Edgewood Centre (the)

Based on interview and record review, it was determined that the facility failed to determine if a resident's request for rehabilitation services was necessary or appropriate for 1 of 1 resident reviewed for Specialized Rehabilitative or Restorative Services in a final sample of 28 residents (Resident identifier is #57). Findings include: Interview on 6/3/25 at approximately 9:30 a.m. with Resident #57's Durable Power of Attorney revealed that he/she had requested Physical Therapy (PT) services because of right shoulder pain. Review on 6/3/25 of Resident #57's Social/Psychosocial note, dated 4/9/25, revealed a meeting was held with the resident, a family member of the resident, the facility administrator, a nurse manager and social services. The note contained the following: [names of family and resident omitted] would like to have a PT eval [evaluation] for [name omitted]'s shoulder, which is causing [pronoun admitted ] a great deal of pain. Interview on 6/5/25 at approximately 8:45 a.m. with Staff C (Rehabilitation Manager) revealed that he/she was not aware of the DPOA's request…

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, it was determined that the facility failed to ensure that the resident's medical records were complete and accurate for 3 of 28 residents in a final sample of 28 residents. (Resident identifier are #44, #46, and #68.) Findings include: Resident #46 Review on 6/3/25 of Resident #46's May and June 2025 Medication Administration Record (MAR) revealed the following physician's orders: Enteral Feed Order two times a day for nutrition, . Nocturnal feeding of Glucerna 1.5 at 60 ml (milliliters)/hr (hour) x 12 hours (up at 6:30 p.m., down at 6:30 a.m., start date 2/26/25 and D/C date 5/22/25 Enteral Feed: Glucerna 1.5 at 50 ml/hr continuous. Up at 6:00 a.m., down at 6:00 p.m. Total volume to be administered daily: 873 mls., . start date 5/30/25. Further review of Resident #46's MAR revealed there was no ml recorded on the following dates: May 2, 6, 7, 8, 12, 14, 15, 18, 20, and 21 June 1, 2, and 3 Interview on 6/4/25 at approximately 11:30 a.m. with Staff A (Assistant Director of Nursing/Infection Preventionist) confirmed the above findings. 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.

Based on interview and record review, it was determined that the facility failed to ensure that residents are offered the COVID-19 and are educated regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations (Resident Identifiers are #46 and #124). Findings include: Review on 6/4/25 of the current CDC immunization guidelines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html revealed People ages 65 years and older .are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. Resident #46 Review on 6/4/25 of Resident #46's vaccination records revealed Resident #46 received the 2024-2025 Moderna COVID-19 on 11/18/24. There was no documentation of Resident #46 being offered or educated about the next dose recommendations. Resident #124 Review on 6/4/25 of Resident #124's vaccination records revealed the 2024-2025 Moderna COVID-19 vaccine was administered on 10/5/2024. There was no documentation of Resident #46 being offered or educated about 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, it was determined that the facility failed to ensure controlled medications were stored in a separately locked, permanently affixed storage compartment in 2 of 2 medication rooms observed, and that the facility failed to ensure that medications were appropriately disposed of in 2 of 3 medication administrations observed. Findings include: Observation on 3/12/24 of [NAME] 1 cart at approximately 8:15 a.m. revealed Staff I (Registered Nurse) dropped one capsule of Colace (Bowel Medication) on the medication cart, then picked it up and threw it in the trash barrel attached to the medication cart. Interview on 3/12/24 at approximately 8:15 a.m. with Staff I confirmed above findings. Observation on 3/12/24 of [NAME] 2 cart at approximately 8:20 a.m. revealed Staff J (Registered Nurse) dropped one tablet (Multivitamin) on the medication cart and then disposed of it in the open trash barrel on the side of the medication cart. Interview on 3/125/24 at approximately 8:20 a.m. with Staff J confirmed the above findings. Interview on 3/14/24…

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 it was determined that the facility failed to make a Level II Pre-admission Screening and Resident Review (PASARR) referral for a resident with a newly evident mental disorder for 1 of 3 residents reviewed for PASARR in a final survey sample of 27 residents (Resident Identifier is #26). Findings include: Review on 3/13/24 of Resident #26's medical record revealed that resident was admitted to the facility on 11/2023 without having a diagnosis of a serious mental illness. Review on 3/13/24 of Resident #26's Level I PASARR form (completed on 11/22/23) revealed: Section 2: Screening for Mental Illness (MI), No was checked. Section 3: Screening for Intellectual Disability/Developmental Disability (ID/DD), No was checked. Section 4: Screening for Related Condition (RC), No was checked. Section 5: Undiagnosed Condition, No was checked. Review on 3/13/24 of Resident #26's Psychiatric Evaluation and Consultation dated 12/6/23 revealed a new diagnosis of Post-Traumatic Stress Disorder (PTSD) and that Resident #26 was started on a new medication 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 record review and interview, it was determined that the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) screening was done for 1 of 3 residents reviewed for PASARR in a final sample of 27 residents (Resident Identifier is #111). Findings include: Review on 3/13/24 of Resident #111's medical record revealed that Resident #111 was admitted to the facility on 2/2024 with a known diagnosis of bipolar disorder. Review of Resident #111s initial PASARR dated 2/15/24 revealed that in Section II titled PASRR Level I Screening for Mental Illness (MI) was answered NO to indicate that Resident #111 did not have a diagnosis of severe mental illness. Therefore, the facility failed to refer the resident to the appropriate state-designated authority for evaluation and determination. Interview on 3/13/24 at 1:35 p.m. with Staff R (Director of Social Services) confirmed that Resident #111 had a diagnosis of bipolar disorder upon admission and the facility did not refer the resident to the appropriate state-designated authority for evaluation 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.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure adequate staffing to provide assistance with breakfast on 1 of 3 units observed (South Unit). Findings include: Interview on 3/12/24 at approximately 9:20 a.m. with Staff K (Licensed Nursing Assistant (LNA)) revealed that the breakfast meal arrives to the unit at approximately 8:15 a.m. Staff K revealed that there are 14 residents on the unit that require total assistance with meals and other residents require cues at meals. Further interview revealed that there are usually 4 LNA's on the unit to assist residents with breakfast. Observation on 3/12/24 at approximately 9:20 a.m. during breakfast dining on the unit revealed 7 resident meal trays remained on the meal truck and had not been given to the residents. Interview on 3/12/24 at approximately 9:35 a.m. with Staff M (LNA) revealed that there are not enough staff on the South Unit to assist all the residents that require assistance with breakfast timely and it was not uncommon for residents to be receiving breakfast after…

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, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records were in order and that an account of all controlled drugs was maintained for 2 of 2 narcotic books reviewed. Findings Include: East Unit Medication Cart Observation on 3/12/24 at approximately 9:30 a.m. of the East Unit Narcotic/Controlled Substance Log - Shift Count revealed missing staff signatures for the following dates: 1/8/24 (day nurse coming on duty), 1/24/24 (night nurse coming on duty), 1/28/24 (day nurse coming on duty & night nurse coming off duty), 2/14/24 (night nurse going off duty), 2/27/24 (night nurse coming on duty), 2/28/24 (night nurse going off duty), 3/3/24 (night nurse going off duty), 3/7/24 (night nurse going off duty), and 3/12/24 (night nurse coming on duty). Interview on 3/12/24 at approximately 9:30 a.m. with Staff P…

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, it was determined that the facility failed to ensure that residents on antipsychotic medications were monitored for side effects for 2 of 5 residents reviewed for unnecessary medications in a final sample of 27 residents (Resident Identifiers are #12 and #42). Findings include: Resident #12 Review on 3/13/24 of Resident #12's March 2024's Medication Administration Record (MAR) revealed the following physician's order: Seroquel Oral Tablet 25 mg [milligrams] [Quetiapine Fumarate] Give 12.5 mg by mouth two times a day for Major Depressive Disorder delusional/agitation, Start Date 9/21/23. Review on 3/14/24 of Resident #12's Abnormal Involuntary Movement Scale (AIMS) revealed that the last one completed with Resident #12 was dated 8/21/23. Interview on 3/14/24 at approximately 10:45 a.m. with Staff C (Assistant Director of Nursing) revealed that the AIMS test should be completed every 6 months when residents are on antipsychotic medications. Further interview revealed that the facility does not have a policy for when AIMS testing should be done.…

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 adhere to facility established infection prevention procedures for 1 of 4 residents reviewed with catheters and for transmission based precautions for 2 of 6 residents reviewed for infection control in a final sample of 27 residents (Resident Identifiers are #75, #172, and #174). Findings include:Resident #174 Record review on 3/12/24 of Resident #174's medical record revealed the resident had a Foley catheter. Observation on 3/12/24 at 12:38 p.m. of Resident #174 revealed them in their room seated in a chair with an uncovered catheter bag and tubing resting on the floor. Observation on 3/13/24 at approximately 12:30 p.m. revealed Resident #174 in their room seated in a chair with an uncovered catheter bag hanging from the heating unit. Interview on 3/13/24 at approximately 12:35 p.m. with Staff S (Licensed Practical Nurse) confirmed the finding. Review on 3/18/24 of the facility policy titled, Emptying Foley Catheter Drainage Bag, revealed: Never allow the drainage tube to touch the floor .Bacteria can very…

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 it was determined that the facility failed to ensure a resident was offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza vaccination for 2 of 5 residents reviewed for vaccinations (Resident identifiers are #29 and #107). Findings include: Resident #29 Review on 3/13/24 of Resident #29's medical record revealed that Resident #29 was admitted to the facility on [DATE]. Further review revealed that Resident #29 had not received an influenza vaccination and had received Pneumovax 23 prior to admission. Interview on 3/14/24 at approximately 11 a.m. with Staff C (Infection Preventionist) revealed that Resident #29 had not been offered or educated on the risks/benefits of the Influenza vaccine or any other additional pneumonia vaccines. Resident #107 Review on 3/13/24 of Resident #107's medical record revealed that Resident #107 was admitted to the facility on [DATE]. Further review revealed that Resident #107 had not received a pneumonia…

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, it was determined that the facility failed to ensure that medications were labeled with an open date or use by date for medications found in 2 out of 3 medication carts and 1 out of 2 medication rooms observed; and failed to ensure medications were secured on 1 out of 3 nursing units observed (Resident identifiers are #15, #19, #26, #31, #82 and #87). Findings include: Observation on [DATE] at approximately 11:45 a.m. on Resident #15's night stand revealed 2 opened bottles of eye drops. Interview on [DATE] at approximately 11:45 a.m. with Staff C (Registered Nurse (RN)) revealed that the eye drops are routinely left on the resident's nightstand. [Pronoun omitted] gets eye drops every hour, so we leave them there. Observation on [DATE] at approximately 7:37 a.m. during medication administration on the East Unit Medication Cart (1 and 3) revealed the following: Resident #26's opened vial of insulin, labeled with an opened expiration date of [DATE]. 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 observation, interview and record review it was determined that the facility failed to follow manufacturer's instructions for medication administration for 1 out of 1 inhaled medications observed and failed to follow physician's orders for 1 out of 1 Gastrostomy tube (G tube) medication administration observed (Resident identifiers are #15 and #21). Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #15 Observation on 2/15/23 at approximately 11:45 a.m. with Staff C (Registered Nurse) revealed Staff C administered the following medications through Resident #15's G tube without flushing before and after…

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.