Edgewater, A Wesleylife Community

In the surveyor’s words

From the most serious findings on record at Edgewater, A Wesleylife Community, in the surveyor’s own words.

• Actual harm, isolatedF695Aug 3, 2026

  Based on clinical record review, facility document review, resident interview, staff interviews, safety data sheets, and policy review, the facility failed to ensure a continuous positive airway pressure (CPAP) machine (device used to keep airway open during sleep) was filled with the correct solution for 1 of 2 residents reviewed (Resident #14) for CPAP use. Staff filled Resident #14's CPAP machine with distilled vinegar (acedic acid) instead of distilled water resulting in the resident complaining of a headache, burning eyes and altered taste. The facility reported a census of 36. Findings include: The Minimum Data Set (MDS) Assessment completed on 7/18/26 revealed Resident #14 admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Jul 27, 2022

  Based on review of documents, observations, resident, and staff interviews, the facility did not ensure: 1. Assistance for safe ambulation 2. Implementation of safe transfer techniques after a fall 3. Supervision during the use of restorative equipment, for 1 of 4 residents (Resident #11) in the sample reviewed for accidents. 4. In addition, the facility did not consistently investigate fall incidents to determine root causes, in order to develop appropriate interventions to prevent or minimize potential occurrences, the facility did not consistently reflect assessments data, and interventions implemented related to falls in the clinical records for 1 of 4 residents (Resident #11) in the sample reviewed for accidents. […]

• No harm, potential for more than minimal, patternF761Oct 17, 2024

  Based on observations, staff interviews and policy review, the facility failed to secure prescribed medications from the possibility of unauthorized access. The facility reported a census of 40 residents. Findings included: On 10/16/24 @ 2:38 am, the medication room door was observed propped open with an angled floor stopper. A small basket of over-the-counter medications (OTC) was positioned on top of a small cart. Two (2) medication packets, Prednisone and Furosemide, were lying on the counter. On 10/16/24 at 2:43 am, Staff A, Licensed Practical Nurse (LPN) stated medications were not stored in the medication room. When Staff A was informed there were medications on the medication room counter, he stated the resident didn't want staff in her room before 6:00 am, so he left them there. […]

• No harm, potential for more than minimal, patternF842Oct 17, 2024

  Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 40 residents. Findings include: On 10/16/24 @ 2:55 am, a document containing resident information was observed on a table in an open area of the unit with no staff present. On 10/16/24 at 2:58 am, Staff A, Licensed Practical Nurse (LPN) stated the form was the 24-hour nurses' report sheet. He also stated he left it out because all of the residents were asleep but it should not be left out when staff are not present. On 10/16/24 at 4:00 PM, the Director of Nursing (DON) stated staff should turn paperwork with resident information over so it's not visible to others. […]

• No harm, potential for more than minimal, patternF803Jul 15, 2024

  Based on observation, menu review, and staff interview, the facility failed to serve the appropriate portions for 5 residents who received mashed potatoes for lunch. The facility reported a census of 35 residents. Findings include: The facility's menu for lunch for 7/14/24 identified the following items to be served as part of the planned regular textured diet: 3 oz of fried chicken 3 oz of beef tips 1/2 cup of mashed potatoes 1/2 cup of parslied rice 1/2 cup of country vegetable blend 2 oz ladle of country gravy Continuous observation of lunch preparation and service began on 7/14/24 at 11:59 am. Staff G, Homemaker cook, placed the following food serving utensils on a dish and identified each serving size. […]