Edgewater Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Edgewater Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 14, 2024

  Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries. Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on [DATE] without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility failed to conduct a skin assessment between the dates of 10/6/23 and 10/18/23. […]

• No harm, potential for more than minimal, widespreadF812Aug 27, 2025

  Based on observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure kitchen staff appropriately cleaned thermometers before and after use. Findings include:I. Improper cleaning of food thermometerA. Professional referenceAccording to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved 9/2/25 from:, revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Equipment, food-contact surfaces and utensils shall be cleaned before using or storing food temperature measuring devices. (4-602.11)B. […]

• No harm, potential for more than minimal, widespreadF812Feb 14, 2024

  Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment refrigerators. Specifically, the facility failed to: -Ensure thawed nutritional supplements and thickened liquids were dated appropriately; -Ensure food was labeled and dated in the nourishment refrigerators; and, -Ensure expired food was discarded in the nourishment refrigerators. Findings include: I. Professional reference The (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved on [DATE], read in pertinent part, A date marking system that meets the criteria may include: Using a method… […]

• No harm, potential for more than minimal, patternF880Aug 27, 2025

  Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of two units. Specifically, the facility failed to:-Ensure housekeeping staff performed appropriate hand hygiene when cleaning residents' rooms,-Ensure staff performed appropriate hand hygiene when performing incontinence care for Resident #23; and,-Ensure staff wore appropriate personal protective equipment (PPE) during high contact resident care for Resident #23 and Resident #4, who were on enhanced barrier precautions (EBP).Findings include: I. […]

• No harm, potential for more than minimal, patternF760Feb 14, 2024

  Based on observation, record review and interviews, the facility failed to ensure that residents were kept free from significant medication errors for two (#54 and #47) of six residents out of 26 sample residents. Specifically, the facility failed to: -Ensure an antipsychotic medication for Resident #54 was obtained and administered according to physician's orders; -Notify resident #54's physician that the resident's antipsychotic medication was not refilled which resulted in the resident missing administration of the medication three days; -Ensure Resident #47 received all ordered doses of her prescribed antibiotic medication; and, -Notify Resident #47's physician when the resident did not receive the antibiotic medication. Findings include: I. […]