Edgewood Manor Rehabilitation & Healthcare Center

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure a resident's safety during perineal care. Actual harm occurred on 06/27/26 at 11:29 P.M. when Resident #69 was receiving perineal care from one staff member and the staff turned to obtain a washcloth from the basin and the resident rolled off the bed onto the floor. Resident #69 sustained a laceration to the left eyebrow that required skin glue to close and sustained left periorbital soft tissue swelling and hematoma. This affected one, (Resident #69) of one reviewed for falls.

Inspectors wroteBased on observation, staff interview, review of facility staffing, and review of facility policy, the facility failed to ensure sufficient dietary staff were available to timely [NAME] the dietary needs of the residents. The facility's failure to provide adequate dietary staffing had the potential to affect all residents, as the facility identified no residents who did not receive meals and food services from the facility kitchen. The facility census was 71.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure dietary staff verified the final cooking temperature of potentially hazardous food prior to placing the food into hot holding. This had the potential to affect all 71 residents receiving meals prepared by the dietary department. The census was 71.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to serve meals in accordance with established meal schedules. This deficient practice had the potential to affect all 71 residents receiving meals from the dietary department. The census was 71.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain sanitary conditions during food preparation and meal service. This had the potential to affect all 71 residents receiving meals prepared by the dietary department. The census was 71.

Inspectors wroteBased on observation, staff interview, resident interview, medical record review, and review of facility policy, the facility failed to ensure the physical environment was maintained in a clean, sanitary, functional, and comfortable manner for residents residing outside of the memory care unit. This deficient practice had the potential to affect all residents residing outside of the memory care unit. The facility census was 71.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure respect and dignity was maintained during meal service. This affected two residents (#26 and #32) out of 12 residents observed during lunch meal service. The facility census was 71. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included dementia, dysphagia, Alzheimer's disease and anxiety. Review of the Minimum Data Set (MDS) assessment for Resident #26 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE]. Diagnosis included dementia, muscle weakness and anxiety. Review of the MDS assessment for Resident #32 revealed a BIMS score of three, indicating severe cognitive deficit. [...]

Inspectors wroteBased on observation, staff interview, resident interview, medical record review, and review of facility policy, the facility failed to ensure the physical environment was maintained in a clean, sanitary, functional, and comfortable manner for one resident (#79) of five reviewed for Activities of Daily Living (ADLs). The facility census was 71.

Inspectors wroteBased on observation, resident interview, staff interview, review of medical record, and review of facility policy, the facility failed to ensure one resident (#79) received assistance with Activities of Daily Living (ADL) . This affected one of five reviewed for ADL's. The facility identified that all facility residents require assistance with ADLs. The facility census was 71. Findings Include:Review of the medical record for Resident #79 revealed an admission date of 06/25/26 with diagnoses including major depressive disorder, Type II Diabetes Mellitus (DM2), anxiety disorder, unspecified psychosis, personal history of suicidal behavior, atherosclerotic heart disease of the native coronary arteries, personal history of transient ischemic attack (TIA), polyneuropathy, urinary retention, acquired absence of other toes, and chronic pain. [...]

Inspectors wroteBased on record review, staff and resident interview, and facility policy review, the facility failed to ensure foley catheters were secured. This affected two residents (#22 and #51) of two residents reviewed for catheter securement devices. The facility census was 71. Findings Include:1. Review of Resident #22's medical record revealed an admission date of 06/05/26. Diagnoses included benign prostatic hyperplasia without lower urinary tract symptoms, obstructive uropathy, urinary retention, hypertension, Type II Diabetes, sepsis, emphysema, and acute respiratory failure with hypoxia. Review of Resident #22's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition and had an indwelling catheter. [...]

Inspectors wroteBased on observation, resident and staff interview, medical record review, review of facility policy, review of distributor documentation, and review of manufacturer documentation, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident (#21) of one resident reviewed for oxygen. The facility identified 10 residents (#9, #13, #14, #20, #21, #28, #43, #53, #57, and #61) with physician orders for oxygen. The facility census was 71. Findings Include: [...]

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were stored in a safe and secure manner this affected one resident (#21). This had the potential to affect three residents (#36, #42, and #78) who were identified by the facility as independently ambulatory and cognitively impaired. The facility census was 71. Findings Include: Review of the medical record for Resident #21 revealed an admission date of 07/31/24 with diagnoses including chronic obstructive pulmonary disease (COPD), generalized muscle weakness, history of falling, abnormalities of gait and mobility, acute respiratory failure, obesity, gastroesophageal reflux disease (GERD), congestive heart failure (CHF), obstructive sleep apnea (OSA), depression, anxiety, hyperlipidemia, hypertension (HTN), and insomnia. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure routine dental care was provided. This affected one resident (#24) out of one reviewed for dental care services. The facility census was 71. Findings Include:Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, dysphagia, and psychosis, major depressive disorder, Alzheimer's, and Type Two Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #24 dated 04/03/26 revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive deficit. Function abilities included partial to moderate assistance with personal and oral hygiene. [...]

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) were maintained for two residents ( #5 and #63). This affected two but had the potential to affect 13 residents (#3, #4, #5, #13, #14, #16, #39, #42, #47, #51, #57, #61, and #63) identified by the facility as having physician orders for EBP. Additionally, the facility failed to ensure a urinary catheter drainage bag was not sitting on the floor. This affected one resident (#51) of three reviewed for urinary catheters. This deficient practice had the potential to affect six residents (#4, #5, #16, #39, #51, and #57) identified by the facility as having indwelling urinary catheters. The facility census was 71. Findings Include: 1. [...]

Inspectors wroteBased on observation, staff interview, review of medical record, review of hospital records, and review of facility policy, the facility failed to ensure wound care was timely ordered and implemented for one resident (#53) of three residents (#52, and #64) reviewed for wound care. The facility census was 62. Findings Include: [...]

Inspectors wroteBased on observation, staff interview, review of medical record, and review of facility policy, the facility failed to ensure adequate infection control practices were implemented. This affected Resident #53 with the potential to affect all facility residents. The facility census was 62. Findings Include: Review of the medical record for Resident #53 revealed an admission date of 04/30/25 with diagnoses including anxiety, injury of unspecified kidney, hypothyroidism, altered mental status (AMS), osteoarthritis, asthma, benign prostatic hyperplasia (BPH), bipolar disorder, cellulitis, cerebral infarctions, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), depression, hyperlipidemia, diverticulitis of intestine, gastro-esophageal reflux disease (GERD), insomnia, suicidal ideations (SI), bipolar II disorder, and other long-term (current) drug therapy. [...]

Inspectors wroteBased on observation, medical record review, and staff interview the facility failed to ensure timely interventions were provided to address resident incontinence patterns. This affected one (#5) of four residents reviewed for incontinence care. The facility census was 66.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review the facility failed to ensure medications were maintained and administered in a secure manner. This affected one resident (#4) observed with medications unattended at the bedside. The facility identified five cognitively impaired independently mobile residents(#19, #24, #25, #26, #27) with a total facility census of 66.

Inspectors wroteBased on record review, hospital discharge instruction reviewed, witness statement review, fall occurrence evaluation review, staff interviews, and policy review, the facility failed to ensure a resident requiring two staff members for bed mobility was implemented which resulted in a fall from the bed with an injury. This resulted in Actual Harm when Resident #65, who was moderately cognitively impaired, required the assistance of two staff for bed mobility sustained a fall from bed, when one staff member was providing care, and the resident fell to the floor. Resident #65 experienced left leg pain and was transferred to the hospital and returned with diagnosis of a supracondylar fracture of the left femur (fracture of the shaft of the left femur), requiring a cast from the foot to the hip and treatment for pain. [...]

Inspectors wroteBased on record review, resident interview, staff interview, medical record review, employee file review, self reported incident review and review of policy, the facility failed to ensure residents were free from abuse by staff. This affected two (#14 and #60) of three residents reviewed for abuse. The facility census was 64.

Inspectors wroteBased on observation, staff interview, record review, Enhanced Information Dissemination and Collection (EIDC) system review, witness statement review, fall occurrence review, and policy review, the facility failed to timely report an incidence of potential neglect to the appropriate state agency. This affected one (#65) of three resident reviewed for reporting potential abuse and neglect. The facility census was 64.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure proper infection control practices were maintained for residents in isolation. This affected one resident (Resident #54) of one resident reviewed for enhanced barrier precautions (EBP). The facility census was 64.

Inspectors wroteBased on review of the staffing schedule, interviews with staff, and facility policy, the facility failed to ensure required Registered Nurse (RN) coverage. This had the potential to affect all 65 residents.

Inspectors wroteBased on observation, staff interview, and review of the pest control service logs, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 65 of 65 residents who received meals from the kitchen.

Inspectors wroteBased on medical record review, interviews with staff, review of Self-Reported Incidents (SRI), and review of facility policy, the facility failed to ensure instances of resident elopement were reported for Resident #54. Additionally, the facility failed to ensure staff allegations of a unlicensed staff member administering unprescribed melatonin were reported for four (#3, #29, #55, and #60) residents. This affected five (Residents #3, #29, #54, #55, and #60) of five residents reviewed for abuse. The facility census was 65.

Inspectors wroteBased on medical record review, interviews with residents, interviews with staff, and review of facility policy, the facility failed to investigate an allegation of unlicensed staff administered unprescribed melatonin to residents. This affected four (Residents #3, #29, #55, and #60) of five residents reviewed for abuse. The facility census was 65.

Inspectors wroteBased on observation, staff interview, resident representative interview, and facility policy the facility failed to ensure the facility was maintained in a clean and sanitary manner. This affected 28 (#3, #5, #14, #15, #18, #20, #22, #23, #26, #27, #29, #32, #33, #34, #36, #38, #39, #42, #43, #44, #45, #46, #51 #52, #55, #56, #60, and #61) residents residing in the memory care unit. The facility census was 65.

Inspectors wroteBased on medical record review, review of the facility Self-Reported Incident (SRI), review of the facility investigation, review of the facility census, resident interview, and staff interview, the facility failed to ensure a resident was free from staff to resident verbal abuse. This affected one (#16) of five residents reviewed for abuse. The facility census was 65.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy, the facility failed to provide adequate supervision to prevent resident elopement. This affected one (#54) of three residents reviewed for elopement. Additionally, the facility failed to ensure fall interventions were in place for one (#58) of three residents reviewed for falls. The facility census was 65.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure Resident #16 received oxygen at the correct rate as prescribed by the physician. This affected one (Resident #16) of two residents reviewed for respiratory care. The facility census was 65.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to discard expired insulin. This affected three residents (#18, #32, and #38) reviewed for insulin storage. The facility census was 65.

Inspectors wroteBased on review of the pharmacy recommendation, review of the medical record, staff interview, and review of the facility policy, the facility failed to ensure laboratory tests were completed per pharmacist recommendation and physician order. This affected one (#53) of one resident reviewed for laboratory testing. The facility census was 65.

Inspectors wroteBased on observation, resident council minutes review, resident and staff interviews, the facility failed to serve hot and palatable foods. This had the potential to affect 65 of 65 residents who receive food from the kitchen. The facility census was 65.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment in the kitchen. This has the potential to affect 65 of 65 residents receiving food and drink from the kitchen and who reside in the facility. The census was 65.

Inspectors wroteBased on record review, interview and policy review, the facility failed to provide showers for residents dependent on staff for activities of daily living. This affected six (Residents #36, #41, #45, #60, #64 and #20) of six residents reviewed for showers and baths. The census was 67. 1. Review of Resident #36's medical record revealed an admission date of 06/27/22. Diagnosis included peripheral vascular disease, chronic kidney disease, prostate cancer, and atherosclerosis. Review of Resident #36's admission Minimum Data Set (MDS) assessment, dated 07/06/22, revealed the resident had a moderate cognitive function. The resident required an extensive assist of one person for personal hygiene, bathing, and dressing. [...]

Inspectors wroteBased on employee file review, staff interview, and policy review, the facility failed to complete annual evaluations on State Tested Nursing Aides (STNA). This affected four (#322, #327, #420, #424) of four STNA employee files reviewed. This had the potential to affect all 65 residents. The facility census was 65.

Inspectors wroteBased on observation, staff interview, review of staff in-services, review of Centers for Disease Control for Prevention (CDC)guidance, and review of facility policy, the facility failed to ensure proper infection control practices and procedures were in place to prevent the spread of COVID-19. This had the potential to affect all 65 residents in the facility. The facility census was 65.

Inspectors wroteBased on observation, and interview the facility failed to provide a dignified dining experience for residents. This affected seven (Residents #5, #24, #38, #40, #50, #53 and #122) of fourteen residents observed for lunch in the dining room. The facility census was 64.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to reassess the effectiveness of interventions and failed to review and update the comprehensive care plan for a resident. This affected one (Resident #53) of 22 residents whose care plans were reviewed. The facility census was 64.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure an indwelling urinary catheter was maintained to prevent infection. This affected one (Resident #44) of one resident reviewed for catheter care. The census was 65.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure a resident who required dialysis was receiving the care and treatment according to physician orders and failed to maintain communication with the dialysis center on coordination of care. This affected one (Resident #61) of one resident reviewed for dialysis. The facility census was 65.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure accurate and complete medical records were maintained. This affected one (Resident #61) of 22 resident records reviewed. The facility census was 65.