Edison Manor Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Aug 3, 2021

  Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to maintain a sanitary kitchen for all residents creating an Immediate Jeopardy (IJ) situation for one of one kitchens. Findings include: The Kitchen Sanitation and Cleaning Schedules policy, dated 2/10/21, indicated that Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. During an interview on 8/2/21, at 10:00 a.m., the Director of Maintenance (DOM), disclosed that on the afternoon of Thursday, 7/29/21, he was notified that there was a leak in the facility kitchen ceiling. Upon investigation, it was determined that there was a leak in a toilet on the floor above the kitchen. […]

• Immediate jeopardy, patternF689Mar 15, 2021

  Based on review of clinical records, facility documentation, and policy and procedures, and staff interviews, it was determined that the facility failed to implement sufficient monitoring interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for two of three residents reviewed who eloped from the facility (Closed Residents CR1 and CR2). Findings include: Review of the facility policy entitled, Elopement/ Unauthorized Absence Policy, dated 10/03/2019, defined elopement as leaving the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. […]

• Immediate jeopardy, isolatedF689Apr 17, 2026

  Based on review of facility policy and documentation, clinical records, and resident and staff interviews, it was determined that the facility failed to implement sufficient safety interventions and supervision to prevent elopement (unauthorized leave from the facility). This failure placed residents at the facility in an Immediate Jeopardy situation for one of four residents reviewed who were at risk for elopement from the facility (Resident R1). Findings include: Review of the facility policy entitled, Elopement Unauthorized Absence Policy, dated 9/02/25, defined elopement as leaving the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. […]

• Immediate jeopardy, isolatedF678Jan 24, 2022

  Based on review of facility policies, clinical records, and facility documentation and staff interviews it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after [CONDITION(S)]) as required for one of one residents reviewed who had requested that CPR be administered in the event that they became unresponsive with no pulse. Resident R1 became unresponsive and pulseless, facility staff did not administer CPR to Resident R1 as required. […]

• No harm, potential for more than minimal, widespreadF812Feb 8, 2024

  Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain sanitary food service operations for one of one kitchens. Findings include: Review of facility policy entitled, Dish Machine Use, last reviewed 1/17/2024, revealed Prior to use, verify temperature and/or chemical sanitizer concentration are within specifications provided by the dish machine manufacturer (see note). If requirements are not met, immediately discontinue use of the dish machine and notify the person in charge. […]