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Deficiency Records for Edenbrook On Second Ave
A list of the most recent deficiencies for Edenbrook On Second Ave. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Edenbrook On Second Ave. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2025-01-10 | 2025-01-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-01-10 | 2025-01-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-11-26 | 2025-01-10 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-11-26 | 2025-01-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-23 | 2024-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-23 | 2024-09-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-23 | 2024-09-24 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-08-23 | 2024-09-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-23 | 2024-09-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-23 | 2024-09-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-23 | 2024-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-23 | 2024-09-24 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-08-23 | 2024-09-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-23 | 2024-09-24 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-08-23 | 2024-09-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-23 | 2024-09-24 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-13 | 2024-09-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-15 | 2024-06-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-15 | 2024-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-15 | 2024-06-05 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-05-15 | 2024-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-15 | 2024-06-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-15 | 2024-06-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-15 | 2024-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-15 | 2024-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-15 | 2024-05-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-15 | 2024-05-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-15 | 2024-05-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-03-15 | 2024-05-15 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-03-15 | 2024-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-20 | 2024-04-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-20 | 2024-04-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-20 | 2024-04-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-22 | 2023-10-31 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-09-22 | 2023-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-22 | 2023-10-31 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-22 | 2023-10-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-22 | 2023-10-31 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-13 | 2023-10-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-13 | 2023-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-13 | 2023-10-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | 2023-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-07-31 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-05-30 | 2023-07-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-30 | 2023-07-06 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-30 | 2023-07-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-30 | 2023-07-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-30 | 2023-07-06 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-02 | 2023-07-06 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-03-10 | 2023-07-06 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-02 | 2023-05-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-02 | 2023-05-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-02 | 2023-05-30 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-10 | 2023-05-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-05-30 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-04 | 2023-05-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-10 | 2023-05-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-10 | 2023-05-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-10 | 2023-05-02 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-10 | 2023-05-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-10 | 2023-05-02 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-12-28 | 2023-01-17 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-28 | 2023-01-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-09 | 2022-10-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-09 | 2022-10-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-02 | 2022-06-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-02 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-02 | 2022-06-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-02 | 2022-06-17 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-02 | 2022-06-17 | Y |
| Report COVID19 data to residents and families. | Health | 2022-06-02 | 2022-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-06-17 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-05-04 | 2022-06-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-06-02 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-04 | Not Fixed | Y |
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