Edenbrook at Hampton

Inspectors wroteBased on clinical record review and interviews with the resident, resident representative, and facility staff, it was determined the facility failed to honor the resident's preferences and failed to provide written notice, including the reason for the room change, prior to a facility-initiated room change for one of 22 residents reviewed (Resident 17).

Inspectors wroteBased on clinical record review, review of facility policy, and staff interview, it was determined the facility failed to establish mechanisms for documenting and communicating a resident's refusal of ordered laboratory monitoring to the interdisciplinary team (group of professionals from two or more disciplines who collaborate to plan and evaluate care) and failed to ensure staff followed facility policy regarding refusal of treatment for one of 22 residents reviewed (Resident 12).

Inspectors wroteBased on clinical record review, review of facility policies, and staff interview, it was determined the facility failed to ensure nursing services were provided in accordance with professional standards of quality, in accordance with Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure that only qualified staff performed and documented the administration of intravenous therapy via a central venous catheter and failed to ensure accurate and consistent documentation of medication administration for one of 22 residents reviewed (Resident 86).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses accurately administered prescribed medication according to physician-ordered parameters for one of 22 residents reviewed. (Resident 9)

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure physician orders were followed for one resident (Resident 7) out of 22 residents reviewed.

Inspectors wroteBased on review of facility policies, clinical records, observations, and staff interviews, it was determined the facility failed to ensure the ready availability of necessary emergency dialysis supplies for one of three residents reviewed who received hemodialysis (Resident 11).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 22 residents reviewed (Resident 3).

Inspectors wroteBased on review of clinical records, select facility policy, and staff interview, it was determined the facility failed to ensure the timely acquisition and availability of prescribed medications for one of five residents reviewed for unnecessary medications (Resident 29).

Inspectors wroteBased on observations, review of clinical records, select facility policy, and interviews with resident, family and staff, it was determined the facility failed to establish and maintain an effective infection prevention and control program by failing to implement Transmission-Based Precautions in accordance with facility policy to reduce the potential spread of infection for one resident of 22 residents reviewed (Resident 86).

Inspectors wroteBased on a review of clinical records, facility policies, internal investigative documentation, and resident and staff interviews, it was determined the facility failed to ensure that two residents (Residents 27 and 31) out of a sample of 21 residents were free from abuse from a resident with a known history of physical aggression (Resident 82). Findings including: A review of the current facility policy entitled Policy and Procedure Vulnerable Adult Abuse and Prevention, last reviewed by the facility March 1, 2025, revealed it was the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation and to enhance the life of all residents through strong programming and appropriate care and treatment. There is a zero tolerance for abuse or harm of any type. [...]

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 21 sampled (Resident 31).

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of two medication carts observed (C Hall).

Inspectors wroteBased on review of Resident Council Meeting minutes and maintenance work orders, observation, and resident and staff interviews, it was determined the facility failed to ensure all residents had access to a resident-only telephone for one of 20 residents sampled (Resident 1) and failed to provide privacy for residents when having telephone calls on three out of three clinical nursing units.

Inspectors wroteBased on observations, a review of clinical records, review of facility grievances, Resident Council Meeting minutes, and resident and staff interviews, it was determined the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced the facility's inability to appropriately manage and supervise the wandering and aggressive behaviors of two residents (Residents 4 and 20) out of 20 sampled.

Inspectors wroteBased on review of facility policy, observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of four of 20 residents sampled (Resident 12, 47, 86, and 46).

Inspectors wroteBased on observations, a review of facility pest service records and staff interview, it was determined the facility failed to maintain an effective pest control program throughout multiple areas of the facility.

Inspectors wroteBased on observation, and staff interviews it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to develop person-centered care plans that include individual medication therapy for one resident out of 20 sampled (Resident 12).

Inspectors wroteBased on a review of clinical records, and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure physician ordered medication, an antibiotic, and additive were timely obtained and administered to treat a urinary tract infection for one resident (Resident 93) out of 20 sampled residents.

Inspectors wroteBased on review of select facility policy, clinical records, and staff interview, it was determined the facility failed to implement individualized approaches for inontinence to provide maintenance care to the extent possible for one out of 20 sampled residents (Resident 25).

Inspectors wroteBased on a review of clinical records and select facility policies and staff interview, it was determined the facility failed to consistently and accurately monitor resident weights to timely identify changes in nutritional parameters for two of 20 sampled residents (Residents 40 and 91).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 20 residents reviewed (Resident 86).

Inspectors wroteBased on review of written facility initiated transfer notices and staff interview it was determined the facility failed to provide sufficiently detailed written notices of facility initiated transfers to the hospital to the resident and the residents' representative for seven out of 20 residents reviewed (Resident 32, 87, 91, 46, 66, 31, and 40).

Inspectors wroteBased on observation and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, and orderly environment in one of the three resident units (C Hall).

Inspectors wroteBased on a review of clinical records, and resident staff interview it was determined that the facility failed to ensure that residents dependent on staff for assistance with activities of daily living consistently were provided showers as planned to maintain good personal hygiene for five of 10 residents sampled (Resident B1, B2, B3, B4, and B5).

Inspectors wroteBased on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that one resident out of 15 sampled was free from verbal and mental abuse (Resident A1).

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy, facility investigation reports, and resident and staff interviews, it was determined the facility failed to timely report the witnessed abuse of one resident out of 15 sampled (Resident A1) to the State Survey Agency.

Inspectors wroteBased on a review of clinical records, select facility incident reports and the facility's abuse prohibition policy and resident and staff interviews, it was determined that the facility failed to timely and thoroughly investigate an injury of unknown source to rule out abuse, neglect or mistreatment for one of 15 residents sampled (Resident CR1) and failed to promptly conduct a thorough investigation into the witnessed abuse perpetrated by Employee 3, and failed to protect residents from the potential for further abuse during the course of the investigation into the abuse of one resident (Resident A1) out of the 15 sampled residents.

Inspectors wroteBased on a review of clinical records and select reports and resident and staff interviews it was determined that the facility failed to provide therapeutic social services to a resident following an incident of verbal and mental abuse perpetrated by staff for one resident out of 15 sampled (Resident A1).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that essential resident care equipment, a sit-to-stand lift, was in safe operating condition. Findings Include: Observation of the second floor B wing residents lounge area on July 2, 2024, at 10:35 AM, in the presence of the Director of Nursing (DON) revealed one out of the three facility sit-to-stand lifts was not operating properly. Observation revealed that the adjustable leg base of the sit-to-stand lift is designed to extend open to accommodate positioning around a toilet, recliner chair, wheelchairs and obstacles, and to provide a wider base of support when transferring a resident from one location to another. Observation revealed that the left leg of the base would not move when activated by the electronic controller. [...]

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to promptly act upon known risk factors, including immobility, for pressure sore development and timely implement individualized measures to prevent pressure sore development and promote healing for one of six residents sampled with pressure sores (Resident 1).

Inspectors wroteBased on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to administer pain medication as prescribed by the physician and attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of six residents reviewed (Resident D2).

Inspectors wroteBased on review of select facility polity, the minutes from Resident Council Meetings and grievance logs and resident and staff interviews, it was determined that the facility failed to demonstrate prompt action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on three of three resident units (A hall, B hall, and C hall Nursing Units)

Inspectors wroteBased on clinical record review and staff and resident interview, it was determined that the facility failed to include the resident's preferences for showers/bathing on the comprehensive care plan of one resident out of five reviewed (Resident 1).