Edgewater Health and Rehabilitation

Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure kitchen staff appropriately cleaned thermometers before and after use. Findings include:I. Improper cleaning of food thermometerA. Professional referenceAccording to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved 9/2/25 from:, revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Equipment, food-contact surfaces and utensils shall be cleaned before using or storing food temperature measuring devices. (4-602.11)B. Facility policy and procedureThe Food Temperatures policy, undated, was provided by the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. It read in pertinent part, To take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is metal stem type. To take hot food temperatures, insert the thermometer at a 45-degree angle…

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, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of two units. Specifically, the facility failed to:-Ensure housekeeping staff performed appropriate hand hygiene when cleaning residents' rooms,-Ensure staff performed appropriate hand hygiene when performing incontinence care for Resident #23; and,-Ensure staff wore appropriate personal protective equipment (PPE) during high contact resident care for Resident #23 and Resident #4, who were on enhanced barrier precautions (EBP).Findings include: I. Failed to ensure housekeeping staff performed appropriate hand hygiene when cleaning residents' roomsA. Professional reference According to The Centers for Disease Control And Prevention's (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers (February 2024), retrieved on 9/2/25 from:…

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 interviews, the facility failed to ensure money from personal funds accounts was managed accurately for one (#13) of five residents reviewed for personal funds accounts out of 34 sample residents.Specifically, the facility failed to notify Resident #13, who was Medicaid funded, or her legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit.Findings include:I. Record reviewA review of Resident #13's current trust account balance revealed the resident had $2,631.92 in her account, which was $631.92 over the allotted limit of $2,000.00 for Medicaid-funded residents.II. Staff interviewsThe financial coordinator and the nursing home administrator (NHA) were interviewed together on 8/27/25 at 9:30 a.m. The financial coordinator said she notified residents or residents' representatives when the residents' personal funds accounts reached $2,000. The financial coordinator said she was unaware that the residents or their representatives needed to be notified when their personal funds account reached…

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, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#10) of one resident out of 34 sample residents. Specifically, the facility failed to:-Obtain a physician's order that addressed Resident #10's medical symptoms; -Ensure ongoing safety risk assessments were completed for the use of restraints for Resident #10; and,-Ensure that the least restrictive measures attempted and proven unsuccessful for Resident #10 were documented. Findings include:I. Facility policy and procedureThe Restraint Assessment and Consent policy and procedure, revised October 2024, was provided by the director of nursing (DON) on 8/27/25 at 9:55 a.m. It read in pertinent part, A physical restraint free or least restrictive environment will be the standard for resident care. If restraints are present, the interdisciplinary team will make every effort to reduce and then eliminate restraints. Purposes for restraint use include resident safety, injury prevention…

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, record review, and interviews, the facility failed to ensure one (#69) of four residents reviewed for activities of daily living (ADLs) out of 34 sample residents received the necessary services to maintain good nutrition and personal care. Specifically, the facility failed to provide meal assistance for Resident #69. Findings include:I. Resident #69A. Resident statusResident #69, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD) , essential hypertension (high blood pressure), and hypothyroidism (low thyroid function).The 8/13/25 minimum data set (MDS) assessment revealed Resident #69 had a memory problem and and was moderately impaired cognitive skills for daily decision making per staff assessment. She required maximum assistance of one staff member with meals and one-person assistance with transfers and…

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, record review and interviews, the facility failed to ensure one (#56) of two residents out of 34 sample residents received proper respiratory care and services in accordance with professional standards of practice, the resident's care plan and the resident's choice. Specifically, the facility failed to:-Ensure Resident #56's continuous oxygen setting was set at the prescribed flow rate; and,-Ensure Resident #56 was provided with continuous oxygen supplementation per physician's orders.Findings include:I. Facility policy and procedureThe Oxygen Titration policy and procedure, reviewed 1/14/25, was provided by the nursing home administrator (NHA) on 8/28/25 at 2:00 p.m. via email. It read in pertinent part, Oxygen will be administered per physician orders and nursing evaluation. Evaluation of thecontinued need for oxygen will be based on diagnoses, history and clinical presentation,including titration results. Continuous oxygen orders will include the liter flow, route andfrequency for…

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 observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure thawed nutritional supplements and thickened liquids were dated appropriately; -Ensure food was labeled and dated in the nourishment refrigerators; and, -Ensure expired food was discarded in the nourishment refrigerators. Findings include: I. Professional reference The (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on 2/15/24, read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date…

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 observation, record review and interviews, the facility failed to ensure that residents were kept free from significant medication errors for two (#54 and #47) of six residents out of 26 sample residents. Specifically, the facility failed to: -Ensure an antipsychotic medication for Resident #54 was obtained and administered according to physician's orders; -Notify resident #54's physician that the resident's antipsychotic medication was not refilled which resulted in the resident missing administration of the medication three days; -Ensure Resident #47 received all ordered doses of her prescribed antibiotic medication; and, -Notify Resident #47's physician when the resident did not receive the antibiotic medication. Findings include: I. Professional reference According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of…

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 observations, the facility failed to ensure six of seven residents out of 36 sample residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician orders, and the resident's care plan. Specifically, the facility failed to ensure the puree textures produced were consistent with the International Dysphagia Diet Standard Initiative (IDDSI) level four puree texture (PU4) for residents prescribed a puree diet. Findings include: I. Professional standard The International Dysphagia Diet Standard Initiative (IDDSI) effective July 2019 and retrieved 2/15/24 from https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf revealed in pertinent part, A level four puree texture (PU4): is usually eaten with a spoon (a fork is possible); should not require chewing if presented in this form; falls off the spoon in a single spoonful when tilted and continues to hold shape on a plate; and has no lumps. No biting or chewing is required and the food is smooth with no lumps. II. Facility…

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, record review and interviews the facility failed to ensure one (#33) of four residents reviewed received treatment and care in accordance with professional standards of practice out of 24 sample residents. Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #33. Findings include: I. Facility policy and procedure The Pressure and Wound Prevention and Skin Monitoring policy, revised April 2020, was provided by the administrator in training (AIT) on 11/2/22 at 3:40 p.m. It read in pertinent part, Identification, prevention, and treatments will be based on National Pressure Ulcer Advisory Panel (NPUAP) definitions, recommendations, and practice of standards. The Nurse identifying a new wound should obtain treatment order based on the resident individualized needs. II. Resident #33 A. Resident status Resident #33, age [AGE], was admitted on [DATE]. According to the October 2022 computerized physician orders (CPO), the diagnosis…

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 record review, the facility failed to implement interventions to reduce hazards and risks for falls for one resident (#42) out of four residents reviewed for falls out of 24 sample residents. Specifically, the facility failed to ensure Resident #42 was provided the assisted devices and interventions recommended to prevent repeated and avoidable falls. Findings include: I. Facility policy and procedure The Fall Management policy, revised 5/7/15, was provided by the director of nursing (DON) on 11/2/22 at 2:05 p.m. It read in pertinent part, As part of the admission process, the fall risk evaluation will be completed. If the resident has a history of falls or is a high risk for falls, an acute temporary care plan will be initiated. As soon as possible, following the incident, CNAs will initiate the HUDDLE follow-up. Timeliness of this initial data collection is emphasized to evaluate the environment and identify precipitating events accurately. This evaluation includes:Care…

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.