education, and conduct a smoking assessment by observing the resident from start to finish of smoking independently. DON stated smoking assessments were completed quarterly and if/when the staff felt the resident was no longer safe to smoke independently. DON stated residents need to be free of burn holes in clothing, extinguish cigarettes appropriately, understand smoking policy and education, and be able to smoke outside independently. DON stated she was not aware R31 had burn holes in her jacket; staff don't routinely check clothing for clothing burns. DON stated a resident with burns in clothing should be reassessed immediately for safety to independently smoke. A facility policy titled Smoking and E-Cigarettes dated 3/1/21, the facility will complete a smoking assessment upon admission, quarterly, or with a change in condition.

245409 02/12/2026

Edenbrook of Rochester 1875 19th Street Northwest Rochester, MN 55901

During observation on 2/10/26 at 1:21 p.m., licensed practical nurse (LPN)-A exited R52's room without proper personal protective equipment (PPE). LPN-A stated he didn't think R52 needed enhanced barrier precautions (EBP) because her room did not have an EBP sign and did not have the isolation equipment hanging on the door. He confirmed R52 had a dialysis line but didn't think her dialysis port needed EBP.

During observation and interview on 2/11/26 at 11:13 a.m., director of nursing (DON) confirmed R52 had a dialysis catheter and should have an EBP sign with isolation equipment hanging on her door.

Upon inspection, the DON confirmed R52 did not have an EBP sign or isolation equipment hanging on her door.

The DON stated the importance of EBP was to protect the residents from infection.

A facility policy titled Enhance Barrier Precautions dated 3/26/24, residents with indwelling medical devices required EBP to prevent infection or colonization from a multi-drug resistant organisms.

Facility policy Foley Catheter Management last revised on 1/28/25, indicated correct positioning of the catheter would be maintained.