Edgebrook Care Center

Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 3) 2025, (April 1 - June 30) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified excessively low weekend staffing had triggered. Review of the nursing schedule from April 1st through June 30th of 2025, identified most weekends had scheduled 7 nursing assistance (NA) and 1 licensed nurse for both the morning shift and the afternoon shift. There were 6 weekends identified that fell below the 7 NA's however, there was an additional licensed nurse scheduled. Interview on 11/18/25 at 2:00 p.m., with the administrator identified on the weekends that had lower nursing assistance scheduled due to call ins or no available staff, the facility had scheduled a licensed practical nurse (LPN) to work the floor as a NA. She…

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 document review, the facility failed to implement and maintain an infection control program that included thorough data collection, analysis of facility infections, and tracking and trending to reduce the spread of infections within the facility. The facility failed to include in their surveillance viral-like illnesses not treated with an antibiotic for staff or residents. In addition the facility failed to ensure staff utilized Personal Protective Equipment (PPE), during 1 of 3 (R37) insulin administration observations. Findings include: Review of the monthly infection surveillance and staff call-in logs from August through October 2025 identified in: 1.August 2025, the surveillance identified 6 UTI's, 2 skin infections, and 1 fungal infection. The log did not identify medications prescribed or that an antibiotic time out had been completed. No residents on enhanced barrier precautions were included in the surveillance. The staff illness log identified 5 staff had called in with nausea and vomiting. 1 staff with diarrhea and fever, and 2 staff with upper…

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 document review, the facility failed to ensure appropriate oversight by the infection preventionist (IP) to ensure thorough implementation of the infection control program. Findings include: Review of the monthly infection surveillance and staff call-in logs from August through October 2025 identified in: 1.August 2025, the surveillance included no map that identified location of the infections. The log identified 6 UTI's, 2 skin infections, and 1 fungal infection. The log did not identify medications prescribed or that an antibiotic time out had been completed. No residents on enhanced barrier precautions were included in the surveillance. Resident infection log identified each resident was on standard precautions. No other precaution type was identified. The staff illness log identified 5 staff had called in with nausea and vomiting, 1 with diarrhea and fever, and 2 with upper respiratory symptoms and fever. The log did not indicate when the symptoms had resolved, the last day the staff worked, or when they returned to work.2.September 2025, the 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 observation, interview, and document review, the facility failed to accurately assess 1 of 1 resident (R6) for a wrist brace/splint present upon admission. Findings include: R6's 10/28/25 5-day admission Minimum Data Set (MDS) assessment identified her cognition was intact, she required the assistance of 1 staff for activities of daily living, (ADLS) and transfers, and had an indwelling Foley catheter in place. She had diagnosis of diabetes type II, high blood pressure, cellulitis, (a bacterial infection of the skin's deeper layers, causing symptoms like redness, swelling, pain and warmth) of her left lower leg, lymphedema (swelling in limbs caused by malfunctioning of lymphatic system), morbid obesity, weakness, urinary retention, disorders of bone density, and heart failure. The MDS failed to include the use of a glove and wrist splint worn daily on her right wrist since admission. Observation of R6 during the period of 10/27/25 through 10/29/25, noted she wore a protective glove under a wrist splint…

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 document review, the facility failed ensure staff clarified a treatment order and accurately documented the administration of an order for 1 of 1 resident (R3) with physician orders for the application of lymphatic boots (devices using air compression to move lymph fluid out of the affected limbs and back into the circulatory system). Findings include: R3's accepted Minimum Data Set (MDS) assessment on 11/11/25, identified R3's cognition was moderately impaired. R3 required substantial assistance with cares and total assistance with toileting. R3 was noted during assessment period to have physical behaviors towards others 1-3-days, verbal behaviors towards others 1-3 days, and other behaviors (not directed at others) for 1-3 days. R3 was noted to wander within the facility 1-3 days and had a wander guard placed. R3 hallucinated and had delusions. R3 had diagnoses of Alzheimer's disease and depression. R3 took an antianxiety, antidepressant, and scheduled pain medication. R3's 9/15/25, provider dictated note identified R3 had been seen by another…

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 document review, the facility failed to develop an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance for 2 of 3 resident (R35 and R42) who had an order for an antibiotic with no indication that an antibiotic time out had been completed.Findings include: R35's 8/31/25 quarterly Minimum Data Set (MDS) assessment, identified his cognition was moderately impaired, he had diagnosis of heart failure, diabetes mellitus, and dementia. R35 was independent with activities of daily living (ADL)'s. R35's August 2025, medication administration record (MAR) identified he was administered cephalexin 500 milligrams three times a day from 8/11/25 to 8/19/25. Review of the facilities monthly infection log identified R35 had been prescribed an antibiotic for a urinary tract infection (UTI) on 8/11/25. The log lacked any indication that an antibiotic time out had been completed. R42's 10/8/25 quarterly Minimum Data Set (MDS) assessment…

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 document review, the facility failed to ensure the required amount of staff determined by their resident census and care levels, resident assessments and individual plans of care, and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 4/1/24 through 6/30, 24 days Triggered = Submitted Weekend Staffing Data Excessively Low. Review of the facility's staffing requirements for weekends during the identified PBJ period of 4/1/24 through 6/30/24 identified staffing numbers required were: Days: 1 nurse: 6:30 a.m. -7:00 p.m. 1 nurse: 6:30 a.m. -3:00 p.m. 1 trained medication aide (TMA)/or Restorative aide (RA) 6:30 a.m. - 2:30 p.m. 1 RA: 6:00 a.m. - 2:30 p.m. 4 nursing assistants (NA): 6:30 a.m. - 2:30 p.m. and 1 NA/bath aide. 6:30 a.m. - 1:00 p.m. Evenings: 2 NAs: 2:30 p.m. - 11:00 p.m. 2 NA's: 2:30 p.m. -9:30 p.m. 1 NA: 5:00 p.m. - 8:00 p.m. 2 TMA's:…

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 document review, the facility failed to ensure a system for periodic reconciliation of controlled substances for the emergency kit stored in a refrigerator. Findings include: On interview and observation 10/13/24 at 3:27 p.m., a tour of the medication room with registered nurse (RN)-A included an unlocked refrigerator with a plastic container that had a breakaway tag on with number 6229540. Inside of the plastic kit was 1 vial of morphine liquid 100 mg/5 ml, Tramadol 50 mg tablets, and 2 vials of lorazepam 2 mg/ml. RN-A indicated they switched pharmacies a few months ago and she stated they have not been counting the narcotics, nor verifying the security of the lock, for medications kept in the refrigerator but probably should be. On interview 10/13/24 at 7:00 p.m., trained medication aide (TMA)-A indicated she does participate in narcotics counts at the end of the shift, but has never counted the narcotics in the medication room refrigerator, or verified the lock was intact. There was no mention of doing either in the medication reconciliation…

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 document review, the facility failed to notify the resident and/or their representative, in writing, of the care facility's bed hold policy, including any potential costs included with the bed hold, at the time of transfer to the hospital for 1 of 5 residents (R10) reviewed for hospitalizations. Findings include: R10's 9/17/24, quarterly Minimum Data Set (MDS) identified R10 had unclear speech, was usually understood, had severe cognitive impairment, displayed continuous disorganized thinking, altered level of consciousness, and had verbal behaviors daily. R10 used a wheelchair for mobility and required total assistance with cares. R10 was identified to have Alzheimer's disease. She had no indications of pain; she had no falls and did not take any psychoactive medication. R10's 6/28/24, progress note identified R10 was positive for COVID-19 and was on droplet precautions. On 6/29/24, at around 7:00 p.m., R10 was assessed and found to have unstable vital signs with shortness of breath and was transported to the emergency room for evaluation. The family was…

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 document review the facility failed to ensure the infection control program used enhanced barrier precautions (EBP) per Centers for Disease Control (CDC) recommendations for 2 of 2 residents (R47 and R19) who had indwelling device present or multi-drug-resistant organism (MDRO). Findings include: R46's diagnosis list printed 10/14/24 included gastrostomy (a feeding tube inserted into the stomach through the abdomen) status. R46's plan of care, dated 9/13/24, included the resident requires tube feeding related to dysphagia (difficulty swallowing). Interventions included no water pitcher at bedside due to nothing per mouth status and elevate head of bed 30-45 degrees during and 30 minutes after the tube feeding is stopped. R46's plan of care did not include EBP precautions. On observation and interview on 10/13/24 at 5:03 p.m., registered nurse (RN)-A gathered supplies for tube feeding, put on a gown she brought with her to R46's room. RN-A stated that when providing cares such as tube feedings or medication administration with the gastrostomy tube…

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 document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly or more often, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4) to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified the following dates triggered for review: 7/16/23, 7/23/23, 7/29/23, 7/30/23, 8/13/23, 8/26/23, 8/27/23, 9/09/23, 9/10/23, 9/16/23, 9/17/23, and 9/30/23 for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules identified the facility had 7 staff identified to have worked, registered nurses (RN)-D, RN-E, RN-F, RN-G, RN-H, RN-I and licensed practical nurse (LPN)-A. Review of staff's time cards on the above-mentioned dates identified licensed nursing staff had worked and the data submitted in the PBJ to CMS was inaccurate. Interview on 1/24/24 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 document review the facility failed to ensure timely submission of a Death in facility Minimum Data Set (MDS) for 1 of 1 resident (R9) who was reviewed for an MDS record over 120 days old. Findings include: R9's medical record identified last scheduled Minimum Data Set (MDS) assessment that had been completed and submitted was on 9/17/23. R9's death in facility MDS was signed by the responsible party on 10/2/23, and locked on 10/11/23. The death in facility MDS had not been successfully submitted and/or transmitted; as R9's electronic health record identified it had been completed rather than accepted under the status section, indicating it had not been submitted. Observation and Interview on 1/23/24 at 9:02 a.m., with registered nurse (RN)-A who revealed she was responsible for R9's MDS completion and submission. Her process was to submit completed MDS's each week. The electronic medical record program, Point Click Care (PCC) would create a batch of MDS's that were eligible for submission. Following submission of a batch of MDS's there would be a validation…

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 document review, the facility failed to notify the designated State Mental Health Authority (SMHA) when 1 of 2 residents (R14) had changes in mental health and/or had new-onset mental illness diagnoses. Findings include: R14's 1/23/24, face sheet identified she was admitted to the facility in June of 2022, with diagnosis of depression. R14's diagnosis list identified that upon admission, she had no diagnosis of mental illness or related condition. On 1/23/23, R14 had a new diagnosis added of psychotic disorder with delusions due to known physiological condition, and new onset anxiety disorder due to a known physiological condition. R14's medical record lacked any indication that the SMHA had been notified of the new diagnoses. R14's 5/16/23, annual Minimum Data Set (MDS) assessment identified R14 experienced delusions and verbal behaviors directed towards others and herself that put R14 at significant risk for injury. R14's 6/27/22, pre-admission screening (PAS) results identified she was being admitted with a primary diagnosis of cognitive impairment with no…

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 follow their policy and ensure discontinued medications were immediately removed from 1 of 1 resident's (R8) medication and not co-mingled with thier current medication supply located in the [NAME] medication cart, and secure them in a locked compartment in the medication room for final destruction. Findings include: R8's 11/29/23, Significant Minimum Data Set (MDS) assessment identified R8's cognition was intact, she required maximal assistance with daily cares, was identified as having pain and took pain medication. She had frequent pain that was severe and took an anti-anxiety, anti-depression, and opioid (narcotic used for pain) medication. R8 had identified diagnosis of anxiety and depression. Observation and interview on 1/24/24 at 10:37 a.m., with registered nurse (RN)-B of the [NAME] medication cart. The locked narcotic box located within the west medication cart contained 2 punch cards for R8 that had a yellow sticker on the punch card that identified it had been discontinued. The first punch card label identified…

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.