Edgewood Convalescent Home

In the surveyor’s words

From the most serious findings on record at Edgewood Convalescent Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF725Oct 31, 2024

  Based on record review, Facility Assessment review, and resident and staff interviews the facility failed to employ sufficient numbers of staff on the weekends to meet resident needs. The facility reported a census of 43 residents. Findings include: A review of the Centers for Medicare & Medicaid Services (CMS) PBJ Staffing Data Report revealed the facility triggered for excessively low weekend staffing for Quarter 3, 2024 (April 1-June 30). A review of the Edgewood Convalescent Home Shift assignment sheets from April 1st through June 30th, 2024 revealed required staff were absent for either partial or whole shifts as follows: First shift- Certified Nursing Aides (CNA) 23 days Second shift- CNA 19 days, Nurse 3 days Third shift- CNA 1 day In an interview on 10/30/24 at 9:25 AM… […]

• No harm, potential for more than minimal, isolatedF883Sep 25, 2025

  Based on clinical record review, 2025 Disease Control and Prevention (CDC) Adult Immunization Schedule and staff interview, the facility failed to offer updated pneumococcal vaccination to 2 of 5 residents sampled (Resident #7 and #36). The facility identified a census of 41 residents.Findings include:1.Resident #7's Electronic Healthcare Record (EHR) Census Report showed he admitted to the facility on [DATE]. Resident #7 Pneumococcal Immunization Informed Consent signed by the resident on 7/16/24 documented the resident had a Pneumococcal Polysaccharide Vaccine 23 (PPSV 23) vaccination on 12/02/13. […]

• No harm, potential for more than minimal, isolatedF658Oct 5, 2023

  Based on observation, clinical record review, insulin pen competency review, Novolog highlights of prescribing information (manufacturer's directions for use), and staff interview, the facility failed to prime the insulin pen with 2 units of insulin prior to the administration of the physician ordered dose of insulin for 1 of 1 residents observed for insulin administration (Resident #5). The facility identified a census of 48 residents. Findings include: Resident #5 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status score of 14 indicating intact cognition. […]

• No harm, potential for more than minimal, isolatedF868Jun 9, 2022

  Based on Continuous Quality Improvement Attendance sheets, policy review, and staff interviews the facility failed to have routine quarterly Quality Assurance and Performance Improvement (QAPI) meetings in the years of 2021 and 2022. In addition the facility failed to have the Medical Director attend 1 of 2 QAPI meetings held in 2021. The facility identified a census of 42 residents. Findings include: A review of the facility Continuous Quality Improvement (CQI) Attendance sheets completed on 6/8/22 revealed the facility held two QAPI meetings in the year 2021 on 8/31/21 and 9/30/21. The facility lacked documentation of a QAPI meeting held in the year 2022. The CQI Attendance sign-in sheet dated 8/31/21 documented that the facility held a QAPI meeting at 8:00 a.m. […]

• No harm, potential for minimal, patternF625Jun 9, 2022

  Based on clinical record reviews, staff interviews, and facility policy review the facility failed to offer Bed Hold agreements to 2 of 2 residents reviewed who transferred to the hospital (Residents #7 and #23). The facility reported a census of 42 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] documented a reentry date as 3/9/22 from an acute hospital stay. The electronic health record's (EHR) section reviewed on 6/9/22 indicated the following discharges with return anticipated to the facility on [DATE], 2/11/22, and 3/6/22. The MDS discharge assessment - return anticipated dated 12/29/21 indicated that Resident #7 discharged to an acute hospital. […]