Edenbrook of St Cloud

In the surveyor’s words

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

• Immediate jeopardy, widespreadF886Dec 30, 2022

  Based on interview and document review, the facility failed to test all employees for COVID-19 during a facility outbreak status as directed by the Center for Disease Control (CDC). The facility failed to review employee testing logs, and as a result 12 staff members worked with residents during the outbreak without being tested every 3-7 days. Of those 12 staff that have worked with residents but not tested , 3 were not vaccinated and at higher risk of contracting COVID-19 when exposed. This deficient practice resulted in an immediate jeopardy (IJ) situation for all 66 residents residing in the facility during a COVID-19 outbreak. […]

• Immediate jeopardy, widespreadF886Oct 12, 2021

  Based on interview and document review, the facility failed to test staff for COVID-19 according to county transmission rate, and outbreak status as directed by the Center for Disease Control (CDC). The facility was in COVID-19 outbreak status since 9/17/21 which resulted in four staff (NA-D, NA-E, PT-A, DA-A) testing positive for COVID-19. Further, the facility failed to restrict 1 of 1 staff (DA-A) to return to work whom had COVID-19 symptoms 3 days earlier, pending the results of COVID-19 testing. This practice resulted in an immediate jeopardy (IJ) situation which had the likelihood to cause serious illness or death for all 67 residents residing in the facility. The immediate jeopardy began on 9/17/21, when the facility was notified a staff member tested positive for COVID-19. […]

• Immediate jeopardy, isolatedF689May 20, 2022

  Based on observation, interview and document review, the facility failed to identify possible elopement behaviors and develop interventions for 1 of 1 residents (R1) who was cognitively impaired, wandered and left the building without staff knowledge. This resulted in an Immediate Jeopardy (IJ). The IJ began on [DATE], when R1 left the building without staff knowledge and was found at the bottom of a steep hill, near a busy street. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 6:50 p.m. The immediate jeopardy was removed on [DATE], at 4:26 p.m. […]

• Immediate jeopardy, isolatedF689Mar 18, 2022

  Based on interview and document review the facility failed to ensure 1 of 1 resident (R1) was appropriately supervised and prohibited from keeping a cigarette lighter and smoking material in his room. R1 was smoking with oxygen on while in his room which resulted in [CONDITION(S)] to his face. The deficiency was identified as past non compliance and issued at Immediate Jeopardy (IJ). The IJ began on 3/8/22, at 4:25 p.m. when R1 received [CONDITION(S)] to his face while smoking and wearing oxygen. However, the facility immediately implemented corrective action to prevent reoccurrence by 3/15/22 before survey started. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on 3/17/22 at 5:25 p.m. as a result of corrective action taken by the facility. […]

• Immediate jeopardy, isolatedF689Jan 18, 2022

  Based on observation, interview, and document review, the facility failed to comprehensively develop appropriate interventions to ensure adequate supervision was provided to prevent known off-campus activities which increased the risk of harm and/or injury for 1 of 1 resident (R5) assessed and care planned to require supervision in the community and identified to repeatedly be leaving the nursing home to purchase and/or use alcohol and marijuana (an illegal psychoactive drug). These findings constituted an immediate jeopardy (IJ) situation for R5. The IJ began on 8/27/21, when R5 left the nursing home campus and was later found at a gas station intoxicated by the local police department. R5 demonstrated mumbled speech and was unable to safely operate his electric scooter. […]