A list of the most recent deficiencies for Edgewood Manor. 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 properly protected cooking facilities. | Fire Safety | 2023-06-21 | 2023-06-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-21 | 2023-06-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-21 | 2023-06-22 | 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 | 2023-03-29 | 2023-03-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-29 | 2023-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-29 | 2023-03-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-02-16 | 2023-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-16 | 2023-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-02-17 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-02-16 | 2023-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2022-12-09 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-01-06 | 2022-01-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-06 | 2022-01-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-06 | 2022-01-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-06 | 2022-01-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-01-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-06 | 2022-01-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-06 | 2022-01-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-29 | 2021-11-08 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-10-23 | 2020-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-23 | 2020-12-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-23 | 2020-12-04 | 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 | 2020-10-23 | 2020-12-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-23 | 2020-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-23 | 2020-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-23 | 2020-12-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-21 | 2020-12-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-21 | 2020-11-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-21 | 2020-11-24 | 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 | 2020-10-21 | 2020-11-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-10-21 | 2020-10-24 | N |
