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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-08-30 | 2023-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-25 | 2023-05-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-25 | 2023-05-29 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-09 | 2023-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-09 | 2023-04-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-09 | 2023-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-09 | 2023-04-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-09 | 2023-04-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-04-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-02-09 | 2023-04-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-09 | 2023-04-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-09 | 2023-04-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-09 | 2023-04-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-02-09 | 2023-04-06 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-02-09 | 2023-04-06 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-02-09 | 2023-03-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-09 | 2023-03-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-09 | 2023-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-09 | 2023-03-15 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-09 | 2023-03-15 | N |
| 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 | 2023-02-09 | 2023-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2023-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-09 | 2023-03-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-02-09 | 2023-03-15 | N |
| Post nurse staffing information every day. | Health | 2023-02-09 | 2023-03-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-09 | 2023-03-15 | 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 necessary and PRN use is limited. | Health | 2023-02-09 | 2023-03-15 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-02-09 | 2023-03-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-09 | 2023-03-15 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-02-09 | 2023-03-15 | 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 | 2023-02-09 | 2023-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-09 | 2023-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-09 | 2023-03-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-09 | 2023-02-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-05 | 2022-12-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-17 | 2022-11-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-17 | 2022-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-17 | 2022-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-12 | 2022-02-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-22 | 2021-10-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-22 | 2021-10-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-28 | 2021-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-09-07 | Y |
| Report COVID19 data to residents and families. | Health | 2021-07-28 | 2021-09-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-16 | 2020-05-15 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2020-03-16 | 2020-05-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-03-16 | 2020-05-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-16 | 2020-05-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-16 | 2020-05-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-16 | 2020-05-15 | N |
| 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 | 2020-03-16 | 2020-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-16 | 2020-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-16 | 2020-05-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-03-16 | 2020-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-16 | 2020-05-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-03-16 | 2020-05-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-01 | 2019-03-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-01 | 2019-03-17 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2019-02-01 | 2019-03-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-01 | 2019-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-01 | 2019-03-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-01 | 2019-03-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-01 | 2019-03-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-01 | 2019-03-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-01 | 2019-03-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-01 | 2019-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-01 | 2019-03-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-01 | 2019-03-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-02-01 | 2019-03-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-02-01 | 2019-03-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-01 | 2019-03-17 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2019-02-01 | 2019-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-01 | 2019-03-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-01 | 2019-03-17 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-02-01 | 2019-03-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-01 | 2019-03-17 | 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 | 2019-02-01 | 2019-03-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-01 | 2019-03-17 | N |
