Edgewood Rehab & Living Ctr

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 1 of 1 wing (Long Term Care), a sitting area and the laundry room for 1 of 1 facility tours.

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written transfer/discharge notices and bed hold notices residents or known family member or legal representative for facility-initiated transfers/discharges for 2 of 4 sampled residents transferred/discharged to an acute care facility. Resident #1(R1) and #8(R8). Additionally, the facility failed to notify the Ombudsman's office.

Inspectors wroteBased on observations, interviews, facility policy the facility failed to update and include interventions on the resident's current comprehensive care plan for the areas of oxygen for 2 of 2 residents (Resident's [R]11 & R34), and in the area of activities for 1 of 4 care plans reviewed for activities (R15).

Inspectors wroteBased on interviews, record reviews, activity calendar review, and Resident Council meeting minutes, the facility failed to provide residents with a continuous resident centered activities program for 3 of 3 residents reviewed for activity participation. (Resident's #[R]6, R15 & R35).

Inspectors wroteBased on observations, record review, interview, and facility policy, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care and failed to obtain a physician order for oxygen for 2 of 2 residents reviewed for respiratory care (Resident [R] 11, 34).

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts for 1 of 3 Controlled Substance Books reviewed (Certified Nursing Assistant-Medication Tech [CNA-M] medication cart book).

Inspectors wroteBased on observations, interviews and the facility's Dish Machine Temperature and Sanitizer Log Form, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling air vents, walls, ceiling tiles, ceiling grids, a food mixer, a food disposal, a wash rack, floors and the dry storage room; and failed to properly label and date foods in the walk-in refrigerator, the reach-in freezers, and the activity room kitchenette area. Additionally, the facility failed to ensure that a kitchen staff members wore hair and facial hair protection. Further, the facility failed to monitor/document dish machine temperatures.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 2 of 3 survey days. (8/18/25 and 8/19/25).

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) - Version 3.0 Assessments were accurately coded in the areas of Health Conditions and Special Treatments for 1 of 13 sampled residents (Resident [R] 34).

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 13 residents reviewed for baseline care plans (Resident #11).

Inspectors wroteBased on record review and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed for care planning (Resident 11).

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to document and adequately monitor a resident after an unwitnessed fall and failed to notify a physician after a fall for 1 of 3 residents reviewed for falls (Resident [R] 34).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 sampled residents reviewed for nutrition (Resident [R]6).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to the storage of a urinary catheter drainage bag for 2 of 3 days of the survey.

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 9 of 18 resident rooms, a dining room, a whirlpool room, a bathroom and the laundry room for 1 of 1 Environmental Tour.

Inspectors wroteBased on facility policy, record review and interviews, the facility failed to complete post fall neurological assessments along with appropriate fall assessments for 3 of 3 residents reviewed for falls (#17, #3, #333). In addition, the facility failed to follow physician orders for 1 of 2 residents reviewed for positioning (#18).

Inspectors wroteBased on facility policy, record review and interviews, the facility failed to adequately ensure medications and biologics were monitored and stored at appropriate temperatures in 1 of 1 refrigerator observed and 3 of 3 months of medication refrigerator logs reviewed.

Inspectors wroteBased on observations, interviews, and review of the facility's Dish Machine Temperature and Sanitizer Log Form, the Refrigerator/Freezer Food Storage and Temperature policies and procedures, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for fans, a food mixer, ceiling vents, ceiling lights, ceiling tiles and a door thresh hold; failed to ensure foods were sealed in the walk-in freezer; failed to monitor the temperatures of the walk-in freezer and the walk-in refrigerator; failed to monitor the dishwasher wash and rinse cycle temperatures as well as the chemical sanitizer levels for the sanitizing sink and the sanitizing buckets for 1 of 1 kitchen tour and for 1 of 1 survey days (10/15/24). This has the potential to affect all residents.

Inspectors wroteBased on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 3 of 3 days and 2 of 2 dumpsters for 1 of 3 days of survey. (10/15/24, 10/16/24 and 10/17/24)

Inspectors wroteBased on immunization record review, review of the facility's immunization policy and interview, the facility failed to implement their pneumococcal immunization policy for 3 of 5 residents whose immunization records were reviewed (#18, #19, #28)

Inspectors wroteBased on clinical record reviews, facility policy review and interview, the facility failed to offer updated (COVID-19) vaccine doses for 5 of 5 residents reviewed. (#7, #15, #18, #19 & #28)

Inspectors wroteBased on interview and record review, the facility failed to ensure that a baseline care plan was developed and implemented within 48 hours, that included instructions needed to provide minimum healthcare information necessary to properly care for 1 of 1 residents reviewed for new admissions (Resident #31).

Inspectors wroteBased on observation, interviews, and Material Safety Data Sheet (MSDS) review, the facility failed to ensure doors were locked where potentially dangerous chemicals were stored for 1 of 3 days of survey.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information on a daily basis including: the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 2 of 3 survey days.

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 10 of 18 resident rooms, the whirlpool room and the laundry room for 1 of 1 Environmental Tour.

Inspectors wroteBased on observations and interview, the facility failed to ensure that medications were stored properly by having unlabeled medications stored in three resident's rooms for 1 of 3 days of survey. (Rooms #6, #7, #8)

Inspectors wroteBased on observations, interviews, and review of the facility's sink/bucket sanitizer form/policy and procedure, the daily high-temperature ware wash checklist/policy and procedure, the freezers and refrigerators temperature forms, and the food storage policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling lights, the food mixer, the dry storage room and the kitchen floor. The facility also failed to remove expired foods and failed to date, label and/or seal foods in the walk-in freezer and in the walk-in refrigerator. Additionally, the facility failed to monitor the temperatures of the walk-in freezer and the walk-in refrigerator. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 2 dumpsters for 3 of 3 days of survey. (2/21/23, 2/22/23 and 2/24/23)

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, neglect, exploitation and misappropriation of resident property by failing to ensure that 2 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training completed the required training (#2 & #3).

Inspectors wroteBased on observations, interview and review of the Safety Data Sheet, the facility failed to ensure that the resident environment remained free from the potential risk of accident when they failed to ensure that a chemical was properly secured for 2 of 2 observations during 1 of 3 days of survey (2/21/23).

Inspectors wroteBased on interview, review of the daily staffing postings the Payroll Based Journal Report, and the nursing working schedule the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week for 1 of 77 days reviewed for Sufficient and Competent Nurse Staffing.