Edgemont Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF558Jul 25, 2025

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide 2 (Resident (R) 54 and R10) of 21 sampled residents the right to reside and receive services with reasonable accommodation of the resident's needs and preferences except when to do so would endanger the health or safety of the resident or others. The facility moved or removed personal items, furnishings, and/or equipment without consideration of resident preferences and accommodation of each resident's individual needs. […]

• Actual harm, isolatedF656Jul 25, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and/or mental and psychosocial needs identified in the comprehensive assessment for three (Resident (R)4, R46, and R36) of 21 sampled residents. The findings include:Review of the facility policy, Comprehensive Care Plans, dated 04/26/2017, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights. Further review revealed the care plan was to include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs.1.a. […]

• Actual harm, isolatedF686Jul 25, 2025

  Based on observation, interview, record review, and review of facility policy, the facility failed to provide treatment and services to prevent development of pressure ulcers for one (Resident (R) 4) of four residents reviewed for pressure ulcers. R4, who required staff assistance with turning and repositioning, was not care-planned with specific intervention for these services. The resident then developed a facility-acquired Stage III pressure ulcer in 01/2025. The Stage III pressure ulcer failed to heal as expected, and was present for 175+ days, as R4 failed to receive pressure relief as needed. The findings include:Review of R4's admission Record revealed the facility admitted the resident on 05/18/2019. […]

• No harm, potential for more than minimal, widespreadF880Jul 30, 2026

  Based on observation, interview, review of a Centers for Disease Control and Prevention (CDC) article, and review of the facility's document and policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 17 sampled residents, Resident (R) 4. In addition, the facility failed to have a water management program to prevent and limit growth and spread of opportunistic pathogens which could potentially affect all 64 residents.The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised 05/18/2026, revealed, [Facility's Name] maintains an… […]

• No harm, potential for more than minimal, widespreadF577Jul 25, 2025

  Based on observation, interview, and record review, the facility failed to post notice of the availability of the most recent survey results and failed to post those results in a place that was readily accessible to residents. The deficient practice had the potential to affect all residents' rights to be fully informed by being able to review that information upon request. The findings Include:Review of the facility's policy titled, Resident Rights, revised 04/12/2024, revealed residents have the right to receive all forms of communication while residing within the facility, and the facility would assist residents in exercising his/her rights.Observation during a tour of the facility on 07/22/2025 at 10:00 AM revealed there was no notice that indicated the location of the most recent state… […]