Edgemont Healthcare

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop and implement policies and procedures that established a protocol for the determination of capacity to consent to sexual contact for 2 of 4 sampled residents, Resident (R) 4 and R13. Observations by staff on 07/27/2025 and 07/28/2025 revealed R4 and R13 were engaged in sexual behavior with one another. However, the facility's policy did not address the requirement to assess residents' capacity to consent to a sexual relationship and there was no evidence the facility assessed the residents for their capacity to consent to a sexual relationship. Additionally, the facility's policy failed to contain the eighth required component, in which the facility must coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to provide 2 (Resident (R) 54 and R10) of 21 sampled residents the right to reside and receive services with reasonable accommodation of the resident's needs and preferences except when to do so would endanger the health or safety of the resident or others. The facility moved or removed personal items, furnishings, and/or equipment without consideration of resident preferences and accommodation of each resident's individual needs. This failure caused R54 emotional distress over a sustained period of time and the resident was tearful as she related that the facility moved and mounted her television on the wall in a place where she had difficulty seeing it due to her physical limitations, as well as removed shelving that housed her personal collectibles.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and/or mental and psychosocial needs identified in the comprehensive assessment for three (Resident (R)4, R46, and R36) of 21 sampled residents.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide treatment and services to prevent development of pressure ulcers for one (Resident (R) 4) of four residents reviewed for pressure ulcers. R4, who required staff assistance with turning and repositioning, was not care-planned with specific intervention for these services. The resident then developed a facility-acquired Stage III pressure ulcer in 01/2025. The Stage III pressure ulcer failed to heal as expected, and was present for 175+ days, as R4 failed to receive pressure relief as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post notice of the availability of the most recent survey results and failed to post those results in a place that was readily accessible to residents. The deficient practice had the potential to affect all residents' rights to be fully informed by being able to review that information upon request. The findings Include:Review of the facility's policy titled, Resident Rights, revised 04/12/2024, revealed residents have the right to receive all forms of communication while residing within the facility, and the facility would assist residents in exercising his/her rights. Observation during a tour of the facility on 07/22/2025 at 10:00 AM revealed there was no notice that indicated the location of the most recent state survey results and there was no visible physical account of the previous survey results. [...]

Inspectors wroteBased on observation, interview, record review, and review of National Weather Service records, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents. The facility failed to promptly respond to problems with its cooling system and ensure that the facility was maintained at a safe, comfortable temperature, with temperatures in resident areas noted as high as 90 degrees Fahrenheit (F). The failure to provide safe, comfortable temperatures had the potential to affect all residents of the facility and constituted Substandard Quality of Care (SQC). In addition, multiple resident rooms (Rooms 209, 302, 317, and 320), a common resident gathering area, and the main dining hall needed repair and/or or cleaning.

Inspectors wroteBased on observation, interview, record review, and review of the facility assessment, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations (including nights and weekends) and emergencies. The facility assessment failed to provide documented information to inform staffing decisions to ensure sufficient staffing to meet residents' needs for each shift and unit, develop and maintain a plan to maximize recruitment and retention of direct care staff, and inform contingency planning for events that did not require activation of the facility's emergency plan, but did have the potential to affect resident care, such as the availability of direct care nurse staffing or other resources for resident care. [...]

Inspectors wroteBased on observation, interview, staff time punch data, and Payroll Based Journal (PBJ) data, the facility failed to have sufficient nursing staff with the appropriate 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 determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. The deficient practice had the potential to affect all residents in the facility with a census of 65.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to properly label drugs and biologicals in accordance with currently accepted professional principles. They did not include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts.

Inspectors wroteBased on observation, interview and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's Infection Control Plan policy, not dated, revealed the purpose of the infection control plan was to provide a safe, sanitary, and comfortable environment for all residents and staff. Review of the facility's Handwashing policy, not dated, revealed all personnel shall follow the established handwashing procedure to prevent the spread of infections and disease to other personnel, residents, and visitors. Wash hands for approximately 10-15 seconds, performed under the following conditions: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The mechanical lift scale was broken, and staff reported the lift function did not always work. The facility had 4 residents who used a Hoyer lift for weights.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 21 sampled residents, Resident (R)4 and R36. The facility failed to ensure R36's visual privacy while she was undressed. The facility failed to ensure R4's catheter collection bag was covered.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to protect the resident from misappropriation of property for 2 of 2 residents investigated for personal property. Resident (R) 24 and R10 filed grievances for missing clothing, but the facility failed to reimburse the residents for their missing items.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' assessments accurately reflected the resident's status for 1 of 21 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was revised following an incident for 1 of 21 sampled residents. Resident (R)2 suffered a fall on 01/24/2025 resulting in injury; however, R2's comprehensive care plan was not revised following the fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to dependent residents to maintain good personal hygiene for 1 of 5 residents investigated for activities of daily living (ADL) care, Resident (R)46.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 1 residents investigated for activities, Resident (R) 36. Observations throughout survey revealed R36 sitting alone in her room, awake, with no television, music, or other form of stimulation available to her.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to provide services to prevent urinary tract infections for 1 of 2 residents with an indwelling catheter, R4. Observations throughout survey revealed R4's catheter tubing and catheter bag dragging the ground under her wheelchair.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure residents requiring dialysis received services consistent with professional standards of practice by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 3 residents reviewed for dialysis, Resident (R)3. Record review and interview revealed the facility failed to obtain or document R3's post dialysis center vital signs, weight and pertinent report information following dialysis visits. Further review revealed the facility failed to provide communication to the dialysis facility for pre-dialysis vital signs, medications and pertinent changes.

Inspectors wroteBased on observation, interview, review of the U.S. Food and Drug Administration Food Code, 2017, and review of the facility's policies, it was determined the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from abuse for one (1) of sixteen (16) sampled residents, Resident #16. Resident #16 was struck in the face by Resident #24.

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to store food delivered from an outside source in accordance with professional standards of food service.

Inspectors wroteBased on observation, interview, and review of facility Policy, it was determined the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Observation on 03/05/19, revealed sewage in the basement area where the dry goods were located.

Inspectors wroteBased on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's medical and nursing needs for one (1) of nineteen (19) sampled residents (Resident #22). Although Resident #22's Annual Minimum Data Set (MDS) Assessment, dated 07/17/18, and Quarterly MDS Assessment, dated 01/08/19, revealed the resident had Functional Limitations in Range of Motion for bilateral upper and lower extremities, there was no documented evidence the Comprehensive Care Plan was developed and implemented to address the resident's limited range of motion/contractures. (Refer to F-688)

Inspectors wroteBased on observation, interview, record review, and review of facility Policy, it was determined the facility failed to provide services to increase or prevent further decrease in range of motion for one (1) of nineteen (19) sampled residents (Resident #22). Although Resident #22 had Functional Limitations in Range of Motion (ROM), record review and staff interview, revealed the resident was not receiving services to increase ROM and/or to prevent further decrease in ROM. (Refer to F-656)

Inspectors wroteBased on observation, interview, record review, review of facility Policies, and review of the Centers for Disease Control (CDC) Guideline for Hand Hygiene in Healthcare Settings, Volume 51, published 10/25/02, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of nineteen (19) sampled residents (Resident #25 and Resident #38). Observation on 03/05/19, revealed Registered Nurse (RN) #1 did not perform hand prior to or post administration of medication for Residents #25 and #38. In addition, RN #1 handled pills with her bare hands prior to administering the medication to these residents.