Pennsylvania Department of Health
EDENBROOK SOUTH
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EDENBROOK SOUTH
Inspection Results For:

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EDENBROOK SOUTH - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to three Complaints and one Incident, completed on June 4, 2025, it was determined that Edenbrook South was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to obtain and provide medications for one of six residents reviewed (Resident 1).

Findings include:

Review of Resident 1's clinical record revealed that the facility admitted him on April 29, 2025. Review of Resident 1's hospital discharge records dated April 29, 2025, indicated that Resident 1 has a history of schizoaffective disorder and was to continue his Ingrezza (can be used off label for schizoaffective disorder, a chronic mental health condition) 40 mg (milligrams) nightly.

A nursing progress note dated April 29, 2025, at 2:51 PM indicated that Resident 1's sister will be bringing in his Ingrezza on April 30, 2025, and that the "pharmacy will not be providing." Resident 1 did not receive his nightly dose of Ingrezza on April 29, 2025.

There was no indication why the pharmacy was not providing the medications, or why Resident 1's sister was expected to bring in the medication. The Ingrezza was the only medication that was not being obtained through the facility's pharmacy.

Review of Resident 1's Medication Administration Record (MAR, a form used to document the administration of medications) dated May 2025, indicated that nursing staff did not administer his nightly Ingrezza 17 times. Nursing staff documented that the medication was not available from pharmacy or was not found in the medication cart.

Review of Resident 1's MAR dated June 2025, indicated that nursing staff did not administer his Ingrezza medication on June 1, 2, or 3, 2025.

Nursing documentation dated June 1, 2025, 10:54 AM indicated that Resident 1's sister was contacted about the facility being "out of" his Ingrezza." Resident 1's sister indicated she was "unsure how to obtain the med from their pharmacy." There was no documented evidence to indicate why the pharmacy was not being contacted to supply the medication.

Interview with the Employee 1, registered nurse, on June 4, 2025, at 3:01 PM confirmed the above findings for Resident 1.

28 Pa. Code 211.9 (a)(1)(d)(e)(4)(k) Pharmacy services

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/15/2025

Pharmacy Services
1.Resident #1 was seen by psych services on June 6, 2025, with an order to discontinue Ingrezza 40mg QHS and starting Austedo 6 mg BID for tardive dyskinesia. He is receiving the Austedo as ordered.
2.A review of current residents prescribed Ingrezza will be completed to validate that ordered medication is available. Corrective action will be taken to obtain medications that are not currently available.
3.Licensed nurses will be educated on F-Tag 577, "Pharmacy Services" to ensure those residents prescribed Ingrezza receive ordered medication and the proper process to be followed if a medication is not available for administration.
4.Audits will be completed by the DON/Designee weekly x 4 weeks and monthly x 1 month to ensure Ingrezza medication is obtained and provided. All findings will be reviewed in QAPI x 2 months.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents during the day shift for one of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility from May 11 to 31, 2025, revealed the following on the day shift:

May 18, 2025, census of 95 with 9.10 NAs, required 9.50

Interview with Employee 2, assistant administrator and scheduler, on June 4, 2025 at 10:53 AM confirmed the above findings.

Plan of Correction - To be completed: 07/15/2025

1.No ill effects to any residents with this deficient practice.
2.Each resident had the potential to have the same deficient practice.
3.The facility will exhaust all attempts/resources to ensure that the minimum ratio for nursing aides per the state minimum is met. The facility will offer bonuses, recruit nursing assistants, and replace shifts to ensure compliance. The RN Supervisors, DON, and Scheduling Manager will be educated on F-Tag, "Nursing Services," by the NHA or designee.
4.The Scheduling Manager and/or designee will audit daily schedules to ensure compliance with the C.N.A. ratios.
Daily labor meetings will be held to review any openings to ensure all ratios are compliant with this regulation.
Random audits will be conducted weekly x 4 weeks and monthly x 1month by the Scheduling Manager and/or designee. Results will be reviewed at QAPI x 2 months.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift for two of the 21 days reviewed and one LPN per 40 residents during the overnight shift for one of the 21 days reviewed.

Findings include:

A review of nursing care hours provided by the facility dated from May 11 to 31, 2025, revealed the following:

Day shift:

May 29, 2025, census of 94 with 3.70 LPNs, required 3.76
May 30, 2025, census of 94 with 2.91 LPNs, required 3.76

Overnight shift:

May 19, 2025, census of 95 with 2.13 LPNs, required 2.38

Interview with Employee 2, assistant administrator and scheduler, on June 4, 2025, at 10:53 AM confirmed the above findings.

Plan of Correction - To be completed: 07/15/2025

1.No ill effects to any residents with this deficient practice.
2.Each resident had the potential to have the same deficient practice.
3.The facility will exhaust all attempts/resources to ensure that the minimum ratio for LPNs per the state minimum is met. The facility will offer bonuses, recruit LPNs, and replace shifts to ensure compliance. The RN Supervisors, DON, ADON, and Scheduling Manager will be educated on F-Tag, "Nursing Services," by the NHA or designee.
4.The Scheduling Manager and/or designee will audit daily schedules to ensure compliance with the L.P.N. ratios.
Daily labor meetings will be held to review any openings to ensure all ratios are compliant with this regulation.
Random audits will be conducted weekly x 4 weeks and monthly x 1month by the Scheduling Manager and/or designee. Results will be reviewed at QAPI x 2 months.

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