Edgewater Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain surgical wound care instructions for a newly placed suprapubic catheter (a urinary drainage device inserted directly into the bladder) for 1 of 3 residents reviewed for wound care. (Resident C)Findings include:Resident C's clinical record was reviewed on 6/15/26 at 10:56 a.m. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, methicillin resistant staphylococcus aureus (MRSA) infection (antibiotic resistant infection), and obstructive and reflux uropathy candidiasis.A progress note, dated 5/21/2026 at 11:28 p.m., indicated a dressing to the suprapubic catheter was intact with minimal yellow drainage.A progress note, dated 5/23/2026 at 12:10 a.m., indicated a dressing to the suprapubic catheter was intact with minimal yellow drainage.A progress note dated 5/23/2026 at 11:28 a.m., indicated a suprapubic catheter dressing had a slight amount of drainage.A progress note, dated 5/26/2026 at…

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 interview and record review, the facility failed to provide residents and/or their representatives with written notice of transfer/discharge and bed hold policy for 1 of 3 residents reviewed for hospitalizations. (Resident 78)Resident 78's record was reviewed on 4/15/126 at 3:51 p.m. Diagnoses included liver cancer, altered mental status, and malnutrition.A 1/29/26 at 12:22 p.m. nurse's note indicated the resident was visited by a Nurse Practitioner (NP) and found to be lethargic and difficult to rouse. The NP ordered the resident sent to the emergency room (ER).A 1/29/26 6:30 p.m. nurse's note indicated the resident was admitted to the hospital.A 1/29/26 notice of transfer/discharge document, provided by the DON on 4/20/26 at 11:18 a.m., lacked an attached bed hold policy. The clinical record lacked documentation that the resident and/or their representative was provided with a written copy of the transfer/discharge form and/or bed hold policy.During an interview, on 4/20/26 at 11:34 a.m., RN 7 indicated when a resident was sent to the ER, a packet of paperwork including…

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 complete a required Preadmission Screening and Record Review (PASRR) Level I screening assessment to determine if a Level II assessment was required when the resident received a new major mental illness diagnosis for 1 of 1 resident reviewed for PASRR. (Resident 11)Finding includes:Resident 11's clinical record was reviewed on 4/17/26 at 3:43 p.m. The resident was admitted to the facility on [DATE]. Diagnosis included schizoaffective disorder, bipolar type. This diagnosis was added in July 2024. A 6/6/24, preadmission Level I PASARR Outcome document indicated a Level II assessment was not required. Rationale: There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral condition. If changes occur or new information refutes these findings, a new screen must be submitted.A current care plan, initiated 7/11/24, indicated the resident had behavioral symptoms of delusions, tangential thoughts, agitation,…

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 communications with a dialysis provider were reviewed to prevent duplicate pneumococcal vaccinations and to ensure continuity of care for 1 or 1 residents reviewed for dialysis. (Resident 2) Findings include:Resident 2's clinical record was reviewed on 4/16/26 at 3:12 p.m. Diagnoses included hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure. Current orders included dialysis on Monday, Wednesday, and Friday (1/6/26).A review of the resident's March 2026, Dialysis Communication facility binder indicated Resident 2 received the Pneumococcal 20-valent conjugate vaccine (Prevnar 20) in her left deltoid while at dialysis on 3/2/26.Review of the resident's clinical record vaccination history indicated a Prevnar 20 vaccination was provided, at the facility, on 3/26/26, in the resident's left deltoid.The clinical record lacked historical data of any previous immunizations.A 3/26/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively…

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 pharmacy recommendations were completed in a timely manner and per facility policy for 3 of 5 residents reviewed for unnecessary medications. Findings include: 1.Resident 3's clinical record was reviewed on 4/16/26 at 1:01 p.m. Diagnosis included chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and morbid obesity due to excess calories. Discontinued orders (on 3/11/26) included ipratropium-albuterol (to treat airflow) solution 0.5 milligrams (mg)-3 mg/3 milliliters (mL); use one vial by inhalation, every 6 hours as needed for shortness of breath; ondansetron (to treat nausea) disintegrating tablet 8 mg, give one tablet every 8 hours as needed for nausea and vomiting; polyethylene glycol 3350 powder (laxative) give 17 grams (gm) oral, mixed with 8 ounces (oz) of fluid, once daily as needed for constipation. A 1/7/26, pharmacy review indicated to see the report for irregularities. A 1/7/26, pharmacy recommendation indicated to consider discontinuation of the as needed orders 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 interview, the facility failed to ensure pneumococcal vaccinations were provided following the Centers for Disease Control and Prevention (CDC) guidelines and facility policy to prevent duplication of administration for 1 of 6 residents reviewed for immunizations. (Resident 2) Findings include:Resident 2's clinical record was reviewed on 4/16/26 at 3:12 p.m. Diagnoses included hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure. A review of the resident's March 2026, Dialysis Communication facility binder indicated Resident 2 received the Pneumococcal 20-valent conjugate vaccine (Prevnar 20) in her left deltoid while at dialysis on 3/2/26.Review of the resident's clinical record vaccination history indicated a Prevnar 20 vaccination was provided, at the facility, on 3/26/26, in the resident's left deltoid.The clinical record lacked historical data of any previous immunizations.A 3/26/26, quarterly, Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired.During an 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect residents from misappropriation when residents' Institutional Special Needs Plan (ISNP) benefits were utilized by a staff member for purposes other than the individual resident's benefit for 3 of 3 residents reviewed for misappropriation of property (Resident D, Resident E, and Resident F). This deficient practice was corrected on 7/18/25, prior to the start of survey, and was therefore past noncompliance. Findings include: 1. Resident E's clinical record was reviewed on 8/28/25 at 11:21 a.m. Diagnoses included aphasia following cerebral infarction, cognitive communication deficit, and expressive language disorder. A quarterly Minimum Data Set (MDS) assessment, dated 6/4/25, indicated the resident was severely cognitively impaired. A progress note, dated 6/23/25 at 1:28 p.m., indicated the resident's representative was notified of a discrepancy with the resident's ISNP card and funds. The facility verified transactions and adjusted as needed…

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 interview and record review, the facility failed to ensure a resident's catheter was anchored according to the physician's orders for 1 of 3 residents reviewed for catheters. (Resident C) Findings include: Resident C's closed clinical record was reviewed on 8/27/25 at 3:36 p.m. Diagnoses included infection and inflammatory reaction due to indwelling urethral catheter, subsequent encounter, other obstructive and reflux uropathy, urinary tract infection, and benign prostatic hyperplasia with lower urinary tract symptoms. Physician orders included cefpodoxime (antibiotic) 200 milligrams (mg) every 12 hours for urinary tract infection (7/25/25 - 7/27/25), levofloxacin (antibiotic) 500 mg daily (7/30/25 - 8/5/25), trospium (for overactive bladder) 20 mg twice a day (7/24/25), Foley catheter: 16 French 5-10 milliliter (mL) bulb (7/25/24 - 7/30/25), Foley catheter: 18 French 10 mL bulb (7/30/25), If resident does not void in six hours anchor foley catheter (7/29/25 - 7/30/25), and May use 18 French catheter to re-anchor until a 16 French 10 mL is available (7/29/25). An admission…

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 interview and record review, the facility failed to provide physician ordered pain medication in a timely manner for 1 of 3 residents reviewed for admission. (Resident C) Finding includes:Resident C's closed clinical record was reviewed on 8/27/25 at 3:26 p.m. Diagnoses included rheumatoid arthritis, polyneuropathy, post-laminectomy syndrome (syndrome after spinal surgery characterized by persistent or worsening pain, numbness, tingling, and weakness in the legs or back), and chronic pain due to trauma. Physician orders included fentanyl (opiate pain medication) patch 75 mcg (micrograms)/hour every other day (7/25/25), hydromorphone (opiate pain medication) 4 milligrams (mg) every four hours as needed (PRN) for moderate pain (7/24/25), ibuprofen (anti-inflammatory medication) 600 mg three times a day (7/25/25), acetaminophen (Tylenol) 650 mg every four hours PRN (as needed) for mild pain (7/24/25), and acetaminophen every four hours (7/24/25). An admission Minimum Data Set (MDS) assessment, dated…

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 interview and record review, the facility failed to ensure resident representatives of cognitively impaired residents were invited to participate in care plan processes for 2 of 3 residents reviewed for notifications. (Resident B and Resident D) Findings include: 1. Resident B's clinical record was reviewed on 6/9/25 at 9:20 a.m Diagnoses included dementia, depressive episodes, gastric ulcer, migraine, gastro-esophageal reflux disease, scoliosis, dysphagia, and hypothyroidism. A quarterly MDS (Minimal Data Set) assessment, dated 3/26/25, indicated the resident was severely cognitively impaired. A care plan summary dated 1/10/25, indicated Resident B was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. A Care Plan Summary dated 3/26/25, indicated Resident B was in attendance for the meeting. No resident representative was listed in attendance. No resident representative was listed as being invited to the summary. Progress notes, dated December 2024 through April 2025,…

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 interview and record review, the facility failed to provide transportation to a medical procedure appointment as previously arranged for 1 of 3 residents reviewed for transportation concerns, resulting in the resident missing the appointment. (Resident C) Findings include: Resident C's clinical record was reviewed on 3/19/25 at 12:09 p.m Diagnoses included emphysema, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, atherosclerotic heart disease of native coronary artery, angina pectoris, diabetes mellitus with diabetic neuropathy, peripheral vascular disease with arterial ulcers to bilateral lower extremities, hypertension, and alcohol abuse. The most recent quarterly MDS (Minimal Data Set) assessment, dated 11/27/25, indicated the resident was cognitively intact. The resident required substantial to maximum assistance for toilet hygiene, lower body dressing, putting on/taking off footwear, chair to bed/chair transfers, toilet transfers, and shower transfers. Method of mobility was a wheelchair. A care plan, dated 11/8/24, indicated…

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 A. Based on observation and interview, the facility failed to utilize infection prevention and control practices related to hand hygiene during laundry delivery. This deficiency had the potential to affect 69 of 70 residents who received facility laundry services. B. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control practices related to enhanced barrier precautions (EBP) during care for residents at higher risk for infection with an indwelling urinary catheter or a feeding tube, for 3 of 5 residents reviewed for infection control. (Residents 8, 10, and 9) Findings include: A1. During a continuous observation on 2/10/25 from 10:24 a.m. to 10:29 a.m., Laundry Attendant 9 pushed the laundry rack onto the Golden Orchard Unit with the curtains in place over the clothing rack. Without performing hand hygiene and using both hands, she opened the curtain on the clothing rack and removed clothing on hangers from the clothing rack. The curtain was placed…

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 urinary output was monitored as ordered and abnormalities reported to the provider for 1 of 2 residents reviewed for urinary catheters. (Resident 8) Finding includes: On 2/10/25 at 11:35 a.m., Resident 8 was asleep in her bed with her catheter hung on the left side of her bed. Urine in the catheter drainage tube was observed to be milky-white. During an interview on 2/11/25 at 11:22 a.m., Resident 8 indicated she was unaware of any current treatment for infections. The urine in the urinary catheter tubing was cloudy and yellow. Resident 8's clinical record was reviewed on 2/11/25 at 2:40 p.m. Diagnoses included dementia of unspecified severity, neuromuscular dysfunction of the bladder, pyuria, stage 4 chronic kidney disease, and moderate protein-calorie malnutrition. A quarterly Minimum Data Set (MDS) assessment, dated 1/9/25, indicated the resident had moderate cognitive impairment. She was dependent on staff assistance for toileting, bathing, dressing, personal hygiene, turning and transfers. The…

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 assure staff handled medications in a sanitary manner and performed hand hygiene during a medication administration observation on the [NAME] Lane Unit. Findings include: During a medication administration observation on the [NAME] Lane unit, on 3/21/24 at 8:48 a.m., RN 2 was preparing medications for a resident. She punched six capsules from the medication card into her bare hand. She opened each capsule with bare hands and emptied the contents into a medication cup. She proceeded to administer the medication to the resident with other crushed medications. RN 2 did not sanitize her hands following administration. At 8:59 a.m., RN 2 prepared an as needed pain pill for a resident and administered the medication. She failed to sanitize her hands. At 9:01 a.m., RN 2 prepared medications for a resident and administered the medications. Upon returning to the medication cart, LPN 3 spoke with RN 2 regarding sanitizing her hands. RN 2 performed hand hygiene using an alcohol based hand rub. During the observation, RN…

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.