Edenbrook on Second Ave

Inspectors wroteBased on observations and staff interviews, it was determined the facility failed to provide a safe, clean, and homelike environment for residents on four out of 5 nursing units (B Hall, C Hall, D Hall, and TCU).

Inspectors wroteBased on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement committee failed to implement and maintain an effective corrective action plan to prevent the recurrence of deficiencies related to providing residents with a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on observations and resident and staff interviews, it was determined the facility failed to provide and maintain a clean, comfortable, and homelike environment for residents on two of three nursing units.

Inspectors wroteBased on observations, clinical record review, select facility policy review, and staff interview, it was determined the facility failed to consistently ensure the provision of respiratory care and supplemental oxygen in accordance with physician orders and facility policy for three residents out of 28 residents reviewed. (Residents 3, 4, and 128).

Inspectors wroteBased on observation, review of facility planned menus, select facility policy review, and resident and staff interviews, it was determined the facility failed to honor resident food preferences and ensure residents received meal items and condiments as identified on meal tray tickets, to the extent possible, for 2 of 28 residents reviewed for food services (Residents 10 and 55), and residents participating in a Resident Council group interview (Residents 5, 112, 46, 88, 51, 13, 10, 83, 8, 12, 120, 108, and 92).

Inspectors wroteBased on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement committee failed to implement and maintain an effective corrective action plan to prevent the recurrence of deficiencies related to providing residents with a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on clinical record review, facility policy review, observations, and staff interview, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to address aggressive behavior interventions and the care, monitoring, and maintenance needs associated with a central line for one of 28 residents reviewed (Resident 58).

Inspectors wroteBased on a review of clinical records, facility policy review, and staff interviews, it was determined the facility failed to develop and implement an individualized, person-centered plan to provide trauma-informed care for one of 28 residents reviewed (Resident 5) with a diagnosis of Post-Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on clinical record review, observation, staff and resident interview, and incident investigation, it was determined that the facility failed to maintain a fully functional call light system for one semi-private room, affecting two of 28 sampled residents (Residents 74 and 127).

Inspectors wroteBased on a review of clinical records, facility documentation, and resident and staff interviews, it was determined the facility failed to develop and implement discharge planning consistent with a resident's expressed discharge goals and demonstrated self-care abilities for one of 28 residents reviewed (Resident 7).

Inspectors wroteBased on review of clinical records, facility initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notice of facility initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for four out of 28 residents reviewed (Residents 1, 2, 14, and 118).

Inspectors wroteBased on a review of facility policies, employee personnel records, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to implement its established abuse prevention and response policies following an allegation of abuse for one resident (Resident 1) out of 9 residents reviewed and failed to follow required employee screening procedures for one of three employees reviewed (Employee 1)

Inspectors wroteBased on observation and staff interviews, 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 and three of five resident pantry areas (Nursing Units Medbridge Hall, A Hall, and B Hall).

Inspectors wroteBased on observations, a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for four out of five nursing units (Units Medbridge Hall, A Hall, B Hall, and D Hall), including experiences reported by two out of three residents interviewed (Residents 1 and 2).

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by three residents out of 29 residents sampled (Residents 2, 3, and 5) and four out of five residents interviewed during a resident group interview (Residents 4, 61, 77, and 112).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to thoroughly assess, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice, for one residents out of 29 sampled residents (Resident 3) and failed to provide nursing care consistent with professional standards of practice in accordance with physician orders for one resident out of 29 sampled residents (Resident 93).

Inspectors wroteBased on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to properly store resident personal care equipment on one of five nursing units (A wing) and failed to store a urinary catheter drainage bag in a manner to limit the potential for infection for one of three sampled residents (Resident 29).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to conduct a care plan conference and failed to ensure that the resident was invited to participate in the care planning process for one of 29 residents reviewed (Resident 112).

Inspectors wroteBased on a review of clinical records, facility investigative documentation, and staff interviews, it was determined the facility failed to provide adequate supervision and implement a planned intervention to prevent intrusive wandering by a cognitively impaired resident (Resident 103) which resulted in a resident-to-resident altercation for two of 29 sampled residents (Residents 91 and 103).

Inspectors wroteBased on observation, staff interview, and review of facility policy and clinical record, the facility failed to ensure respiratory equipment was maintained in a sanitary and functional condition for one resident (Resident 40) out of 29 sampled residents.

Inspectors wroteBased on clinical record review, payor source data, resident and staff interview, it was determined the facility failed to ensure timely and necessary dental services for one resident who is a Medicaid recipient (Resident 110) out of 29 residents reviewed.

Inspectors wroteBased on a review of clinical records, select facility policy, documentation provided by the facility, and staff and resident family interviews, it was determined the facility failed to ensure residents have the right to personal privacy for one resident out of eight sampled (Resident 1).

Inspectors wroteBased on review of clinical records and staff interview it was determined the facility failed to ensure that a resident's room change was not completed for the purpose of staff convenience for one resident out of 8 sampled residents. (Resident 1)

Inspectors wroteBased on review of facility investigative reports, clinical records, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 8 sampled residents (Resident 1).

Inspectors wroteBased on clinical record review, observation, and staff and resident interviews, it was determined the facility failed to reasonably accommodate a request and need for more frequent bed linen changes for one resident out of eight residents sampled (Resident 2). Findings incudes: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include morbid obesity (complex chronic disease in which a person has a body mass index of 40 or higher) and lymphedema (chronic condition that causes tissue swelling usually in the arms or legs in which accumulated fluid could break the skin resulting in leakage). [...]

Inspectors wroteBased on clinical record and facility policy review and staff interview, it was determined the facility failed to ensure that in preparation for a room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for two of 15 room changes completed by the facility from October 30, 2024, through November 4, 2024 (Resident 1 and Resident 2).

Inspectors wroteBased on a review of clinical records and resident and staff interview, it was determined the facility failed to provide care in a manner that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by seven residents out of the 29 residents sampled (Residents 3, 34, 85, 66, 57, 6, and 38).

Inspectors wroteBased on observation, review of select facility policy, clinical record review, and resident and staff interviews, it was determined the facility failed to provide housekeeping services to maintain a clean and safe resident environment in two resident rooms and the A unit. (Resident 68 and Resident 39)

Inspectors wroteBased on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to maintain oxygen equipment in a functional and sanitary manner for three residents out of 29 sampled (Residents 9, 22, and 135).

Inspectors wroteBased on observation, select facility policy review and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed. (Medication Storage Room B).

Inspectors wroteBased on review of the facility's abuse policy, clinical records, facility investigations, information submitted by the facility to the state agency, and staff interview it was determined the facility failed to timely report an alleged violation of misappropriation of resident property for one resident out of 26 reviewed (Resident 42).

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined the facility failed to develop and implement a person-centered care plan to meet the specific needs of two residents out of 29 sampled (Residents 63 and 87). Findings including: A clinical record review revealed Resident 63 was admitted to the facility on [DATE], with diagnoses that include hemiplegia (paralysis on one side of the body) and cerebral infarction (brain damage that results from a lack of blood). [...]

Inspectors wroteBased on a review of clinical records and resident and staff interviews, it was determined the facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, by failing to provide showers/bed bath as scheduled and personal grooming for two of 26 residents sampled (Residents 42 and 138).

Inspectors wroteBased on a review of clinical records and resident and staff interview, it was determined the facility failed to provide person-centered quality care by failing to follow physician orders for NPO (nothing by mouth) in preparation for an abdominal ultrasound for one resident (Resident 133) and failed to follow physician orders for the consistent application of a prescribed therapeutic measure, ace wraps, for one resident of 29 sampled (Resident 87).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interview it was determined the facility failed to ensure that physician ordered intravenous (IV- medication is administered through needle or tube inserted into a vein) medications, an antibiotic, were administered as prescribed for one resident out of 26 sampled (Resident 67).

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to maintain complete and accurate records of treatment administration to one resident of 29 sampled (Resident 87).

Inspectors wroteBased on observation, a review of clinical records, CDC infection control guidance, and staff interview it was determined the facility failed to implement transmission-based precaution control practices to mitigate the risk of COVID-19 infections in the facility for four out of five residents sampled for transmission-based precautions (Residents 2, 63, 66, and 121) and failed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one out of 29 residents sampled (Resident 49).

Inspectors wroteBased on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to ensure each resident room is designed and equipped to assure full visual privacy for one out of the 29 residents sampled (Resident 107).

Inspectors wroteBased on review of the facility's abuse prohibition policy, clinical records, and select investigative reports and staff interview it was determined that the facility failed to ensure that one resident out of 10 sampled was free from verbal abuse (Resident 2).

Inspectors wroteBased on review of clinical records, the facility's abuse prohibition policy and staff witness statements, and staff and family interview, it was determined that the facility failed to timely and thoroughly investigate an allegation of resident abuse and prevent the potential for further abuse during the course of the investigation for one resident out of 10 resident sampled (Resident 2).

Inspectors wroteBased on review of clinical records and select facility policy and resident and staff interviews it was determined that the facility failed to provide necessary supervision and effective safety measures to prevent an elopement by one resident (Resident 1) out of 10 sampled residents

Inspectors wroteBased on observation, select facility policy review and staff interview, it was determined that the facility failed to implement procedures to ensure acceptable storage and use by dates for multi-dose medications on two of four medication carts observed (B hall and C hall).

Inspectors wroteBased on clinical record, select facility policy and incident report reviews and staff interviews it was determined that the facility failed to provide individualized services necessary to maintain continence and prevent continued decline and assure the resident received the necessary staff assistance to meet the resident's toileting needs in an attempt to decrease incontinency for one resident out of 25 sampled (Resident 27).

Inspectors wroteBased on a review of clinical records and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for diabetes management for one resident (Resident 7) out of 25 sampled.