Edgemere Estates

In the surveyor’s words

From the most serious findings on record at Edgemere Estates, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 19, 2024

  Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 2 (Resident #2 and #3) of 6 residents reviewed for vehicle safety. -Maintenance Director failed to ensure Resident #2 and #3 were secured in the vehicle on 06/17/2024, while transporting residents back to the facility from dialysis visit, which resulted in falls with injuries. The noncompliance was identified as PNC. The IJ began on 06/17/2024 and ended on 06/18/2024. […]

• Immediate jeopardy, isolatedF600Apr 1, 2024

  Based on observation, interview and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 14 residents reviewed for neglect in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A who was responsible for Resident #1 did not know the process and procedures that were to be followed when a full-code resident was found unresponsive, resulting in the resident not being provided CPR. An IJ was identified on [DATE] at 10:25 AM. The IJ template was provided to the facility on [DATE] at 10:25 AM. […]

• Immediate jeopardy, isolatedF678Apr 1, 2024

  Based on observation, interview and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 14 residents reviewed for physician's orders for provision of basic life support in that: Resident #1 was found unresponsive on [DATE] around 7:25 AM by CNA C who immediately notified RN A. RN A went to the resident's room and checked him for signs of life but did not know how to respond when she did not find a pulse, and did not immediately start CPR or other life-sustaining measures, resulting in Resident #1's wishes to be resuscitated not being honored. […]

• Actual harm, isolatedF689Mar 14, 2024

  Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for1 (Resident #37) of 21 residents reviewed for an environment free of accident hazards as possible. The facility failed to ensure that the mechanical lift (Hoyer) sling used to transfer Resident #37 was in good working order, resulting in a sling strap tearing, and Resident #37 falling to the floor. This failure could result in residents fearing transfers using a mechanical lift, and serious injury, including fractures. Findings included: Record review of Resident #37 ' s face sheet dated 03/14/2024 revealed he was [AGE] years old and was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF921Mar 14, 2024

  Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in four of four halls reviewed for condition of handrails. The facility failed to ensure that the handrails throughout the facility did not have the paint worn off them. This failure could put residents at risk of feeling a decreased sense of well-being, and at increased risk for splinters because of the poorly maintained condition of the handrails. Findings included: Handrails: Observation on 03/14/2024 at 2:30 PM of the handrails in the 100 and 200 halls revealed that the brown paint on all handrails was worn through and that the wood showed through the paint. […]