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Deficiency Records for Edgewood Manor Health Care Center
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.
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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-10-01 | 2024-11-14 | 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 | 2024-10-01 | 2024-11-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-10-01 | 2024-11-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-10-01 | 2024-11-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-01 | 2024-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-10-01 | 2024-11-14 | 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 | 2024-10-01 | 2024-11-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-10-01 | 2024-11-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-10-01 | 2024-11-14 | N |
| Provide appropriate foot care. | Health | 2024-10-01 | 2024-11-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-10-01 | 2024-11-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-10-01 | 2024-11-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-10-01 | 2024-11-14 | N |
| Post nurse staffing information every day. | Health | 2024-10-01 | 2024-11-14 | 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 | 2024-10-01 | 2024-11-14 | 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 | 2024-10-01 | 2024-11-14 | N |
| Provide or obtain dental services for each resident. | Health | 2024-10-01 | 2024-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-01 | 2024-11-14 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-10-01 | 2024-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-01 | 2024-11-14 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-10-01 | 2024-11-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-10-01 | 2024-11-14 | N |
| 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 | 2024-10-01 | 2024-11-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-10-01 | 2024-11-14 | Y |
| 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 | 2024-10-01 | 2024-11-14 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-01 | 2024-11-14 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-08-23 | 2024-08-23 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-04-18 | 2024-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-27 | 2024-02-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-26 | 2024-02-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-12-26 | 2024-02-09 | Y |
| 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 |
| 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 |
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