Edison Christian Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include:On 9/15/25 at 9:32 AM, An interview with Production Manager (PM) SS found that staff check dates of food products daily. Further review of the walk-in cooler found an open package of roast beef with no date, a container of cut pineapple with no date, pumpkin dated 8/25 to 8/31, a bag of kielbasa sausages open with no date, and a container of scrambled eggs uncovered and not dated. On 9/15/25 at 9:38 AM, Observation of the two door Traulsen cooler found a container of leaf lettuce dated 9/6 to 9/9. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section,…

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 DPS #1 Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, affecting residents in the following areas:Findings include: DPS #2 Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in 1 (Resident #18) of 19 residents reviewed for a clean, homelike environment, resulting in a build of up dust and debris on surfaces in the resident's room and the potential for decreased satisfaction with the living environment.Findings include: On 9/15/25 at 10:24 AM, Observation of the Main dining room found the cabinet underneath the ice machine with an accumulation of black staining and debris. On 9/15/25 at 10:38 AM, Observation of the [NAME] dining room found trash bags stored underneath the sink, with the cabinet having a large hole in the back where plumbing comes from the wall. Further…

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, interview, and record review the facility failed to implement an person-centered care plans in 1 (Resident #57) of 19 residents reviewed for care planning, resulting in the potential for unmet care needs. Findings include: Resident #57 Review of an admission Record revealed Resident # 57 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dysphagia (difficulty swallowing food or liquids) and mild intellectual disabilities. Review of Resident #57's Care Plan revealed, (Resident #57) has potential for alteration in nutrition/hydration status r/t (related to) therapeutic diet, meds which may affect appetite/wt (weight) . hx (history) of swallowing issue at previous facility .spilling food d/t (due to) shaking hands. Date initiated: 1/20/25. Interventions: Diet as ordered: Consistent carbohydrate, regular texture, thin liquids. Small portions to promote weight loss and glycemic control. NO straws and weighted utensils. Date initiated: 1/20/25. Revision:…

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 prevent significant medication errors in 1 (Resident #65) of 5 residents reviewed for medication errors, resulting in Resident #65 receiving an unprescribed antiseizure medication and the potential for adverse side effects. Findings include: Resident #65 Review of an admission Record revealed Resident #65 was originally admitted to the facility on [DATE] with pertinent diagnoses which included severe intellectual disabilities and chronic pain. Review of Resident #65's Progress Note dated 9/8/25 and documented by Licensed Practical Nurse (LPN) BB revealed, Due to med (medication error), full head to toe performed (assessment). Resident appears at baseline, other than drowsiness, denies pain when asked, responds yes when asked if sleepy. Vitals: BP (Blood pressure): 131/84, P (pulse): 78, O2 (oxygen saturation) 93 % RA (room air), RR (respiration rate): 16, T(temperature): 97.8. Resident ate 0-25% of lunch and did not drink well this shift. Would purse…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents. Findings include: During the initial tour of the kitchen, starting at 9:48 AM on 9/10/24, an interview with Food Service Director (FSD) Z found that the facility date marks potentially hazardous food items for a three-day discard. Observation inside the walk-in cooler found a half gallon of skim milk dated 8/18 to 8/21 and an open thickened dairy beverage dated 8/18 to 8/21. Observation of the preparation cooler, at 10:02 AM on 9/10/24, found a container of egg salad and a container of tomato soup with no dates to indicate the discard for each product. Further observation found an open package of hot dogs dated 9/5 to 9/8. Observation of the South dining room, at 11:15 AM on 9/10/24, found an open thickened cranberry juice with no date to indicate discard. the item states its good for 7 days after opening.…

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, interview, and record review the facility failed to: 1. Date mark and discard potentially hazardous foods; 2. Properly restrain facial hair while working with food; 3. Ensure proper working order of dish machine; 4. Clean non-food contact surfaces to sight and tough; and 5. Ensure proper cooling of potentially hazardous foods. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 94 residents who consume food from the kitchen. Findings Include: 1. In an observation on 8/28/23 beginning at 11:40 a.m., reviewed the main facility kitchen. Observed two large, white, rolling bins below the counter, which contained flour and sugar. No dates noted to indicate when these items were placed in the bins (no open dates or use by dates). In an observation on 8/28/23 beginning at 11:40 a.m., reviewed the main facility kitchen. Observed the following items in the reach-in cooler: An opened 12 ounce container of [NAME] mayonnaise,…

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, interview, and record review the facility failed to provide a dignified dining experience in 11 residents (Resident #11, #395, #78, #73, #18, #34, #44, #53, #41) observed during dining, from a total sample of 20 residents, resulting in the potential for decreased self-esteem and feelings of disappointment with the dining experience. Findings include: During an observation on 08/30/23 at 08:28 AM in the west dining room, eight residents (Resident #11, #395, #78, #73, #18, #89, #34, and #35) were seated at tables, 5 CNA's (Certified Nursing Assistant) were waiting for trays to be prepared and Kitchen Staff (KS) EEE was plating food. At 8:32 AM a cart with 6 meal trays, for residents that were eating in their rooms was wheeled out of the dining room. During subsequent observations on 08/30/23 at 8:33 AM, an additional unknown female resident walked into the west dining room and was immediately served her breakfast. Resident #395 was observed sitting at a table alone, watching the staff…

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 (1) obtain a physician order for medicated topical skin creme and (2) prevent Certified Nursing Assistants from administering medicated topical skin cream required to be administered by licensed nursing staff for 1 resident (Resident #8) of 2 residents reviewed for skin conditions, resulting in the potential for residents to have received inappropriate or inadequate care, lack of communication among care providers, and the potential for the residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #8 In an observation on 8/28/2023 at 12:02 in Resident #8's room, Resident #8 asked Certified Nursing Assistant (CNA) EE to put Biofreeze Cream on his legs. Two tubes of Biofreeze Cream were found in Resident #8's bedside drawer and rubbed onto his legs and feet by CNA EE. Review of Resident #8's electronic medical record on 8/28/2023 at 12:15 PM revealed no order for Biofreeze Cream. In an interview on 8/28/2023 at 12:26 PM, CNA EE reported CNAs are…

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 discontinue psychotropic PRN (as needed) medications after 14 days and/or document clinical rationale and indicate a timeframe for extend PRN psychotropic medication use in 1 of 5 residents (Resident #38) reviewed for psychotropic medications, resulting in the potential for unnecessary medication use and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #38 Review of an admission Record revealed Resident #38 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and anxiety. Review of Resident #38's Physician Orders revealed, Xanax Oral Tablet 0.5 MG (Alprazolam) (a medication used to treat anxiety) Give 1 tablet by mouth as needed for Anxiety/Agitation Not to exceed to 2.0mg per day with scheduled dose. Active 7/10/2023 at 2:30 PM. The medication order did not include a stop date. In an interview on 08/30/23 at 11:06…

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.