Edgewood Manor of Wellston

Inspectors wroteBased on record reviews and staff interview, the facility failed to ensure as needed psychotropic medications were not prescribed for longer than 14 days without being re-ordered by the physician or discontinued. This affected two residents (#37 and #42) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 40.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, this facility failed to ensure a care plan was in place for a resident diagnosis with Post-Traumatic Stress Disorder (PTSD) This affected one (Resident #3) of the one resident reviewed for accurate PTSD care planning. The facility census was 40.

Inspectors wroteBased on interview and record review the facility failed to ensure a referral appointment was made timely with ophthalmology for Resident #11. This affected one (Resident #11) of two residents reviewed for communication and sensory. The facility census was 40. Review of the medical record for Resident #11 revealed a readmission date of 04/10/25 with diagnoses including heart failure, chronic obstructive pulmonary disorder, atrial fibrillation, diabetes mellitus type two, peripheral vascular disease, dementia and bilateral cataracts. Review of the physician orders revealed an order written on 04/11/25 for audiology, dental, vision and podiatry ancillary services per 360 as needed. An order dated 04/14/25 for artificial tears ophthalmic solution 1%, instill one drop in both eyes three times daily. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, this facility failed to ensure neuro checks were completed after a resident experienced a unwitnessed fall. This affected one (Resident #23) of the four residents reviewed for falls. The facility census was at 40. Findings Include: Review of the medical record for Resident #23 revealed an admission date of 08/31/2020. Diagnoses included senile degeneration of the brain, peripheral vascular disease, restlessness and agitation, and optic atrophy bilateral. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 indicating a severely impaired cognition for daily decision-making abilities. [...]

Inspectors wroteBased on resident record review, staff interview, and review of hospital discharge instructions, the facility failed to ensure discharge orders for medications were accurately implemented. This affected one resident (#39) out of the 16 residents whose medications were reviewed. The facility census was 40.

Inspectors wroteBased on record review, review of a facility fall report, policy review and interview, the facility failed to provide timely and necessary pain management (including the administration of effective pain medication) for Resident #23 following the identification of an injury to the resident's hip/leg. Actual Harm occurred on 05/19/24 when direct care staff identified Resident #23, who was severely cognitively impaired had increased incontinence (not his baseline) and verbal and non-verbal signs of pain including facial grimacing and grabbing his right leg during care resulting in unrelieved pain. On 05/19/24 at 11:16 A.M. nursing staff received an order for Ultram for pain. However, the medication was not administered on this date until 4:05 P.M. (almost five hours after the order was received). The resident was subsequently transferred to the emergency room on 0519/24 at 8:32 P.M. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to include pertinent information on the minimum data set (MDS) assessment for two residents (#15 and #26) out of 13 residents reviewed for assessment accuracy. The facility census was 44.

Inspectors wroteBased on record review and interview, the facility failed to submit a resident review (RR) when Resident #17 received a new diagnosis. This affected one (Resident #17) of two residents reviewed for PASARRs (pre-assessment screens and resident reviews). The facility census was 44.

Inspectors wroteBased on interview and record review the facility failed to ensure the Pre admission Screening and Resident Review (PASARR) was accurate upon admission for Resident #15. This affected one of two residents reviewed for PASARR. The facility census was 44.

Inspectors wroteBased on record review and interview, the facility failed develop a care plan addressing schizophrenia for Resident #17 and Post Traumatic Stress Disorder (PTSD) for Resident #15. This affected two (Resident #15 and #17) of two residents reviewed for comprehensive care plans.

Inspectors wroteBased on interviews, observations, record review and policy review, the facility failed to have bilateral palm protectors in place for one (Resident #10) reviewed for prevention of decrease of limited range of motion. The facility census was 44.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure an order and care plan interventions were in place for a dialysis site for one resident (#26) of one reviewed for dialysis. The facility census was 44.

Inspectors wroteBased on interview, medical record review and policy review the facility failed to ensure Resident #15 was not appropriately assessed to identify the cause of the residents' Post Traumatic Stress Disorder (PTSD), how to minimize triggers and or re-traumatization. This affected one of two residents identified as having PTSD. The facility census was 44.

Inspectors wroteBased on interviews and record reviews, the facility failed to identify specific target behaviors related to major depressive disorder with implementation of a care plan for one resident (#26) of seven residents reviewed. The facility census was 44.

Inspectors wroteBased on closed record review, policy review, and interview, the facility failed to ensure Resident #22 was free from significant medication errors. This affected one resident (#22) of four residents reviewed for unnecessary medications. The facility census was 44. Actual Harm occurred on 11/27/23 and continued through 01/29/24 when the facility failed to clarify medication orders with Resident #22's referring hospital and include the resident in an admission care plan meeting, resulting in chemotherapy medication being administered in error to Resident #22. As a result of the medication errors, Resident #22 reported and suffered increased weakness, pain, nausea, constipation, and weight loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of unnecessary medications. This affected two residents (#33, #44) of four residents reviewed for unnecessary medications. The facility census was 44.

Inspectors wroteBased on record review and interviews the facility failed to provide an appropriate diagnosis for the use of an antipsychotic. This affected one resident (Resident #40) of five residents reviewed for unnecessary medications. The facility census was 45.