Edenbrook Omro

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 14, 2023

  Based on observation, staff and resident interview, and record review, the facility did not ensure necessary care and services were provided to prevent pressure injuries from developing or worsening and/or promote healing for 2 Residents (R) (R10 and R30) of 4 sampled residents. R10 was admitted to the facility following a fall that resulted in a right hip fracture. R10 was assessed to be at risk for the development of pressure injuries. Interventions to elevate and protect R10's heels were not initiated until R10 developed suspected deep tissue injuries (DTIs) (areas of soft tissue damage due to pressure or shear which are anticipated to evolve into a deep PI, but have not yet done so. […]

• No harm, potential for more than minimal, widespreadF725Sep 10, 2025

  Based on observation, resident and staff interview, the facility did not ensure staffing was sufficient to meet care needs of residents. This had the potential to affect all 37 residents. Schedules were compared with daily census as well as the Facility Assessment and there were days staffing did not meet the needs of the daily census.Interviewed residents and family members indicated they waited a long time for call lights and call lights were observed to be turned off prior to the resident need being met. Interviews revealed weekends were more challenging because there was no office staff to assist as needed.Interviewed staff which revealed that the facility has many 2 person assist transfers and high acuity residents which affects care needs being met as well as meal times. […]

• No harm, potential for more than minimal, widespreadF880Jun 14, 2023

  Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 36 residents residing in the facility. The facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2021

  Based on observation, staff interviews, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner which had the potential to affect all 37 residents residing at the facility. Dietary Manager (DM-G) did not perform hand hygiene between glove changes while serving [DATE] breakfast. DM-G had fingernail polish on both the right and left hands and had only one glove on while plating food and cooking eggs during the [DATE] breakfast service. The Activity refrigerator contained expired and improperly dated items and freezer temperatures were not logged daily. Findings: 1. […]

• No harm, potential for more than minimal, patternF761Oct 16, 2024

  Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was observed unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. On 10/16/24, the 100 wing medication cart was left unlocked and unattended during medication administration for 3 residents (R) (R6, R7, and R4). Findings include: The facility's Administering Medications policy, dated 1/2024, indicates: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .Procedure: .18. […]