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Deficiency Records for Edgehill Nursing and Rehab Cen
A list of the most recent deficiencies for Edgehill Nursing and Rehab Cen. 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 Edgehill Nursing and Rehab Cen. 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? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-10-15 | 2024-12-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-10-09 | 2024-12-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-10-09 | 2024-12-02 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-10-09 | 2024-12-02 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-10-09 | 2024-12-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-10-09 | 2024-12-02 | 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 | 2024-10-09 | 2024-12-02 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-10-09 | 2024-12-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-10-09 | 2024-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-09 | 2024-12-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-10-09 | 2024-12-02 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-10-09 | 2024-12-02 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-10-09 | 2024-12-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-25 | 2024-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-25 | 2024-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-25 | 2024-09-09 | Y |
| Meet other general requirements. | Fire Safety | 2024-02-16 | 2024-03-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-16 | 2024-03-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-16 | 2024-03-25 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-12-21 | 2024-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-23 | 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 | 2023-03-03 | 2023-04-24 | N |
| Dispose of garbage and refuse properly. | Health | 2023-03-03 | 2023-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-03 | 2023-04-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-13 | 2023-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-13 | 2023-04-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-13 | 2023-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-13 | 2023-04-07 | N |
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