Edgewood Health And Rehab

Based on observations, interviews, and document reviews, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day, for 7 days a week, and the Director of Nursing (DON) did not serve as the RN in the facility. This failed practice had the potential to affect all residents residing in the facility. The facility census was 84. Findings included: A review of an undated document, titled Job Description Charge Nurse/Shift Supervisor, revealed the primary purpose of the position was to direct nursing care that included: participation in surveys, admit, transfer, and discharge residents, administering medications, arranging diagnostic services, consulting with physician for resident care and treatment, ensuring resident treatments are performed, evaluate residents physical and emotional status, provide catheterization, tube feedings, dressing application/changes, massages, range of motion exercises, obtaining lab specimens, and checking residents, unable to utilize the call light, frequently, and supervise nursing activities performed by nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to ensure staff performed hand hygiene during meal service. Specifically, staff failed to perform hand hygiene between serving resident trays, prior to entering or leaving resident rooms on 1 (300) hall of 1 hall observed during meal service; and failed to ensure hand hygiene was performed during perineal care with a brief change for 1 (Resident #12) of 21 sampled residents. The facility also failed to initiate Enhanced Barrier Precaution (EBP) for 1 (Resident #34) of 1 resident reviewed for enhanced barrier precautions. Findings included: A review of a facility policy titled, Handwashing/Hand Hygiene, revised 10/2023 revealed, the facility trained and expected all employees to follow the policy on hand hygiene, as the facility considered hand hygiene the primary means of preventing the spread of healthcare-associated infections. Hand hygiene was to be performed, c. after contact with . body fluids .d. after touching a resident;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure dietary staff effectively washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, These failed practices had the potential to affect 78 residents who received meals from the kitchen. The findings included: The following observations were made during the supper meal on 09/06/2023. a. Dietary Employee (DE) # 1 at 4:11 PM, removed a can of cream of chicken soup from the storage room and placed it on the counter. She picked up a pan from below the food preparation counter and placed it on the counter. She turned on the sink faucet and rinsed the pan and placed the pan on the counter with her fingers inside the pan. b. At 4:13 PM, DE #1 opened a can of cream of chicken soup and emptied it into a contaminated pan and placed it on the stove. She placed chicken into a pot and started to cook. c. Dietary Employee #2 at 4:15 PM, was holding a box of gloves with his bare hand removed the gloves from the box and placed his hands…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide a sanitary environment for 79 residents and failed to ensure furnishings were free of tears to promote a homelike environment affecting 15 residents residing in the 100 unit. Findings included: A. During observation of the nurses' station on 09/07/2023 at 9:56 AM the wall guard had a layer of dust resting on top. B. During observation of Unit 100 on 09/06/2023 at 2:28 PM, a blue chair in the common area outside the nurses' station had a tear approximately 7 x 2.5 with cream colored foam exposed. The foam area had a hole in the middle and appeared picked apart. C. During interview on 09/07/2023 at 9:18 AM CNA #1 said, residents stick tissues into the hole that is in the blue chair. D. During interview on 09/07/2023 at 9:28 AM, the Surveyor asked Maintenance Director who is responsible for the furnishings, and is it appropriate to use chairs that are ripped with stuffing exposed? The Maintenance Director said he is responsible for furnishings, and it does not make for a homelike appearance. E. During interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure that insulin bottles were dated after opening. The failed practice had the potential to effect 13 residents with orders to receive insulin, and the facility failed to ensure the refrigerated narcotic medications were stored in a permanently affixed container, and locked, to prevent the potential of misappropriation of resident property affecting 79 residents. The findings included: On 09/07/2023 at 7:40 AM the Surveyor observed LPN #1during medication pass on Hall 100. An open bottle of Glargine Insulin was unlabeled and undated. The Surveyor asked LPN #1 is it standard practice to label a new insulin bottle with the open date? LPN#1 stated, They are supposed to be, but she is a fairly new admit. During interview on 09/07/2023 at 11:47 AM, the Surveyor asked the Director of Nursing (DON) should insulin be dated when opened? The DON said, yes in order to discard the bottle within 28 days. Observation of the medication storage room on 09/07/2023 at 3:15 PM showed the following: a. One open bottle of Levemir Insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure personal medical information and privacy was protected for 1of 1 Resident (Resident #279) during medication administration. This failed practice had the potential to affect 19 Residents on Hall 300 receiving medications. The findings included: During the morning medication pass on 09/07/2023 at 7:40 AM, the Surveyor observed LPN#1 leave Resident #279's empty medication blister pack on top of the medication cart with Resident #279's name and medication information visible to anyone in 300 hall. During interview on 09/07/2023 at 7:45 AM LPN#1 said, she forgot and left the empty medication pack on the cart visible, and confirmed there was personal information of Resident #279's on the pack. On 09/07/23 at 11:47 AM, the Director of Nursing (DON) confirmed medication cards with resident information should not be left unattended and visible on the medication cart. Review of facility's policy titled Computer Terminals/Workstations on 09/08/2023 at 11:50 AM provided by the Nurse Consultant showed, Printed information that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control measures were implemented during medication administration to help prevent the development and transmission of communicable diseases and infections for 1 of 1 blood glucose observation. The following observations and interviews were made on 09/07/2023 of (Licensed Practical Nurse) LPN #1 during the morning medication pass. a. On 09/07/2023 at 7:39 AM LPN#1 came out of a resident's room with gloved hands that were worn while checking a resident's blood glucose level. LPN#1 pulled the handle on the bottom drawer of the medication cart wearing the same gloves. LPN#1 then pulled the glove off his right hand, laid it on top of the medication cart, and proceeded to open the drawer where insulin was stored. The Surveyor asked LPN#1 if there was an issue with trying to open the medication cart drawer with the same gloves worn for checking glucose. The LPN#1 stated, You don't want to transfer any germs. I'm sorry you caught me off guard. During interview on 09/07/2023 at 11:47 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure foods stored in the refrigerators, freezer, and dry storage room were dated and failed to ensure foods stored in the freezer were sealed to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 71 residents (total census 73) who received meals from the kitchen as documented on a list provided by the Director of Nursing (DON) on 06/09/22 at 1:35 PM. The findings are: 1. On 06/06/22 at 9:22 AM, during the initial tour of the kitchen with the Registered Dietician (RD) and the Dietary Manager (DM) the following observations were made: a. At 9:57 AM, in the Walk-In freezer there was a box of Vanilla Ice Cream Sandwiches not dated. The RD could not find the box they came out of. She stated she would throw them away. The RD guessed there was 15-20 Ice Cream sandwiches in the box. An open bag of breaded chicken fillets was not sealed. Whitish gray crystals had formed on the fillets. The RD stated they will throw them out.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure assistance with meals was provided to meet the needs of the residents to improve, maintain or prevent a decline in their eating abilities for 1 (Resident #56) of 2 (Residents #56 and 176) of sampled residents who required their food to be cut up and failed to ensure one on one assistance with eating was provided for 1 (Resident #57) of 1 sampled resident who had physician orders for one on one meal assistance. The findings are: 1. Resident #56 had diagnoses of Dementia, Hemiplegia, Chronic Pain, Osteoporosis Unspecified Cerebral Infarction, Muscle wasting and Atrophy Multiple Sites. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision with set up only for eating. a. A current physician's orders documented, Regular-Enhanced diet Regular texture, regular consistency . b. The Care Plan with a revision date of 5/17/22 documented, 1:1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 4 residents who received pureed diets as documented on a list received from the Director of Nursing (DON) on 06/09/22 at 1:32 PM. The findings are: 1. On 06/07/22 at 11:12 AM, Dietary Employee (DE) #1 pureed beef patties and emptied the food processor contents into a metal steam table pan and covered the pan with plastic wrap and placed it on steam table. The Surveyor took a spoonful of the pureed beef patties and felt texture with her fingers. There were pieces of hard fat, 1/2 the size of a pea throughout the spoonful of pureed beef patties. The Registered Dietician (RD) felt the fat balls and stated the beef patties, pork, and sausage were difficult to puree. 2. The RD informed DE #1 to puree the meat more and add two slices of bread per the recipe to make a smooth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate to facilitate the ability to plan and provide necessary care and services for 3 (Resident #25, 69 and 70) of 11 (Residents #14, 69, 55, 13, 51, 25, 70, 72, 56, 49 and 38) sampled residents who received Plavix, and failed to ensure accurate completion of the MDS related to a significant change in condition for 1 (Resident #42) of 13 (Residents #14, 75, 39, 32, 71, 59, 50, 77, 62, 6, 43, 42 and 13) sampled residents who were hospitalized , admitted or discharged from Hospice Services or had a decline in care areas the last 120 days. These failed practices had the potential to affect 14 residents with Physician Orders for Plavix according to list provided by the Director of Nursing (DON) on 6/8/22 at 3:20 PM and 34 residents who were hospitalized , admitted , or discharged from Hospice services or who had a decline in care areas the last 120 days according to a list provided by the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the comprehensive person centered plan of care addressed the medical and nursing needs related to the administration of an anticoagulant medication to alert staff of the necessary care and monitoring to minimize the potential for complications for 1 (Resident #36) of 9 (Residents #36, 55, 51, 19, 34, 226, 59, 176 and 67) sampled residents who had physician orders for an anticoagulant medication. The findings are: 1. Resident #36 had diagnoses of Hypertension, Personal History of Pulmonary Embolism and Thrombosis and Embolism. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an anticoagulant 7 days of the 7 day look back period. a. The Physician's Order dated 10/18/21 documented, Eliquis Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to Personal History of Other Venous Thrombosis and Embolism . b. On 06/09/22 at 9:47 AM, the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.