Focused Care at Allenbrook

In the surveyor’s words

From the most serious findings on record at Focused Care at Allenbrook, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 4, 2025

  Based on observation, interview and record review, the facility failed to ensure the environment remained as free from accidents as possible and that each resident received adequate supervision and assistance to prevent accidents for 1 of 30 residents (Resident #2) reviewed for adequate supervision.The facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering from his previous facility and eloped from this facility in 1/7/25. He was found by a good Samaritan in his wheelchair across the street from the facility.This noncompliance was identified as Past Non-Compliance. The IJ began on 1/7/2025 and ended on 1/8/2025. […]

• Actual harm, patternF689Dec 14, 2023

  Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls for 1 (Resident #1) of six residents reviewed for accidents, hazards, and supervision. The facility interventions did not prevent 18 unwitnessed falls and 16 witnessed falls with multiple injuries and hospitalization . The facility failed to implement the physician order for a use of a helmet to prevent injuries from falls. Facility staff, the NP and the Rehab Director were unaware of this physician order. […]

• No harm, potential for more than minimal, widespreadF812Nov 2, 2023

  Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen: -The facility failed to ensure that the kitchen floors were clean and free of food particles. -The facility failed to ensure that food preparation equipment was clean and free of grease build up. -The facility failed to ensure food items in the refrigerator\freezer were dated, labeled, and appropriately sealed. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation on 10/31/23 from 9:15AM to 9:30AM, revealed the following: *the kitchen floor was dirty with food particles and grease around the cooking area and behind the stove. […]

• No harm, potential for more than minimal, widespreadF761Oct 8, 2021

  Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 ( B &C Hall Nurse Cart, A & B Medication Aide Cart and A & D Nurse Cart) medication carts reviewed for medication storage. […]

• No harm, potential for more than minimal, widespreadF812Apr 13, 2021

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: A pan of frozen chicken being thawed under running water with a temperature of 79 degrees Fahrenheit. This failure could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings included: Observation of the facility's kitchen and interview on 4/11/21 between 8:30 am and 8:40 am with Cook A revealed the following: Observation on 4/11/21 at 8:30 AM revealed that the chicken was inappropriately being thawed evidenced by the chicken had an internal temperature of 57 degrees Fahrenheit and… […]