Edgewood Health & Rehabilitation

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to maintain dining room furniture in a safe/clean/comfortable/homelike environment for two (2) of four (4) days of survey.

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to immediately protect one (1) of three (3) resident reviewed for an allegation of abuse. Resident #62.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to complete the discharge Minimum Data Set (MDS) in accordance with the Center for Medicare and Medicaid Services (CMS) guidelines for one (1) of (22) sampled residents. Resident #104.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the resident's use of an indwelling suprapubic catheter and colostomy for one (1) of (22) sampled residents. Resident #22.

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to store medications properly for one (1) of five (5) residents observed for medication administration. (Resident # 32)

Inspectors wroteBased on observation, interview record review and facility policy review, the facility failed to follow infection prevention practices during medication administration for one (1) of five (5) residents observed. Resident #103. Findings Include:Record review of the facility policy Infection Prevention and Control Program with a revision date of 5/26 revealed, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines . During an observation on 7/22/26 at 8:01 AM, observed Licensed Practical Nurse (LPN) #2 administer medications to Resident# 103. [...]

Inspectors wroteBased on policy review, record review and interviews, the facility failed to ensure the residents' right to be free from abuse and failed to protect Resident #1 from abusive and degrading treatment by Certified Nurse Aide (CNA) #1 and CNA #2 during the provision of care on the evening of 2/10/26. The abusive conduct included the use of disparaging, derogatory, and humiliating language and intimidation toward Resident #1 while the resident requested assistance and complained of pain during care for one (1) of four (4) sampled residents. Resident #1. The State Agency (SA) identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/26/26. [...]

Inspectors wroteBased on policy review, record review and interviews, the facility failed to report an allegation of verbal abuse of a resident within the required timeframe of two (2) hours after the allegation was reported to facility staff. The allegation was reported to the facility on 2/14/26 at approximately 8:40 AM but was not reported to the State Agency until 2/16/26 at 11:30 AM. This was for one (1) of four (4) sampled residents. Resident #1. This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02/14/26 and placed Resident #1 and all other residents in a situation that was likely to cause serious harm, serious impairment, serious injury or death. [...]

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to thoroughly investigate an allegation of abuse in a timely manner to prevent further potential abuse. The facility failed to initiate a prompt and thorough investigation after an allegation of verbal abuse of Resident #1 was reported on 2/14/26. The facility did not immediately interview staff or residents, did not initiate protective interventions, and delayed investigative actions until 2/16/26. This deficient practice affected one (1) of three (3) reviewed incidents with documented indications of possible abuse. Resident #1. The facility's failure to initiate a timely investigation and implement protective measures created the likelihood of continued abuse of Resident #1 and other residents and placed them in a situation that was likely to cause serious harm, serious injury, serious impairment or death. [...]

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure administrative leadership implemented timely actions to respond to and manage an allegation of verbal abuse involving Resident #1. The Administrator was notified of the allegation on 2/14/26 at approximately 9:00 AM but failed to ensure the allegation was reported within required timeframes, failed to ensure the alleged perpetrator was immediately removed from resident contact, and failed to ensure a prompt investigation was initiated. This deficient practice affected one (1) of four (4) sampled residents. Resident #1. [...]

Inspectors wroteBased on observations, interviews, record review and facility policy review the facility failed to provide assistance with turning and repositioning per standards of care for two (2) of nine (9) sampled residents who required assistance with activities of daily living (ADL) and repositioning. Resident #1 and Resident #2.

Inspectors wroteBased on interviews and record review the facility failed to ensure accurate labeling of medication for one (1) of three (3) medication carts. The 400 Hall Medication Cart.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure that the comprehensive person-centered care plan was implemented for one (1) of four (4) sampled residents (Resident #1).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure adequate supervision and the implementation of safety interventions to prevent accidents for two (2) of four (4) sampled residents (Resident #1 and Resident #2)

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review the facility failed to ensure staff who perform resident transportation possessed and demonstrated the competencies necessary to carry out their responsibilities safely one (1) of four (4) residents dependent on the facility for transportation, Resident #2.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 6/10/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was let out of the building by a lawn service worker. She exited the facility in her wheelchair unnoticed and was last seen inside the facility at 11:05 AM. She was found at 11:08 AM by a visitor walking into the facility in the facility's parking lot, approximately 145 feet from the front door of the building. [...]

Inspectors wroteComplaint: MS #29210 Based on record review, interview, and facility policy review, the facility failed to develop and revise a comprehensive care plan in accordance with physician orders and professional standards for one (1) of three (3) residents reviewed for respiratory equipment (Resident #2). Specifically, the facility failed to update the resident's care plan to reflect a new physician order dated 1/31/25 for an auto-adjusting -(continuous positive airway pressure) C-Pap at 8-18 cm (centimeter) of H20 (water), with modem setup, and the interdisciplinary team did not review or implement updated interventions related to the resident's new therapy.

Inspectors wroteComplaint MS #29210 Based on record review, interview, and facility policy review, the facility failed to ensure services were provided and documented according to professional standards for one (1) of three (3) sampled residents receiving individual Continuous Positive Airway Pressure (C-Pap). Resident #2. Specifically, the facility failed to follow and transcribe a physician's order dated 1/31/25 for a new C-Pap machine, until 5/28/25.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from abuse for two (2) of seven (7) sampled residents reviewed, Resident #1 and Resident #2.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions on the Activities of Daily Living (ADL) care plan for Resident #7 when the resident's drink was left unopened, her cereal was served dry, and her utensils were placed out of reach during the evening meal on 3/20/25 for one (1) of seven (7) sampled residents reviewed. Resident #7.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide appropriate services to maintain the ability to carry out activities of daily living (dining/eating) when the resident's drink was left unopened and her utensils were left out of reach during the evening meal on 3/19/25, which prevented her from feeding herself for one (1) of seven (7) sampled residents reviewed.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide a meal that was palatable in appearance when the facility posted Club Sandwich and French Fries on the menu for the evening meal on 3/19/25 and the sandwiches served were not palatable in appearance and did not match the facility's recipe for two (2) of seven (7) sampled residents reviewed. Resident #3 and Resident #4.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure the written contents of the notice of discharge included all of the requirements for a facility-initiated discharge for one (1) of two (2) Residents reviewed. (Resident #1) Findings Include: A review of the facility's policy titled, Transfers and Documentation, dated 02/2024, revealed Transfers may occur within the facility for the following reasons: 1. The needs of the resident cannot be met in the section of the facility in which he/she is residing. 2. The resident threatens the safety of himself/herself or the safety of other residents in the facility. 3. The health or other residents is endangered. 4. The resident and/or resident representative requests a transfer made . [...]

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store food and use sanitary practices in accordance with professional standards for food service safety related to unlabeled food items, food items exposed, overly ripe produce, improperly stored foods, and contaminated dry bin items for one (1) of two (2) kitchen observations. This has the potential to affect all residents who receive meals from the dietary department. Findings Include: A review of the facility's policy titled Food Storage Labeling, dated 3/24, revealed, . All food items that are not in their original containers must be labeled with the common name of the food and the use-by date Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed the manufacturer use-by date or expiration date . [...]

Inspectors wroteBased on observation, record review, policy review, and interviews, the facility failed to ensure a resident was free from physical restraints, as evidenced by not completing an assessment and evaluation for an upper body harness vest and by not ensuring the upper body vest was the least restrictive device for one (1) of one (1) sampled residents for restraints. Resident #88 Findings Included: A record review of the facility's policy titled Physical Restraint, dated 2/20/12, revealed .Restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully .1. Restraints will only be used after alternatives have been tried unsuccessfully, and only with informed consent from the resident, physician, and/or responsible party . [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed accommodate the needs of a resident, as evidenced by, leaving a resident who was dependent on staff for eating, unassisted and unfed during a meal, for one (1) of 23 sampled residents. Resident #70. Findings Include: A review of the facility's policy titled Residents Rights dated 1/24/22 revealed, Policy Statement .Residents' rights policies and procedures shall ensure that each resident admitted to the center .Policy Interpretation and Implementation .9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs . On 07/29/24 at 12:44 PM, an observation with Resident #70 revealed she was sitting up in her electric wheelchair. Both of her arms were contracted down by her sides. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper storage of respiratory equipment as evidenced by tubing not dated or bagged when not in use for one (1) of one (1) resident sampled for respiratory care. Resident #88 Findings Include: A record review of the facility policy titled Nebulizer and Oxygen Tubing Storage Policy, dated April 2007, revealed, POLICY It was the policy of the facility to decrease the risk of potential and/or direct exposure to infectious diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment . The facility will replace all respiratory tubing weekly. These tubings will be dated and stored in a dated plastic bag when not in use. The plastic bags will also be changed out weekly . [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee as evidenced by one (1) re-cited deficiency originally cited in July 2023 on an annual recertification survey. Findings Include: A record review of the facility policy Quality Assurance and Performance Improvement (QAPI) Plan of Action dated 4/1/2021 revealed on page seven and page eight: Quality Assurance Program Tools: This facility's QAPI systems and processes are maintained within an ongoing program that is dynamically designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and resolve identified problems .Focus Indicators: [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the Physician or the Resident Representative (RR) when a resident experienced pain to her right knee after a resident transfer which resulted in a femoral fracture that was diagnosed the following day for one (1) of ten (10) sampled residents that require a mechanical lift for transfers. (Resident #5) Findings Include: A review of the facility's policy Resident Change in Condition revised 2016, revealed, .It is the policy of this facility to promptly notify the resident, his or her attending physician, and the resident representative (RR) of changes in the resident's condition .Procedure 1. The Charge Nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury .b. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions related to pain when Resident #5 yelled out in pain during a transfer for one (1) of 23 residents reviewed for care plans. (Resident #5) Findings Include: A review of the facility's Following the Care Plan Policy, dated 1/2011, revealed, .It is the Policy of this facility to follow a written and approved care plan for each resident. All employees will be .required to follow the care plan. Procedure .All employees will follow the written care plan that is developed in order to assure the residents needs are met. A record review of the Comprehensive Care Plan with an initiation date of 6/2/23 revealed Focus: Resident is at risk for pain .Interventions initiated on 6/2/2023 .Document type, location and severity of pain .Give medications as ordered . [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and/or hazards when facility staff were aware a resident who was care planned for a mechanical lift was sliding from a wheelchair and the staff detached the lift pad from the mechanical lift, causing the resident to further slide and be manually transferred which resulted in a right femur fracture for one (1) of ten (10) sampled residents that required transfers via mechanical lift. (Resident #5) Findings Include: A review of the facility's Responsibility for Accident/Incident Report Policy dated [DATE] revealed, .It is the policy of this facility for all Incidents and Accidents involving resident's to be investigated immediately upon knowledge of the incident. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure pain management was provided to a resident who complained of pain after a manual transfer from her wheelchair to the bed and was subsequently diagnosed with a femoral fracture for one (1) of 23 residents reviewed for pain, Resident #5. Findings Include: A record review of the facility's policy Pain Assessment/Management revised 09/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of the residents at risk of acute and chronic pain. Each resident's pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications .pain will be assessed and recorded on the medication administration record. [...]

Inspectors wroteBased on record review, staff interviews and facility policy review, the facility failed to ensure a care plan was implemented to prevent a resident's access to a medication cart, when a resident, without supervision, opened an unlocked medication cart and drank Lactulose liquid for one (1) of nine (9) sampled residents. Resident #1 The facility's failure to implement care plan interventions placed this resident and other cognitively impaired residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 6/4/24, when Resident #1 opened an unlocked and unattended medication cart and took a bottle of Lactulose and drank from the bottle. The facility Administrator was notified of the IJ on 6/20/24 at 4:25 PM and was presented with the IJ Template. [...]

Inspectors wroteBased on observation, staff interviews, record review and facility policy review the facility failed to provide an environment free from accident/hazards and supervision, as evidenced by leaving a medication cart unlocked and unattended, allowing a resident to remove and ingest a medication from the cart for one (1) of nine (9) sampled residents. Resident #1 The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 6/4/24, when Resident #1 opened an unlocked and unattended medication cart and took a bottle of Lactulose and drank from the bottle. The facility's failure to ensure the resident was protected from accident/hazards placed this resident and other residents at risk and in a situation likely to cause serious injury, serious harm, serious impairment or death. [...]

Inspectors wroteBased on observations, staff and Resident Representative (RR) interview, record review and facility policy review the facility failed to notify the RR/family of a severely cognitively impaired resident of a change in the resident's condition, for one (1) of nine (9) sampled residents.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure an allegation of resident-to-resident non-consensual sexual contact was reported to the State Agency (SA) for two (2) of nine (9) sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the environment was free from accident hazards and residents received adequate supervision to prevent a resident from ingesting a cleaning solution retrieved from an unsecured housekeeping cart for one (1) of two (2) residents reviewed with wandering behaviors. (Resident #1)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to timely manage and treat complaints of pain for two (2) of four (4) sampled residents, when the unit the residents resided on did not have a licensed nurse to assess, monitor, or treat complaints of pain from approximately 7:00 PM on 3/22/24 until approximately 1:47 AM on 3/23/24. Residents #2 and #4 Findings Include: Record review of the facility policy titled, Pain Assessment/Management, revised 9/10, revealed, It is the policy of this facility to provide guidelines in the identification and treatment of residents at risk for acute and chronic pain. [...]

Inspectors wroteBased on interview, record review, facility investigation and facility policy review, the facility failed to protect a resident from misappropriation of funds for one (1) of three (3) residents sampled.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to revise a comprehensive care plan regarding interventions to prevent a dependent resident from falling for one (1) of three (3) residents reviewed for falls. Resident #98.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide care in a manner to protect vulnerable residents from falls resulting in injury for one (1) of three (3) residents reviewed for falls.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that the resident or the resident's representative received education regarding influenza and pneumonia immunizations and were given the opportunity to receive or refuse the immunizations for 20 of 25 residents reviewed for immunizations. Resident #8, Resident #16, Resident #17, Resident #19, Resident #26, Resident #28, Resident #31, Resident #33, Resident #41, Resident #44, Resident #48, Resident #49, Resident #55, Resident #62, Resident #70, Resident #71, Resident #85, Resident #98, Resident #102, Resident #304

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure a resident's privacy as evidenced by posting of clinical care signage on the resident's wall for one (1) of 22 residents reviewed in sample. Resident #75. Findings Include: Record review of policy titled, Resident Room Postings, dated 2/2020, revealed, It is the policy of this facility to support a resident's right to personal privacy and confidentiality in all aspects of care and services, to include personal and medical record. The policy goes on to read that 4. Resident room postings will only be allowed if resident or resident's representative request posting at the bedside or if used as a visual safety reminders. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to obtain a physician order for the use of a restraint for one (1) of three (3) residents reviewed for restraints.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to accurately code the discharge Minimum Data Set (MDS) assessment for one (1) of two (2) sampled closed records. Resident #102.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide the appropriate care and services to a resident who was incontinent to prevent urinary tract infections for one (1) of three (3) residents reviewed for incontinent care. Resident #17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents and or family were educated on the risk of bedrails and failed to evaluate and document alternatives prior to the application and use of bed rails for one (1) of 22 sampled residents, Resident #75. Findings Include: Review of the facility policy revealed a policy for restraint use but no policy for use of bedrails. On 07/24/23 12:17 PM, observation revealed the resident lying in bed with the head of the bed slightly elevated with quarter side rails up. Observation on 07/25/23 2:02 PM, revealed quarter side rails were up and continued to be raised on the resident's bed. Observation on 07/26/23 at 1:25 PM, revealed quarter side rails continue to be used. Interview on 07/26/23 at 1:30 PM, with the Maintenance Director, revealed bed rails are checked monthly to ensure safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure as needed (prn) psychotropic medications were limited to 14 days unless a longer timeframe was documented appropriate by the attending physician for one (1) of 22 residents reviewed. Resident #85 Findings Include: Record review revealed resident is currently taking the following psychotropic med Lexapro 10 mg (milligrams) daily, Seroquel 25 mg @bedtime, Buspirone 15 mg BID (twice a day), Klonopin 0.5mg 1/2 (one-half) daily, and Ativan 0.5mg, 1 tablet by mouth every 12 hours as needed. Review of Order Summary revealed Resident #85 was prescribed Ativan 0.5 mg by mouth every 12 hours as needed for agitation related to anxiety disorder. Prescription start dated noted as 02/23/23. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for two (2) of twenty-two (22) sampled residents.