Edgewood Manor of Greenfield

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to notify the resident and the resident's representative of a change in medical condition. This affected one (Resident #10) of three residents reviewed for notification of change in medical condition. The facility total census was 46 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to provide wound treatments as ordered by the physician and per professional standards of nursing practice. This affected three (Residents #10, #32 and #20) of three resident reviewed for wound care. The facility census was 46 residents.

Inspectors wroteBased on medical record review, staff interview. and review of the facility policy, the facility failed to document changes in a resident's medical condition in the medical record. This affected one (Resident #10) of three residents reviewed for documentation of a change in condition. The facility total census was 46 residents.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure resident dependent on staff for activities of daily living received a bath or shower as scheduled or requested. This affected one (Resident #32) out of four residents reviewed for bathing care. The facility census was 48.

Inspectors wroteBased on medical record review, observations, and staff interview, the facility failed to ensure call lights to request for help or assistance was within reach for all residents. This affected one (Resident #32) out of four residents reviewed for call lights. The facility census was 48.

Inspectors wroteBased on resident and staff interview, review for the facility grievance log, and review of a facility policy, the facility failed to make prompt efforts to resolve dietary grievances. This had the potential to affect all 50 residents residing in the facility. The facility census was 50.

Inspectors wroteBased on observation, staff interview, review of menu spreadsheets, and review of a facility policy, the facility failed to ensure menus were followed during meal service. This affected all 50 residents residing in the facility. The facility census was 50.

Inspectors wroteBased on observation, staff interview, review of a dishwasher operation manual, and facility policy review, the facility failed to ensure food was served in a safe and sanitary manner, failed to ensure the kitchen was properly cleaned, and failed to ensure the dishwasher was appropriately functioning. This affected all 50 residents residing in the facility. The census was 50.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to maintain a clean, sanitary, and homelike environment. This had the potential to affected all 50 residents residing at the facility. The facility census was 50.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were encoded and transmitted within required timeframes. This affected five (#17, #5, #30, #27, and #11) of five residents reviewed for resident assessment. The facility census was 50.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to develop care plans to address resident needs and interventions. This affected four (#12, #24, #39, and #42) of 24 residents reviewed for care planning. The facility census was 50.

Inspectors wroteBased on observation, staff interview, review of a resident list, and review of a food recipe, revealed the facility failed to prepare food in a palatable and attractive manner. This affected four (#1, #3, #6, and #42) of four residents who received mashed potatoes during meal observations. The facility census was 50.

Inspectors wroteBased on observation, staff interview, review of a resident diet list, the facility failed to ensure mechanically altered meat was prepared in a form to meet resident needs. This affected 11 (#1, #4, #3, #6, #20, #23, #36, #42, #46, #47, and #202) of 11 residents that received mechanically altered diets. The facility census was 50.

Inspectors wroteBased on medical record review and staff interview, the facility failed notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident with a change in their mental health condition. This affected two (#2 and #33) of three residents reviewed for PASARR. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview, hospital documentation review, and review of a facility policy, the facility failed to ensure non-pressure wounds were properly assessed and treated in a timely manner. This affected one (#37) of one residents reviewed for wounds. The facility census was 50. Findings Include: Record review for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included, rheumatoid arthritis, essential primary hypertension, gastro-esophageal reflux disease (GERD), chronic pain syndrome, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Resident #37 was dependent on staff for bathing, toilet use, dressing, and personal hygiene, and required maximum assistance from staff with eating, and oral hygiene. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure a resident was served food on a divided plate per the physician order. This affected one (#37) of one residents reviewed for assistive eating equipment and utensils. The facility census was 50.

Inspectors wroteBased on observation, medical record review, staff interview, policy review, the facility failed to maintain proper signage and personal protective equipment for a resident with an indwelling medical device placed on enhanced barrier precautions. This affected one (#9) of five residents reviewed for infection control. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to timely administer pneumococcal vaccines. This affected two (#11 and #29) of five residents reviewed for vaccinations. The facility census was 50.

Inspectors wroteBased on observations and staff interview, the facility failed to provide a safe and functional environment for the residents. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observation, staff interviews, record reviews, and review of online Centers for Disease and Control (CDC) guidance, the facility failed to ensure the use of appropriate Personal Protective Equipment (PPE) and hand hygiene when providing care to residents in isolation precautions for active infection with Clostridium Difficile (C-Diff). This had the potential to affect all residents residing in the facility except two residents (#13 and #399) who had an active infection with C-Diff. The facility census was 48.

Inspectors wroteBased on patient trust account review, surety bond review, policy review, and staff interviews, the facility failed to ensure the surety bond covered the total balance of resident funds. This had the potential to affect 23 of 23 residents who had their funds handled by the facility. The facility census was 48.

Inspectors wroteBased on medical record review, Beneficiary Notice- Residents discharged list review, and staff interview, the facility failed to inform the resident or his or her legal representative in writing that Medicare will not pay for covered skilled services, and why these specific services may not be covered and the potential liability for payment for the non-covered services. This affected three (#30, #97, and #98) of three residents reviewed for beneficiary notices. The facility census was 48.

Inspectors wroteBased on medical record review, resident personal funds list review, policy review, and staff interview, the facility failed to notify a resident who receives medicaid benefits when their personal funds account reaches less than $200 of the Supplemental Security Income (SSI) resource limit of $2000. This affected two (#20 and #44) of five reviewed for personal funds. The facility currently identified eight (#2, #5, #6, #7, #20, #22, #28, and #44) residents with over $2000 in their accounts. The facility census was 48.

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the ombudsmen of a resident's discharge from the facility. This affected one (#28) of two residents reviewed for hospitalization. The facility census was 48.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to provide bed hold notices to residents/resident representatives within 24-hours of transferring to the hospital. This affected two (#10 and #28) of two residents reviewed for hospitalization. The facility census was 48.

Inspectors wroteBased on medical record review, observation, staff interview, and policy reviews, the facility failed to ensure a resident was lifted in a safe manner in order to prevent potential injury. The facility also failed to ensure fall interventions were implemented. This affected one (#10) of two reviewed for accidents. The facility census was 48.

Inspectors wroteBased on review of the facility's vaccination matrix, review of staff vaccination records, staff interview, review of Centers for Medicare & Medicaid Services (CMS) memorandum, and review of the facility's policy, the facility failed to ensure 100 percent of their staff were fully vaccinated against COVID-19 or had been granted a medical or religious exemption. The vaccination rate for the facility was calculated at 94.2%. The facility census was 48.

Inspectors wroteBased on medical record review, observations, staff interviews, and review of the facility's policy, the facility failed to ensure a resident's call light was properly functioning. This affected one (Resident #19) of 16 residents reviewed in the initial pool sample. The facility census was 48.

Inspectors wroteBased on observations, staff interviews, and review of facility's policy, the facility failed to ensure the use of overhead paging was for only emergency situations. This had the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to have a policy or procedure for time frames in the medication regimen review and steps when an irregularity required immediate action and failed to ensure a residents pharmacy recommendations were not addressed for over a month. This affected one Resident (#32) of five Residents reviewed for medications and had the potential to affect all residents who had monthly pharmacy medication reviews. The facility census was 59.

Inspectors wroteBased on observation, interview, and facilities policy review, the facility failed to provide a clean and well maintained resident smoking area that was free from used smoking materials and failed to keep ash trays emptied and in good condition. This had the potential to affect 20 residents ( Resident #16, #28, #256, #40, #44, #43, #39, #5, #307, #257, #13, #258, #29, #22, #306, #305, #255, #41, #34, and #37) in the facility who are smokers. The facility census was 59.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately assess antidepressant use on a resident's comprehensive admission Minimum Data Set (MDS) assessment. This affected one resident (Resident #25) of five residents reviewed for unnecessary medications. The facility census was 59.

Inspectors wroteBased on observation, resident record review, and staff interview, the facility failed to ensure a complete Long Term Care Minimum Data Set (MDS) 3.0 (a health status screening and assessment tool used for all residents of long term care nursing facilities) assessment was completed. This affected one resident (Resident #4) of 15 resident records reviewed. Findings Include: Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, bipolar disorder, depression and schizophrenia. The physician's orders included Prolixin 2.5 milligrams (mg) daily for schizophrenia. Review of the annual MDS 3.0 assessment completed on 04/28/19 revealed Section C (cognitive assessment), Section D (mood assessment), and Section F (personal preferences) was not completed for Resident #4. [...]

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to follow up on the assistive hearing device needs for one (Resident #17) of one resident reviewed for hearing services. The facility census was 59.

Inspectors wroteBased on observation, staff interview and document review, the facility failed to ensure a resident with oxygen had the nasal cannula changed and dated weekly. This affected one (Resident #16) of two Residents reviewed for oxygen care. This had the potential to affect 15 (Resident #2, #12, #15, #16, #17, #21, #25, #28, #34, #37, #44, #48, #52, #256, and #308,) facility identified residents on oxygen. The facility census was 59.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to monitor behaviors for one resident (Resident #4) who was receiving antipsychotic medications of six residents were reviewed for unnecessary medications. The facility census was 59. Findings Include: Resident #4 was admitted to the facility on [DATE] with diagnoses including dementia, Alzheimer's disease, bipolar disorder, depression and schizophrenia. The physician's orders included Prolixin 2.5 milligrams (mg) daily for schizophrenia. The plan of care dated 10/12/17 indicated Resident #4 received an antipsychotic medication and to monitor behavior symptoms with the goal the resident would not resist care. A Psychoactive medical evaluation completed on 05/02/19 identified Prolixin was used for the diagnosis of schizophrenia. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facilities policy review, the facility failed to follow infection control practices with a resident on contact precautions. This affected one (Resident #13) of two residents reviewed on precautions. The facility census was 59.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure a list of pertinent state agencies and advocacy groups and the complaint hotline were posted in the facility. This had the potential to affect all 59 residents residing in the facility.