Edenbrook Pine Haven

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 21, 2022

  Based on observation, interview and document review, the facility failed to complete comprehensive fall assessments with root cause analysis, identify patterns of falls, and failed to consistently implement immediate individualized appropriate interventions to prevent additional falls for 3 of 25 residents (R8, R5, R4), who were at high risk for falls. This deficient practice resulted in an immediate jeopardy (IJ) when R8 sustained a fractured neck and ultimate death, R5 who sustained degloving of the hand and a facial laceration requiring emergency room visit, and R4 who sustained a fall with a pelvic fracture. […]

• Immediate jeopardy, patternF806May 20, 2022

  Based on interview and document review, the facility failed to ensure staff were aware of resident food allergies for 1 of 3 residents (R3) reviewed for food allergies. R3 was served a Candy Bar Cheesecake dessert which contained chopped Reese's Peanut Butter Cup and Butterfingers candies causing an [MEDICATION(S)] reaction requiring Benadryl and an [MEDICATION(S)] at treatment at the facility, and R3 was sent to the emergency department (ED) for treatment. The deficient practice was identified as an immediate jeopardy (IJ). The IJ began on 5/18/22, at lunch time when R3 was served a lunch tray which included a Candy Bar Cheesecake dessert containing Reese's Peanut Butter Cup and Butterfingers candies. […]

• Immediate jeopardy, patternF600Jul 22, 2021

  Based on observation, interview, and document review the facility failed to ensure safety and protect residents from physical and verbal abuse, during resident to resident altercations. This resulted in an immediate jeopardy (IJ) when resident (R) 1 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The Immediate Jeopardy began on 6/5/21, when the facility failed to protect R2 and other residents after R1 aggressively yelled and swung at her. There was 8 other residents (R2, R3, R4, R5, R6, R7, R8, and R9) identified to have had known suffering by either physical abuse, verbal abuse, or physical aggression. The IJ was identified on 7/19/21. The administrator and director of nursing (DON) were notified on 7/19/21, at 5:12 p.m. The IJ was removed on 7/22/21, at 2:58 p.m. […]

• Immediate jeopardy, isolatedF689Jul 8, 2021

  Based on observation, interview, and document review, the facility failed to comprehensively assess each fall and identify casual factors to determine reason for falls, identify potential effective interventions to decrease the risk for falls, and failed to comprehensively evaluate the effectiveness of fall interventions for 2 of 3 residents (R1, R2) reviewed for accidents. R1 had history of falls with fractures and sustained another left ulnar fracture. These deficient practices resulted in immediate jeopardy (IJ) for R1. […]

• Actual harm, isolatedF689Jan 23, 2024

  Based on observation, interview and document review, the facility failed to ensure a transfer belt to assist with a safe transfers for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm for R1 who fell when being transferred without a transfer belt, which which resulted in a fall with a pelvic fracture and subdural hematoma (brain bleed) requiring hospitalization . This deficient practice is being cited at past non-compliance related to corrective action taken to ensure proper use of transfer belt prior to the survey. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition with diagnoses of stroke with left sided hemiplegia (paralysis on one side of body) and a history of falling. […]