Inspection Reports for
Edgewater Woods

The complaint investigation substantiated misappropriation of residents' ISNP benefits cards by the Activities Director, improper catheter care for Resident C, and delayed pain medication administration for Resident C. The misappropriation was substantiated with reimbursement to affected residents and staff education. The catheter was not re-anchored timely due to resident refusal and supply issues. Pain medication was delayed due to pharmacy and ordering processes.

The facility was found to have failed to protect residents from misappropriation of their ISNP benefits by a staff member, failed to ensure proper anchoring of a resident's urinary catheter according to physician orders, and failed to provide timely physician-ordered pain medication for a newly admitted resident.

This citation relates to Complaint IN00459983.

The facility failed to ensure resident representatives of two cognitively impaired residents were invited to care plan meetings. Documentation lacked evidence of notification or invitation of the residents' responsible parties to care plan summaries.

Complaint IN00459983 was substantiated with federal/state deficiencies cited at F553 related to failure to invite resident representatives to care plan meetings for cognitively impaired residents.

The facility failed to ensure that resident representatives of cognitively impaired residents were invited to participate in care plan processes for 2 of 3 residents reviewed (Resident B and Resident D). Documentation and invitations to family representatives were lacking for care plan meetings.

Complaint IN00455522 was substantiated with federal/state deficiencies cited. Complaint IN00454528 was not substantiated with no deficiencies cited.

The facility failed to provide transportation to a medical procedure appointment for 1 of 3 residents reviewed, resulting in the resident missing the appointment. The appointment was rescheduled with no negative outcomes. The facility lacked a backup transportation plan and the responsible transport driver was terminated.

This citation relates to complaint IN00455522.

The facility failed to provide transportation for one resident to a scheduled medical procedure, resulting in the resident missing the appointment. The transport driver did not report to work and no backup plan was in place, leading to a rescheduled appointment 11 days later.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included an undercharged portable fire extinguisher, therapy room door lacking a positive latching mechanism, improper use of extension cords and power strips in patient care areas, and failure to conduct required testing and maintain documentation for Patient Care Related Electrical Equipment (PCREE).

Complaint IN00448154 was investigated with no deficiencies related to the allegations cited.

The facility was found deficient in monitoring and documenting urinary catheter output for one resident, and failed to follow infection prevention and control practices related to hand hygiene during laundry delivery and enhanced barrier precautions for residents at higher risk of infection.

The investigation was complaint-driven, focusing on infection control and catheter care deficiencies. The complaint was substantiated with findings of inadequate urinary output monitoring and poor infection prevention practices.

The facility failed to ensure proper urinary catheter output monitoring and reporting, and failed to implement adequate infection prevention and control practices, including hand hygiene and enhanced barrier precautions for residents with indwelling catheters or feeding tubes. Observations revealed lapses in catheter care, laundry delivery hygiene, and use of personal protective equipment.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included unsealed penetrations in smoke barrier walls, improper use of power strips as substitutes for fixed wiring, and an oxygen trans-filling room not protected with a one-hour fire-resistive construction.

Complaints IN00429208, IN00429965, IN00430343, IN00430730, and IN00430721 were investigated with no deficiencies related to the allegations cited.

No deficiencies were cited related to the complaints investigated. However, a deficiency was found related to infection prevention and control, specifically staff failing to handle medications in a sanitary manner and not performing hand hygiene during medication administration.

The facility failed to ensure staff handled medications in a sanitary manner and performed hand hygiene during medication administration. Observations showed a nurse did not sanitize hands between medication preparations and did not wear gloves when opening capsules.

The facility was found not in compliance with life safety requirements, specifically related to electrical safety issues including improperly maintained ground fault circuit interrupters (GFCI), use of non-compliant power strips, and improper use of extension cords. Corrective actions were implemented promptly.

The facility was found deficient in multiple areas including failure to provide dignity in care for dependent residents, improper management of resident funds, inadequate assistance with activities of daily living, insufficient activity programming for developmentally disabled residents, failure to follow oxygen administration orders, and improper labeling and storage of insulin pens.

The facility failed to provide dressing assistance to physically dependent residents, manage resident funds with proper accountability, provide adequate nail care, offer sufficient activities programming for developmentally/intellectually disabled residents, follow physician orders for oxygen administration, and ensure proper labeling of insulin pens in medication storage.