A list of the most recent deficiencies for Edgewater, A Wesleylife Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2024-01-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-05 | 2024-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-05 | 2023-12-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-05 | 2023-12-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-12-05 | 2023-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-27 | 2022-08-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-27 | 2022-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-27 | 2022-08-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-27 | 2022-08-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-27 | 2022-08-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-27 | 2022-08-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-27 | 2022-08-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-27 | 2022-08-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-27 | 2022-08-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-07-27 | 2022-08-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-27 | 2022-08-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-27 | 2022-08-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-27 | 2022-08-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-27 | 2022-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-27 | 2022-07-29 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-27 | 2022-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-27 | 2022-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-27 | 2022-07-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-27 | 2022-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-23 | 2021-07-23 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-06-23 | 2021-07-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-23 | 2021-07-23 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-06-23 | 2021-07-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-23 | 2021-07-23 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-23 | 2021-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-23 | 2021-07-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-23 | 2021-07-23 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-21 | 2021-07-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-06-21 | 2021-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-21 | 2021-07-01 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-21 | 2021-06-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-21 | 2021-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-21 | 2021-06-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-21 | 2021-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-21 | 2021-06-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-21 | 2021-06-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-21 | 2021-06-23 | N |
