A list of the most recent deficiencies for Edgerton Care Center, Inc. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-25 | 2023-11-17 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-25 | 2023-11-17 | Y |
| 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 | 2023-02-14 | 2023-03-15 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-14 | 2023-03-15 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-25 | 2023-03-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-25 | 2023-03-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-25 | 2023-03-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-25 | 2023-03-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-25 | 2023-03-01 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-01-25 | 2023-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-25 | 2023-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-25 | 2023-03-01 | Y |
| 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 | 2023-01-25 | 2023-03-01 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-01-25 | 2023-03-01 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-25 | 2023-03-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-25 | 2023-03-01 | Y |
| 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 | 2023-01-25 | 2023-03-01 | Y |
| 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 | 2023-01-25 | 2023-03-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-25 | 2023-03-01 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-25 | 2023-03-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-25 | 2023-03-01 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-25 | 2023-03-01 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-25 | 2023-03-01 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-25 | 2023-03-01 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-13 | 2023-02-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-13 | 2023-02-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-13 | 2023-02-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-13 | 2023-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-25 | 2023-02-23 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-13 | 2023-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-13 | 2023-02-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-13 | 2023-02-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-13 | 2023-02-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-13 | 2023-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-13 | 2023-02-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-31 | 2022-11-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-31 | 2022-11-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-31 | 2022-11-28 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-31 | 2022-11-25 | Y |
| 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 | 2022-10-31 | 2022-11-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-27 | 2022-10-21 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-27 | 2022-10-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-27 | 2022-09-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-15 | 2022-09-08 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-15 | 2021-11-04 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-09-15 | 2021-10-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-15 | 2021-10-15 | 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 | 2021-09-15 | 2021-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-15 | 2021-10-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-09-15 | 2021-10-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-20 | 2021-10-13 | 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 | 2021-09-20 | 2021-10-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-15 | 2021-10-07 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-09-15 | 2021-10-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-07 | 2021-10-01 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-15 | 2021-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-07 | 2021-09-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-07-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-07-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-18 | 2021-06-15 | Y |
| 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 | 2021-05-18 | 2021-06-15 | Y |
| 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 | 2021-05-18 | 2021-06-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-18 | 2021-06-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-18 | 2021-06-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-06-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-06-25 | 2019-06-25 | N |
