Edgewood Manor Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 7, 2026

  Based on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure a resident's safety during perineal care. Actual harm occurred on 06/27/26 at 11:29 P.M. when Resident #69 was receiving perineal care from one staff member and the staff turned to obtain a washcloth from the basin and the resident rolled off the bed onto the floor. Resident #69 sustained a laceration to the left eyebrow that required skin glue to close and sustained left periorbital soft tissue swelling and hematoma. This affected one, (Resident #69) of one reviewed for falls.Findings included: Review of Resident #69's medical record revealed an admission date of 02/26/25. […]

• Actual harm, isolatedF689Nov 18, 2024

  Based on record review, hospital discharge instruction reviewed, witness statement review, fall occurrence evaluation review, staff interviews, and policy review, the facility failed to ensure a resident requiring two staff members for bed mobility was implemented which resulted in a fall from the bed with an injury. This resulted in Actual Harm when Resident #65, who was moderately cognitively impaired, required the assistance of two staff for bed mobility sustained a fall from bed, when one staff member was providing care, and the resident fell to the floor. […]

• No harm, potential for more than minimal, widespreadF802Jul 7, 2026

  Based on observation, staff interview, review of facility staffing, and review of facility policy, the facility failed to ensure sufficient dietary staff were available to timely [NAME] the dietary needs of the residents. The facility's failure to provide adequate dietary staffing had the potential to affect all residents, as the facility identified no residents who did not receive meals and food services from the facility kitchen. The facility census was 71.Findings include:Observation on 06/28/26 at 7:50 A.M. revealed an insufficient number of dietary staff available to complete meal preparation, tray assembly, and meal distribution. Dietary [NAME] #119 could not be located by Dishwasher #170. […]

• No harm, potential for more than minimal, widespreadF804Jul 7, 2026

  Based on observation, staff interview, and policy review the facility failed to ensure dietary staff verified the final cooking temperature of potentially hazardous food prior to placing the food into hot holding. This had the potential to affect all 71 residents receiving meals prepared by the dietary department. The census was 71. Findings include:Observation of lunch preparation on 06/28/26 at approximately 12:30 P.M., revealed the facilities business manager (BM) #104 acting as dietary staff transferred cooked hamburgers directly from the grill to the steam table without obtaining or documenting the internal temperature of the hamburgers prior to placement into hot holding.Interview on 06/28/26 at approximately 12:30 P.M. […]

• No harm, potential for more than minimal, widespreadF809Jul 7, 2026

  Based on observation, staff interview, and facility policy review, the facility failed to serve meals in accordance with established meal schedules. This deficient practice had the potential to affect all 71 residents receiving meals from the dietary department. The census was 71. Findings include:Interview with the facility Administrator on 06/28/26 at 10:45 A.M. verified the lunch service would be pushed back to start serving at 12:45 P.M. due to the delayed breakfast times. Administrator verified with surveyor that all Residents and staff would be notified. Meal service was delayed beyond the facility's scheduled mealtimes due to inadequate staffing that affected the delivery of breakfast.Observation on 06/28/26 of the lunch tray line began at approximately 1:30 P.M. […]