Edgewood Rehab & Living Ctr

Based 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).Findings: Review of Resident #11's clinical record revealed an MDS Quarterly Assessment was completed on 3/13/25. Further review of Resident #11's clinical record lacked evidence that an interdisciplinary team (IDT) meeting was held within 7 days following the assessment.On 8/20/2025 at 10:22 a.m. during an interview, the Director of Nursing reviewed Resident #11's clinical record and confirmed there was no IDT meeting held following the 3/13/25 MDS assessment.

Based 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).Findings:Review of policy, Falls Management Policy, revised 2/2025, states, .A fall incident report will be completed after a resident has had a fall, whether it is witnessed or not.A neurological assessment tool will be initiated for falls where there is a known 'head bump . Neurological Assessment Policy, revised 1/2019, states, Neurological assessment following head injury will be completed for all residents sustaining head trauma or suspected head trauma In EMR [Electronic Medical Record]: Neuro Checks will be conducted - every 15min x 4, every 30min x 4, every 1 hr. x 4, every 4 hr. x 2, and every 8 hr. x 1.The physician will be notified of any significant changes. This will be documented in the narrative notes.1. Review of R34's clinical record revealed he/she sustained an unwitnessed fall on 6/22/25 at 2:10 a.m., 8/2/25, 8/17/25…

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 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).Findings:Review of R6's care plan updated 5/8/25 states Nutrition: Alteration in nutrition/hydration secondary to obesity, diabetes, liver failure, need for adaptive equipment. Goal: [R6] will make food choices within parameters of prescribed therapeutic diet. Will maintain or demonstrate weight loss of 1-2#per week over the next 90 days.Intervention: Monitor eating pattern and record intake. Review of R6's LTC Meal intake dated August 2025 lacks evidence of intake/refusal during breakfast on 8/9/25, lunch on 8/6/25, 8/9/25, 8/11/25, and diner on 8/1/25, 8/8/25, and 8/15/25.During an interview on 8/19/25 at 11:02 a.m. Certified Nursing Assistant (CNA)3 states they are supposed to document meal intakes 3 times a day and if a meal is refused, they should offer an alternative, if that is refused, to document it and notify the charge nurse.During a review of R6's intakes on 8/19/25…

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 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.Findings:R4 has diagnoses to include obstructive uropathy and indwelling urinary catheter.On 8/18/25 at 12:04 p.m. and 8/19/25 at 9:38 a.m., during an observation of R4's room, R4's urinary catheter drainage bag, with urine in the tubing and bottom of the drainage bag, was hanging under the sink.On 8/19/25 at 3:05 p.m., a surveyor and the Director of Nursing (DNS) observed R4's drainage bag hanging under his/her sink. At this time, a surveyor discussed the above findings with the DNS.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On 10/17/24 from 8:33 a.m. to 9:00 a.m., an Environmental Tour was conducted with the Administrator and the Maintenance Director in which the following findings were observed: > The laundry room had debris in the two ceiling lights by the dryers. The wooden stand, under the washing machine's chemicals, was untreated creating an uncleanable surface. > The standing floor fan in large dining room was heavily soiled with dust/dirt. > The bathroom by the nurses station had a chipped/worn toilet seat and the floor was heavily soiled with dirt around the edges and over the entire floor. > The whirlpool room was missing floor tiles along the edge of the wall and had a large brown stain on one ceiling tile. > 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: Section V. Procedure of the Fall Management Policy (dated 7/2019), subsection E states to, Complete Post Fall Observation tool, following a fall and subsection F states Documentation must be completed in the nurse's note on each shift X3 following the fall. The Neurological Assessment Policy (dated 1/2019) states, Residents with suspected neurological compromise will have a neurological sign monitored and recorded for a minimum of 12 hours. Subsection III Procedures states A neurological assessment following resident head injury will be completed for all residents sustaining head trauma or suspected head trauma. In EMR: Neuro Checks will be conducted-every 15 minutes x4,…

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 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. Findings: Facility policy and procedure for Omnicare Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 8/1/24 states, Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia (USP) guidelines for temperature ranges and manufacturer guidance . refrigeration: 36° to 46°F. On 10/15/24 at 12:15 p.m., observation of the medication storage room with Registered Nurse (RN) contained a refrigerator containing insulin, 8 boxes of influenza vaccinations, and Tuberculin Purified Protein. At this time, the RN states that refrigerator temperatures are checked twice daily. The facilities Medication Refrigerator log indicates temperatures are to be monitored twice daily. Review of the temperature logs from 8/2024…

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 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. Findings: The facilities Dish Machine Temperature and Sanitizer Log Form noted: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will…

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 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) Findings: 1. On 10/15/24 at 9:30 a.m., a surveyor observed the large trash dumpster had left side slide door missing/open and the top left front door open both exposing trash, a small dumpster which had the front right top open on it and plastic and paper trash on the ground around the dumpsters. Additionally, trash was observed stored in an open top cart outside the laundry room exit. On 10/15/24 at 9:40 a.m., in an interview, the Administrator confirmed the findings. 2. On 10/16/24 at 7:35 a.m., a surveyor observed the left side door missing and the right side door of the large trash dumpster to be fully open, exposing trash. The surveyor also observed plastic and paper trash on the ground around the dumpster. On 10/16/24 at 8:30 a.m., in an interview, the Administrator confirmed the findings. 3. 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 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) Findings: The facility's Immunization Policy indicated in Procedure I: Before offering the Influenza or Pneumococcal vaccine, each resident, and/or resident's legal representative will receive education produced by the Maine and/or Federal Centers for Disease Control regarding the benefits and potential side effects of the vaccines for the current year. The resident's clinical record will include the following documentation: Signature of the person receiving the educational material, designating receipt and understanding of the material. Verbal consent may also be obtained if communication is done via a telephone conversation. Proof the resident either received the Influenza and/or the Pneumococcal vaccine, the vaccine(s) was contraindicated for medical reasons, or 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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) Findings: The facility's policy, Policy for Suspected or Confirmed Coronavirus (COVID-19) revised 5/7/24 indicated under Vaccines: The facility will be required to educate residents and employees on vaccines and offer updated vaccines to all residents. On 10/17/24, between 11:20 a.m. and 11:45 a.m., during an interview with the Director of Nursing and the Infection Preventionist, the following resident's vaccination records were reviewed and confirmed that the updated 2023-2024 COVID-19 vaccinations were not offered: 1. Resident #7 was admitted to the facility on [DATE]. Resident #7 was diagnosed with COVID-19 on 9/5/24. Resident # 7's last documented COVID-19 vaccination was 12/21/23. The clinical record lacked evidence of offering the updated COVID-19 vaccination. 2. Resident #15 was admitted to the facility on [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.

Based 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). Finding: Resident #31 was admitted to this facility on 7/12/24. The admission history and physical states Resident #31 had a diagnosis of Acute Ischemic Stroke where the Medical Doctor (MD) noted that he/she had mild left upper extremity weakness along with reports of difficulty swallowing, mixed Alzheimer's and Vascular Dementia with some agitation requiring the resident to be redirected and newly anticoagulated for Atrial Fibrillation. Resident #31 had medication orders for an anticoagulant, antidepressant, beta blocker, and an opioid. As of 10/17/24 there was no evidence of a baseline care plan that included instructions necessary to provide safe and effective care to Resident #31. On 10/17/24 at 9:39 a.m., the above information was confirmed with the Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On 10/15/24 at 9:48 a.m., a surveyor observed the Soiled Utility room, located on the Long-Term Care unit unlocked. Inside the Soiled Utility room, were four cabinets with four unlocked padlocks that contained the following: 1 bottle of Eco lab Rapid Multi Surface Disinfectant cleaner, 1 can of 3M Glass cleaner, 1 container of Simplex scour power and instant chlorine bleach, 1 can of WD-40, 1 bottle of True Clean Emerald Optically Enhanced floor cleaner and 1 bottle of Apollos Power Clean Industrial Grade cleaner & detergent. The Material Safety Data Sheets, each dated 1/1/2007, were reviewed and indicated the following: 1. Eco Rapid Multi Surface Disinfectant cleaner Section 4 First Aid Measures Eyes: Rinse immediately with plenty of water, also under the eyelids, for at least 15 minutes. Continue…

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 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. Finding: On 10/15/24 and 10/16/24, a surveyor observed the nurse staffing information, posted in the main entrance, the posting lacked the total number of hours and the actual hours worked for the Registered Nurse, Licensed Practical Nurse and unlicensed nursing staff responsible for direct resident care. On 10/16/24 at 9:26 a.m., the above was confirmed with the Director of Nursing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: On 2/24/23, from 8:33 a.m. to 9:03 a.m., an Environmental Tour was conducted with the Administrator and the Maintenance Director in which the following findings were observed: > Resident room [ROOM NUMBER]: The floor was dirty around base of toilet and the entire bathroom floor was heavily soiled with dirt/debris. > Resident room [ROOM NUMBER]: The white raised toilet seat was dirty with brown fecal looking material. The paint was chipped/missing on the wall under the room window. The varnish is worn/missing on the bureau next to the sink. > Resident room [ROOM NUMBER]: There were ten cracked/broken floor tiles as you enter the room. The floor was dirty around base of toilet and the entire bathroom floor was heavily soiled with…

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 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) Findings: 1. On 2/21/23 at 9:31 a.m., a surveyor observed in room [ROOM NUMBER], which is shared by two residents, there was an unlabeled medication (muscle rub ointment per DON) in a medication cup on the bedside table of Resident #11. 2. On 2/21/23 at 9:31 a.m., a surveyor observed in room [ROOM NUMBER], which is shared by two residents, there was an unlabeled medication (Nystatin powder per DON) in a medication cup on the shared sink. Nystatin powder is used to treat fungal or yeast infections of the skin. 3. On 2/21/23 at 9:31 a.m., a surveyor observed in room [ROOM NUMBER], an unlabeled medication (Nystatin powder per DON) on the bedside table and another unlabeled medication (Nystatin powder) in the bathroom on top of the paper towel dispenser. In addition, on the bedside table there was a…

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 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. Further, the facility failed to monitor the dishwasher wash and rinse cycle temperatures as well as the chemical sanitizer levels for the dishwasher, the sanitizing sink, and the sanitizing bucket for 1 of 1 survey days (2/21/23) in the kitchen. This has the potential to affect all residents. Findings: On 2/21/23 from 8:40 a.m. to 9:20 a.m., in an initial kitchen tour with the Food Service…

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 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) Findings: 1. On 2/21/23 at 9:20 a.m., the surveyor and the Food Service Director observed 1 of 2 dumpsters with the left front lid and the back right lid opened. The dumpster was full of cardboard and bagged trash sticking out of the dumpster. The Food Service Director confirmed the finding at this time. 2. On 2/22/23 at 8:20 a.m., a surveyor and the laundry worker observed 1 of 2 dumpsters with the left front lid opened. The dumpster was full of cardboard and bagged trash sticking out of the dumpster. The laundry worker confirmed the finding at this time. 3. On 2/24/23 at 8:05 a.m., a surveyor observed 1 of 2 dumpsters with the left front lid opened. The dumpster was full of cardboard and bagged trash sticking out of the dumpster. The surveyor discussed the finding with the Administrator.

Based 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). Findings: On 9/24/23 during a review of facility staff education records the following were noted: CNA #2 was hired on 12/5/12. The last Abuse training received by CNA #2 was completed on 11/11/20. The record lacks evidence of mandatory Abuse training in 2021. CNA #3 was hired on 8/6/96. The last abuse training received by CNA #3 was completed on 8/19/20. The record lacks evidence of mandatory Abuse training in 2021. On 2/27/23 at 2:50 p.m. the Director of Nursing confirmed that not all of the mandatory training required was done in 2021 for the staff reviewed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: 1. On 2/21/23 at 9:30 a.m., a surveyor observed a 10.1 fluid ounce spray bottle of Fabreze One - Fabric and Air Mist in a pink wash basin on the floor in the bathroom of Resident room [ROOM NUMBER]. 2. On 2/21/23 at 1:25 p.m., two surveyors observed the same 10.1 fluid ounce spray bottle of Fabreze One - Fabric and Air Mist on the back of the toilet. The bathroom is shared by rooms [ROOM NUMBERS] and utilized by 4 residents. The Safety Data Sheet for Fabreze One - Fabric and Air Mist noted: Section 4. First Aid Measures Eye Contact: Rinse with plenty of water. Get medical attention immediately if irritation persists Skin Contact: IF ON SKIN(or hair), Remove/Take off immediately all contaminated…

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, 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. Finding: A review of the Payroll Based Journal Report for Fiscal Year Quarter 4 2022 (July 1- September 30) indicated that the facility failed to have Licensed Nursing Coverage 24 hours/Day with infraction dates on 07/04/22 (Monday), 07/16/22 (Saturday), 08/27/22 (Saturday) and 09/24/22 (Saturday). A review of the nursing working schedule, indicated that on 7/16/22 (Saturday) the facility did not have an RN on duty for at least 8 consecutive hours. On 2/24/23 at 11:44 a.m., in an interview with the Director of Nursing (DON), she reported that the facility did have a Registered Nurse coverage for 8 consecutive hours on 7/04/22, 8/27/22, and 9/24/22. In addition, the DON provided copies of the schedule showing a Registered Nurse worked for eight hours on these days. On 2/24/23 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.