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Deficiency Records for Edenbrook of Edina
A list of the most recent deficiencies for Edenbrook of Edina. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Edenbrook of Edina. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-05 | 2024-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-21 | 2024-07-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-21 | 2024-07-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-11 | 2024-06-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-11 | 2024-06-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-21 | 2024-04-12 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-03-21 | 2024-04-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-29 | 2024-02-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-29 | 2024-02-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-29 | 2024-02-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-12-29 | 2024-02-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-29 | 2024-02-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-29 | 2024-02-19 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-12-29 | 2024-02-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-29 | 2024-02-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-27 | 2024-02-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-06 | 2023-07-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-11 | 2023-04-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-11 | 2023-04-30 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-11 | 2023-04-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-11 | 2023-04-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-26 | 2023-02-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-07 | 2022-10-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-07 | 2022-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-14 | 2022-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-19 | 2022-06-30 | Y |
| Install resident room doors of proper design and width. | Fire Safety | 2022-05-04 | 2022-06-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-05 | 2022-06-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-05 | 2022-06-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-05-05 | 2022-06-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-05 | 2022-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-05 | 2022-06-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-10 | Y |
| Provide appropriate foot care. | Health | 2022-05-05 | 2022-06-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-05 | 2022-06-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-05 | 2022-06-10 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-05 | 2022-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-05 | 2022-06-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-05 | 2022-06-10 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2022-05-04 | 2022-06-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-14 | 2022-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-23 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-17 | 2022-03-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-17 | 2022-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-03-04 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-05 | 2022-01-28 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-01-05 | 2022-01-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-30 | 2022-01-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-30 | 2022-01-28 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-28 | 2021-12-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-26 | 2019-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-26 | 2019-10-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-26 | 2019-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-26 | 2019-09-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-26 | 2019-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-26 | 2019-09-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-07-26 | 2019-09-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-07-26 | 2019-09-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-07-26 | 2019-09-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-26 | 2019-09-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-07-26 | 2019-09-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-26 | 2019-09-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-26 | 2019-09-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-26 | 2019-09-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-26 | 2019-09-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-26 | 2019-09-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-26 | 2019-09-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-07-26 | 2019-09-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-26 | 2019-09-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-26 | 2019-09-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide or obtain dental services for each resident. | Health | 2019-07-26 | 2019-09-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-07-26 | 2019-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-26 | 2019-09-16 | N |
| Dispose of garbage and refuse properly. | Health | 2019-07-26 | 2019-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-26 | 2019-09-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-26 | 2019-09-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-26 | 2019-09-16 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-07-26 | 2019-09-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-07-26 | 2019-09-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-07-26 | 2019-09-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-23 | 2019-09-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-23 | 2019-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-23 | 2019-09-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-23 | 2019-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-23 | 2019-09-16 | N |
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