Edenbrook of Edina

In the surveyor’s words

From the most serious findings on record at Edenbrook of Edina, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 9, 2026

  Based 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. […]

• Actual harm, isolatedF686Jan 26, 2023

  Based on interview and document review, the facility failed to effectively monitor and report skin condition changes for 1 of 3 residents (R3) reviewed for pressure ulcers. R1 developed an avoidable stage 2 pressure ulcer (defined as skin breaking open, wears away, or forms an ulcer) and deep tendon injury (defined as purple or maroon localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Findings include: R3's undated face sheet identified current diagnoses as acute or chronic congestive heart failure, chronic kidney disease (stage 4), anemia, shortness of breath, weakness, spinal stenosis, acute pericarditis, pleural effusion, chronic embolism and thrombosis of unspecified vein, thrombocytopenia, prosthetic heart valve,… […]

• No harm, potential for more than minimal, widespreadF867Jan 9, 2026

  Based 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. Findings include:Based on review of facility records, Quality Review minutes, QAPI documentation, incident reports, and staff interviews, the facility failed to implement its QAPI program in accordance with its written plan, including failure to identify falls as a high-risk and problem-prone area, failure to initiate and sustain Performance Improvement Projects, failure to conduct comprehensive root cause analysis, and failure to… […]

• No harm, potential for more than minimal, widespreadF761Jun 6, 2023

  Based on observation and interview the facility failed to store medications at proper temperatures and other appropriate environmental controls to preserve their integrity for 2 of 2 medication refrigerators when the refrigerator door was left open for an unknown amount of time. During an observation on [DATE], at 9:32 a.m. a refrigerator door was open in a locked medication room on the second floor with several medications visible both in the door of the refrigerator and inside. The refrigerator is small and there is a noted freezer section in the upper right side that is overgrown with ice and frost, a thermostat is inside however unreadable through the window. During an interview with LPN-A on [DATE], at 9:37 a.m. […]

• No harm, potential for more than minimal, widespreadF812May 5, 2022

  Based on observation, interview, and document review, the facility failed to have a method to consistently monitor dish machine temperatures to ensure proper sanitation of dishware. In addition, the facility failed to date opened containers of food stored in the kitchen refrigerator. These practices had the potential for food-borne illness and could affect 62 of 62 residents who utilized facility supplied dishware and/or received meals prepared and served by the facility. Findings include: TEMPERATURE MONITORING On 5/3/22, at 10:16 a.m. the Dishmachine Temperature Log (high temp machine) dated 4/22, contained dish machine temperature documentation for 42 of 93 (43.8%) opportunities. […]