Edgewater Woods

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse by a visitor for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse.The Immediate Jeopardy began on 7/30/26 when Resident B was sexually abused by a visitor, and staff failed to intervene. The Regional [NAME] President of Operations, Corporate Nurse Consultant, Administrator, and interim DON were notified of the Immediate Jeopardy on 8/5/26 at 3:32 p.m. […]

• Immediate jeopardy, isolatedF609Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff reported an allegation of sexual abuse immediately to the administrator or designee when a visitor was observed fondling Resident B's breast for 1 of 3 residents reviewed for abuse. (Resident B) The failure to report led to the same staff member later observing the same visitor with his hand down Resident B's brief, fondling her perineal area. Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse. The Immediate Jeopardy began on 7/30/26 when the staff failed to report and intervene when Resident B was sexually abused by Family Member 6. […]

• Immediate jeopardy, isolatedF610Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff intervened to protect a resident when they were sexually abused by a visitor when the visitor was observed by the staff member fondling Resident B's breast The facility also failed to investigate and prevent further abuse as evidenced by the same visitor being later observed fondling Resident B's perineal area under her incontinence brief for 1 of 3 residents reviewed for abuse. (Resident B) Using the reasonable person concept, it is likely Resident B would experience humiliation and fear related to the sexual abuse. […]

• Actual harm, isolatedF686Mar 1, 2022

  Based on record review and interview the facility failed to prevent the development and worsening of pressure ulcers for 1 of 5 resident observed for wounds. (Resident 47) This deficient practice resulted in unstageable pressure ulcers developing and worsening. Findings include: Resident 47's clinical record was reviewed on 2/25/22 at 2:52 p.m diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 47 had a quarterly Minimum Data Set assessment (MDS) on 1/24/22 which indicated the resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, was always incontinent of bowel and bladder and had a stage IV pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF880Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure an ice machine was maintained in a hygienic manner for 1 of 2 facility ice machines observed. (Willow Way hall) This deficient practice had the potential to affect 66 of 70 residents who received ice from the machine. Findings include:Review of an anonymous intake filed with the Indiana Department of Health (IDOH) indicated the facility's ice machine had mold growing inside of it. During a facility tour, on 8/6/26 at 3:37 p.m., accompanied by the Maintenance Director, CNA 5 filled three foam cups with ice from the ice chest located in the [NAME] Lane clean utility room. The ice machine on [NAME] Lane was observed to be unlocked, with the lock laying on top of the machine. […]