Deficiency Records for Edgewood Manor Health Care Center
Updated as of September 01, 2020
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? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2020-03-16 | 2020-05-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-18 | 2020-01-09 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-05-07 | 2019-05-20 | Y |
| 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 |
| Be properly staffed | 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 other general requirements that are deficient. | 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-17 | 2018-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-17 | 2018-12-04 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-05-02 | 2018-06-16 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-05-02 | 2018-06-16 | Y |
| 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 necessary and PRN use is limited. | 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 |
| 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 |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-09-20 | 2016-10-31 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-09-20 | 2016-10-31 | 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 | 2016-09-20 | 2016-10-31 | 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 | 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 |
| Ensure that residents are safe from serious medication errors. | 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 |
