Edenbrook of Rochester

In the surveyor’s words

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

• Immediate jeopardy, isolatedF803Jan 13, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Oct 11, 2022

  Based on interview and document review the facility failed to identify, monitor, and comprehensively assess a change in respiratory status for 1 of 3 residents (R1) reviewed for respiratory change in condition. This resulted in an immediate jeopardy when R1 demonstrated symptoms of respiratory distress, the facility failed to immediately assess, failed to immediately provide respiratory interventions, and failed to notify the physician which resulted in delay in treatment, hospitalization , and death. The IJ was identified on [DATE], and Administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE], at 12:05 p.m. […]

• Immediate jeopardy, isolatedF600Jun 23, 2021

  Based on interview and document review, the facility failed to follow the facility's abuse prevention policy and procedures when the facility failed to timely report allegation of abuse, immediately initiate an investigation including the protection of residents for 1 of 1 (R1) resident reviewed for an allegation of staff to resident abuse. This resulted in an immediate jeopardy (IJ) for R1 and had the potenial to affect all residents residing in the facility. The IJ began on 6/16/21, when R1 alleged a nursing assistant (NA) pushed her into bed that evening. The IJ was identified on 6/22/21, and the executive director of operations, clinical nurse consultant, and the director of operations were informed of the IJ on 6/22/21, at 12:15 p.m. The IJ was removed on 6/23/21, at 3:40 p.m. […]

• Actual harm, isolatedF684Jun 15, 2026

  Based 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.Findings include:R1's admission note dated on 6/3/26 at 6:53 p.m. written by licensed practical nurse (LPN)-B included, [AGE] year-old male admitted to facility following a hospitalization for a fractured left femur which became infected. Resident came in a wheelchair and was accompanied by his daughter and granddaughter. […]

• Actual harm, isolatedF684Jul 30, 2024

  Based 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. Findings include R5's Minimum Data Set (MDS) assessment dated [DATE], indicated R5 admitted to the facility on [DATE] from a hospital with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, and type 2 diabetes mellitus. The MDS indicated R5 had a major surgical procedure during her prior inpatient hospital stay that required active care during her stay at the facility and had surgical wounds. […]