The Plaza at Edgemere

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to ensure that only paper towels were placed in 3 of 3 handwashing sink garbage receptacles.The facility failed to ensure that 1 of 3 handwashing sinks had a garbage receptacle.The facility failed to maintain the sanitizing solution used in the manual dishwashing process at the proper chemical concentration required for effective sanitation.The facility failed to ensure that stored canned goods had uncompromised seals and were free from dents.These failures could have placed residents at risk for food-borne illness and cross contamination. Observation of the kitchen on January 20, 2026, at 10:06 a.m., revealed the following:2 of 3 handwashing sinks had garbage receptacles that contained items other than disposable paper towels, including disposable gloves, product boxes, food, and other forms of trash.1 of 3 handwashing…

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 electronically submit to CMS complete and accurate direct care staffing information for the fourth quarter (July 1, 2025, to September 30, 2025). The facility failed to submit complete PBJ staffing information to CMS for July 1, 2025, to September 30, 2025. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included:Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 4 (July 1, 2025- September 30, 2025). No other quarter triggered. An interview with the Administrator on 01/20/2026 at 9:30 am, revealed she was not employed by this facility during that reporting period. She stated that she was unaware of the failure to report data for that reporting period.An interview with the Executive Director on 01/20/2026 at 9:31 am revealed the facility simply did not get the data entered in the system in 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, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #14, and #71) of four residents observed for infection control in that: LVN A failed to disinfect the blood pressure cuff (used to take blood pressure), and the thermometer in between vital sign checks for Resident #14, and Resident #71. This failure could place residents at risk for spread of infection through cross-contamination. Findings included:Review of Resident #14's 5-day MDS assessment, dated 01/10/2026, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with the following diagnoses: hypertension (high blood pressure), diabetes (increase of blood sugar), and anxiety disorder (anxious and nervous). Resident #14's BIMs score of 15 indicated the resident was alert and oriented 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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #2) of 4 residents reviewed for care plan review and revision.The facility failed to review and revise Resident #2's care plan after he fell on [DATE] and 06/22/2025. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls. The findings included: Record review of Resident #2's Face Sheet, dated 10/09/2025, reflected the resident was a [AGE] year-old male who admitted on [DATE]. Resident #2 had diagnoses which included dementia (decline in cognitive function that interferes with daily life) and a history of falls. Record review of Resident #2's Quarterly MDS (tool used to measure health…

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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 2 kitchens reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure foods in the refrigerator and freezer, were properly sealed from air-borne contaminations. 2. The facility failed to clean the food storage bins in the dry food storage area in the main kitchen. The facility failed to clean the Ice Machine on both the 3rd floor (Main Kitchen) and 2nd floor (Secondary Kitchen). These failures could place residents at risk for cross contamination and air-borne illnesses. Findings included: Observations on 10/01/24 from 8:39 AM to 9:00 AM in the facility's main kitchen reflected: The food storage bins in the dry food storage area, were noted to have stains to the top of the container lid. Observations on 10/01/24 from 12:27 PM to 12:33 PM in the facility's secondary kitchen area located on the second floor reflected: Ice machine upper inside…

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, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Resident #6, Resident #15, and Resident #32) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #6's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #15's CPAP mask (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 3. The facility failed to ensure that Resident #32's CPAP mask was stored properly. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Review of Resident #6's Face Sheet, 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 electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 4 FY quarters (FY Quarter 3 for 2024 (April 1-June 30) reviewed for administration. The facility failed to submit staffing data to CMS for (April 1- June 30). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings included: Record review of the CMS PBJ Staffing Data Report, CASPER Report 1705D FY Quarter 3 2024 (April 1 - June 30), dated 09/24/2024, revealed the following entry: Failed to Submit Data for the Quarter .Triggered .Triggered=No Data Submitted for the Quarter. In an interview on 10/03/24 at 12:55 PM, ADMIN said that he was responsible for uploading the PBJ he said he…

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 observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #18 and Resident #198) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA A changed her gloves and performed hand hygiene while providing incontinent care to Resident #18. 2. The facility failed to ensure that CNA B and the MDS Nurse changed their gloves and performed hand hygiene while providing incontinent care to Resident #198. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #18's Face Sheet, dated 10/03/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #18 was diagnosed with abnormalities of gait and mobility. Review of Resident #18'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #29) of 5 residents reviewed for dignity. The facility failed to treat Resident #29 with dignity and promote enhancement of his quality of life when the resident's catheter bag was not placed away from the door as care planned. This failure placed residents at risk of not having their right to a dignified existence maintained. Findings included: Review of Resident #29's Face Sheet, dated 10/03/2024, reflected resident was a [AGE] year-old male admitted on [DATE]. Resident #29 was diagnosed with complete at T2 - T6 (second to sixth thoracic vertebrae) level of thoracic spinal cord (bundle of nerve fibers), paraplegia (paralysis of the lower part of the body), and neurogenic dysfunction of bladder (the normal bladder function is disrupted due to…

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, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #32) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #32's Comprehensive MDS Assessment accurately reflected that Resident #32 was using a CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). This failure could place residents at risk for not receiving care and services to meet their needs, for diminished function of health, and for regressions in their overall health. Findings included: Review of Resident #32's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. Resident #32 was diagnosed with acute and chronic respiratory failure with hypoxia (insufficient amount of oxygen in the body). Review of Resident #32's Comprehensive MDS Assessment, dated 08/30/2024, reflected Resident #32 had…

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, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #19) of seven residents reviewed for Care Plans. The facility failed to ensure Resident #19 was care planned for Hospice Care. This failure could place the residents at risk of not receiving the necessary care and services. Findings included: Review of Resident #19's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #19 was diagnosed with dementia. Review of Resident #19's Quarterly MDS Assessment, dated 07/18/2024, reflected Resident #19 had severe impairment in cognition with a BIMS score of 00. Resident #19's Quarterly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that one (Resident #148) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LVN C did not leave Resident #148's medications inside the resident's room. This failure could place the residents at risk of not receiving medications as ordered by the physician. Findings included: Review of Resident #148's Face Sheet, dated 10/03/2024, reflected the resident was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included encephalopathy (a disease that affects the brain), depression, and cognitive communication deficit. Review of Resident #148's Quarterly MDS Assessment, dated 07/08/2024, reflected resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment also indicated Resident #148 had debility (weakness) and cardiorespiratory (relating to the heart and the lungs) conditions. Review 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.