Edenbrook South

In the surveyor’s words

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

• Actual harm, isolatedF600May 2, 2024

  Based on review of select facility policies, facility documentation, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free from neglect for one of five residents reviewed resulting in actual harm (Resident 1, East Hall Nursing Unit). This deficiency is cited as past noncompliance. Findings include: The current facility policy entitled Abuse, revealed that they identified neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• No harm, potential for more than minimal, widespreadF812Feb 11, 2026

  Based on observations and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen and store a resident's tube feed in a safe and sanitary location on one of four nursing units reviewed (North Hall Nursing Unit, Resident 11). Findings include: Initial tour of the facility's main kitchen with Employee 9, Dietary Director, on February 8, 2026, at 9:10 AM revealed the following: A hand-washing sink was starting to detach from the wall. A section of wall behind the dishwasher had flaking paint. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2025

  Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on January 21, 2025, at 8:58 AM with Employee 1, dietary director, revealed the following: Two large bulk clear plastic containers were observed on a lower shelf of a production table with a white substance in each container. One container was labeled as flour and the other sugar, but there was no date to indicate when the products were placed in the containers or when they needed used by. Several white potholders were observed sitting on top of the convection oven. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2024

  Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen and employee breakroom. Findings include: Observation of the facility's main kitchen on February 13, 2024, at 9:30 AM with Employee 1, food service director revealed the following: A large gray garbage can in the food preparation area across from the coolers was observed with visible dried food and dried liquid runs on the exterior of the lid and can, crumbs and debris were observed collected in the grooves of the handles. The coating of shelves in the coolers by the floor mixer was peeled/worn off in several locations exposing rust colored metal. […]

• No harm, potential for more than minimal, widespreadF812Feb 5, 2021

  Based on observation and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's main kitchen. Findings include: Initial tour of the facility's main kitchen on February 3, 2021, at 9:00 AM with Employee 3, dietary manager, revealed the following: In the dry storage area five plastic containers were located on top of a cart, which appeared to contain dry cereal. Three of the containers did not contain any label of what was in the container or a date the product needed to be used by. A bag labeled from the manufacturer as Rice Krispies was opened and there was no label to indicate when the bag was opened, but it was labeled by the manufacturer with a use by date of [DATE]. […]