Deficiency Records for Edgewood Manor Health Care Center
Updated as of January 01, 2019
This is not the most recent data for Edgewood Manor Health Care Center. For the most recent information, click here.
A list of the most recent deficiencies for Edgewood Manor Health Care Center. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Have exits that are accessible at all times. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-12-11 | 2018-01-23 | 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 | 2017-12-11 | 2018-01-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-12-11 | 2018-01-23 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2017-12-11 | 2018-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-11 | 2018-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-11 | 2018-01-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-12-11 | 2018-01-23 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2017-12-11 | 2018-01-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2017-12-11 | 2018-01-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-12-11 | 2018-01-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne | Health | 2017-12-11 | 2018-01-23 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2017-12-11 | 2018-01-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-11 | 2018-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-11 | 2018-01-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-12-11 | 2018-01-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-08-09 | 2017-09-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-09 | 2017-09-26 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-09-20 | 2016-10-31 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-09-20 | 2016-10-31 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-09-20 | 2016-10-31 | N |
| An externally vented heating system. | Fire Safety | 2016-09-20 | 2016-10-31 | N |
| Restrictions on the use of flammable curtains. | Fire Safety | 2016-09-20 | 2016-10-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-09-20 | 2016-10-31 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2016-09-20 | 2016-10-31 | N |
| Upon the death of a resident, convey the resident?s personal funds and an accounting of those funds to the appropriate party. | Health | 2016-09-20 | 2016-10-31 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-09-20 | 2016-10-31 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2016-09-20 | 2016-10-31 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2016-09-20 | 2016-10-31 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-09-20 | 2016-10-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-09-20 | 2016-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-20 | 2016-10-31 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2016-09-20 | 2016-10-31 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-09-20 | 2016-10-31 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-09-20 | 2016-10-31 | N |
| Keep all essential equipment working safely. | Health | 2016-09-20 | 2016-10-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-09-20 | 2016-10-31 | N |
| Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. | Health | 2016-09-20 | 2016-10-31 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-09-20 | 2016-10-31 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-09-20 | 2016-10-31 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-09-20 | 2016-10-31 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-09-20 | 2016-10-31 | Y |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-09-20 | 2016-10-31 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2016-09-20 | 2016-10-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-02-05 | 2016-03-24 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-02-05 | 2016-03-24 | Y |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2016-02-05 | 2016-03-24 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-02-05 | 2016-03-24 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-10-23 | 2016-03-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2015-10-23 | 2016-03-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2015-10-23 | 2016-03-24 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2015-10-23 | 2016-03-24 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2015-10-23 | 2016-03-24 | N |
| Use a registered nurse at least 8 hours a day, 7 days a week. | Health | 2015-10-23 | 2016-03-24 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2015-10-23 | 2016-03-24 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Portable fire extinguishers. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Exits that are free from obstructions and can be used at all times. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Have other fire safety features required by fire safety codes. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Emergency showers. | Fire Safety | 2015-10-23 | 2015-12-18 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2015-10-23 | 2015-12-18 | N |
| Provide written records when a resident is transferred or discharged. | Health | 2015-10-23 | 2015-12-18 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2015-10-23 | 2015-12-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2015-10-23 | 2015-12-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2015-10-23 | 2015-12-18 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2015-10-23 | 2015-12-18 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2015-10-23 | 2015-12-18 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-10-23 | 2015-12-18 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-10-23 | 2015-12-18 | N |
| Keep all essential equipment working safely. | Health | 2015-10-23 | 2015-12-18 | N |
