Edenbrook on Second Ave

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 6, 2023

  Based on a review of clinical records and select incident reports and staff and resident interviews it was determined that the facility failed to provide necessary staff assistance and assistance devices as planned for performing resident transfers resulting in a fractured arm for one resident (Resident 7) and failed to ensure safe technique was used during transfers causing a fractured finger for one resident (Resident 49) out of three sampled residents. Findings include: A review of the clinical record revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses, which included diabetes, chronic kidney disease, and fracture of the upper end of the right humerus. […]

• Actual harm, isolatedF689Mar 10, 2023

  Based on a review of clinical records and facility investigation reports and staff interview, it was determined that the facility failed to implement necessary individualized safety measures and staff supervision of resident identified with poor safety awareness and a history of falls to prevent a fall with serious injury, a hip fracture, for one of 29 sampled residents (Resident 76). Findings include: Clinical record review revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses to include dementia and a history of falls. […]

• Actual harm, isolatedF600Dec 21, 2021

  Based on a review the facility's abuse prohibition policy, clinical records and select facility investigative reports and staff interviews it was determined that the facility failed to ensure that one resident out of 18 sampled was free from sexual abuse, which caused severe bruising, pain and emotional upset (Resident 2). Findings include: Review of the facility's abuse policy dated as reviewed June 2021, indicated that the purpose of the document was to keep residents free from abuse, neglect and corporal punishment of any kind by any purpose. The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property and exploitation. […]

• Actual harm, isolatedF684Sep 8, 2021

  Based on review of clinical records and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses timely and consistently evaluated the resident's condition and provided necessary care for one resident out of eight residents reviewed (Resident CR1) displaying a change, and continued decline, in condition, delaying the resident's transfer to the hospital, and subsequent admission to the intensive care unit and below the knee amputation, which compromised the resident's clinical condition and ability to maintain and/or reach his highest practicable physical well-being and delayed the provision of necessary care and treatment to prevent further decline in physical… […]

• Actual harm, isolatedF684Aug 17, 2021

  Based on a review of clinical records and staff interview it was determined that the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the physician ordered bowel protocol indicated that both Residents A1 and A2, were prescribed Milk of Magnesia Suspension 1200 MG/15 ML ([MEDICATION(S)], a [MEDICATION(S)]) Give 1 Tbsp by mouth as needed for constipation on second shift of day 3 no BM, [MEDICATION(S)] Suppository 10 MG, Insert 1 suppository rectally as needed for constipation given on 1st shift of day 4 no BM and Fleet Enema Enema 7-19 GM/118 ML ([MEDICATION(S)]), Insert 1 application rectally as needed for constipation give on 1st shift on day 5 of no BM. […]