The Plaza at Edgemere

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (Residents #1 and #2) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1 and Resident #2 did not develop wounds due to ill-fitting (too small) briefs for both, and the use of a mechanical lift sling that was too small for Resident #1. This failure could place residents at risk for pain and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that only paper towels were placed in 3 of 3 handwashing sink garbage receptacles. The facility failed to ensure that 1 of 3 handwashing sinks had a garbage receptacle. The facility failed to maintain the sanitizing solution used in the manual dishwashing process at the proper chemical concentration required for effective sanitation. The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents. These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the kitchen on January 20, 2026, at 10:06 a.m., revealed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the fourth quarter (July 1, 2025, to September 30, 2025). The facility failed to submit complete PBJ staffing information to CMS for July 1, 2025, to September 30, 2025. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included:Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 4 (July 1, 2025- September 30, 2025). No other quarter triggered. An interview with the Administrator on 01/20/2026 at 9:30 am, revealed she was not employed by this facility during that reporting period. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain 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 for two (Resident #14, and #71) of four residents observed for infection control in that: LVN A failed to disinfect the blood pressure cuff (used to take blood pressure), and the thermometer in between vital sign checks for Resident #14, and Resident #71. This failure could place residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #2) of 4 residents reviewed for care plan review and revision. The facility failed to review and revise Resident #2's care plan after he fell on [DATE] and 06/22/2025. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 2 kitchens reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure foods in the refrigerator and freezer, were properly sealed from air-borne contaminations. 2. The facility failed to clean the food storage bins in the dry food storage area in the main kitchen. The facility failed to clean the Ice Machine on both the 3rd floor (Main Kitchen) and 2nd floor (Secondary Kitchen). These failures could place residents at risk for cross contamination and air-borne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #6, Resident #15, and Resident #32) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #6's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #15's CPAP mask (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure that Resident #32's CPAP mask was stored properly. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 3 for 2024 (April 1-June 30) reviewed for administration. The facility failed to submit staffing data to CMS for (April 1- June 30). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain 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 for two (Resident #18 and Resident #198) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA A changed her gloves and performed hand hygiene while providing incontinent care to Resident #18. 2. The facility failed to ensure that CNA B and the MDS Nurse changed their gloves and performed hand hygiene while providing incontinent care to Resident #198. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #29) of 5 residents reviewed for dignity. The facility failed to treat Resident #29 with dignity and promote enhancement of his quality of life when the resident's catheter bag was not placed away from the door as care planned. This failure placed residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #32) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #32's Comprehensive MDS Assessment accurately reflected that Resident #32 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #19) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #19 was care planned for Hospice Care. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Resident #148) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LVN C did not leave Resident #148's medications inside the resident's room. This failure could place the residents at risk of not receiving medications as ordered by the physician.