Edgewood Health & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 2, 2026

  Based on policy review, record review and interviews, the facility failed to ensure the residents' right to be free from abuse and failed to protect Resident #1 from abusive and degrading treatment by Certified Nurse Aide (CNA) #1 and CNA #2 during the provision of care on the evening of 2/10/26. The abusive conduct included the use of disparaging, derogatory, and humiliating language and intimidation toward Resident #1 while the resident requested assistance and complained of pain during care for one (1) of four (4) sampled residents. Resident #1.The State Agency (SA) identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 2/26/26. […]

• Immediate jeopardy, isolatedF609Mar 2, 2026

  Based on policy review, record review and interviews, the facility failed to report an allegation of verbal abuse of a resident within the required timeframe of two (2) hours after the allegation was reported to facility staff. The allegation was reported to the facility on 2/14/26 at approximately 8:40 AM but was not reported to the State Agency until 2/16/26 at 11:30 AM. This was for one (1) of four (4) sampled residents. Resident #1.This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 02/14/26 and placed Resident #1 and all other residents in a situation that was likely to cause serious harm, serious impairment, serious injury or death.The IJ and SQC existed at:CFR 483.12(c)(1)(4) Reporting of Alleged ViolationsScope and Severity (S/S)… […]

• Immediate jeopardy, isolatedF610Mar 2, 2026

  Based on policy review, record review, and interviews, the facility failed to thoroughly investigate an allegation of abuse in a timely manner to prevent further potential abuse. The facility failed to initiate a prompt and thorough investigation after an allegation of verbal abuse of Resident #1 was reported on 2/14/26. The facility did not immediately interview staff or residents, did not initiate protective interventions, and delayed investigative actions until 2/16/26. This deficient practice affected one (1) of three (3) reviewed incidents with documented indications of possible abuse. […]

• Immediate jeopardy, isolatedF835Mar 2, 2026

  Based on policy review, record review, and interviews, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure administrative leadership implemented timely actions to respond to and manage an allegation of verbal abuse involving Resident #1. The Administrator was notified of the allegation on 2/14/26 at approximately 9:00 AM but failed to ensure the allegation was reported within required timeframes, failed to ensure the alleged perpetrator was immediately removed from resident contact, and failed to ensure a prompt investigation was initiated. This deficient practice affected one (1) of four (4) sampled residents. […]

• Immediate jeopardy, isolatedF689Jun 19, 2025

  Based on observation, staff interview, record review, and facility policy review, the facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1 On 6/10/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of seven (7), was let out of the building by a lawn service worker. She exited the facility in her wheelchair unnoticed and was last seen inside the facility at 11:05 AM. She was found at 11:08 AM by a visitor walking into the facility in the facility's parking lot, approximately 145 feet from the front door of the building. […]