Edgewood Manor Health Care Center

In the surveyor’s words

From the most serious findings on record at Edgewood Manor Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 20, 2025

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from verbal and physical abuse by two staff members, Licensed Practical Nurse A and Certified Nursing Assistant (CNA) A. Multiple facility staff observed the interaction and did not intervene. LPN A and CNA A worked the entire shift after the abuse incident. The facility had 78 residents. The Administrator was notified on 3/20/25 at 1:13 P.M., of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 3/12/25. The facility started their investigation on 3/13/25 and suspended LPN A and CNA A and they were terminated on 3/14/25. The facility in-serviced staff before the start of their next shift. […]

• Immediate jeopardy, isolatedF689Nov 17, 2022

  Based on interview and record review, the facility failed to provide supervision to prevent an elopement from a locked behavioral unit for one sampled resident (Resident #1), who was identified at risk on the facility elopement risk assessment and on his/her care plan. On 11/14/22 about 5:30 P.M. the resident broke a window in room [ROOM NUMBER] and said he/she wanted out. The resident was moved down the hall to room [ROOM NUMBER]. The Administrator sat on the hall to provide monitoring for the resident behavior and placed his/her chair in front of room [ROOM NUMBER] until the Administrator provided report to Hall Monitor A on resident behaviors at 7:00 P.M. There was no instruction to monitor room [ROOM NUMBER] with the broken window to Hall Monitor A. […]

• Immediate jeopardy, isolatedF689Jan 12, 2022

  Based on observation, interview and record review, the facility failed to ensure safe smoking practices were followed and to provide protective oversight for one sampled resident (Resident #1) who required direct supervision while smoking, was at risk of smoking in his/her room and required oxygen, which resulted in a burn to his/her face. This deficient practice affected 1 out of 8 sampled residents. The census was 64 residents. The Administrator was notified on 1/6/22 at 1:30 P.M. of an Immediate Jeopardy (IJ) which began on 1/4/22. The IJ was removed on 1/8/22, as confirmed by surveyor onsite verification. Record review of the Facility Smoking Safety Regulations policy dated 7/9/21 showed the facility would provide direct supervision for smoking classified as not responsible. […]

• Actual harm, isolatedF600Apr 6, 2026

  Based on observation, interview and record review, the facility failed to prevent abuse for one sampled resident (Resident #8) out of fourteen sampled residents. On 4/2/26, Resident #7 attacked Resident #8 while Resident #8 was in bed, resulting in superficial scratches on Resident #8's face, arm, abdomen and back. The facility census was 72 residents.Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which could include staff-to-resident abuse and certain resident-to-resident altercations. […]

• Actual harm, isolatedF689Oct 1, 2024

  Based on interview and record review, the facility failed to ensure the safety when on 6/19/24 Agency Certified Nursing Assistant (CNA) E transferred one sampled resident (Residnet #17) identified as a fall risk, by himself/herself that caused a fall which resulted in a closed right sided tibial fracture (a tibial fracture occurs along the length of the bone, below the knee and above the ankle), and failed to complete a fall investigation for the fall, out of 19 sampled residents. […]