Inspection Reports for
Edgewood Convalescent Home

The facility failed to offer updated pneumococcal vaccinations to 2 of 5 residents sampled. Documentation and assessment of pneumococcal vaccination were incomplete, and the facility lacked evidence of offering updated vaccines as per CDC guidelines.

The deficiency resulted from the investigation of complaint #1714110-C.

The facility failed to offer updated pneumococcal vaccination to 2 of 5 residents sampled (Resident #7 and Resident #36) despite having a census of 41 residents. Documentation and offering of updated pneumococcal vaccines were lacking, and the facility policy was to assess pneumococcal vaccination upon admission but did not ensure annual assessment.

The visit was complaint-related due to reports of insufficient weekend staffing. Resident and staff interviews substantiated the complaint, noting inadequate CNA and nurse coverage leading to delayed care.

The facility failed to employ sufficient numbers of staff on weekends, with multiple shifts showing absent Certified Nursing Aides and nurses. Residents and staff reported inadequate staffing leading to delayed care, especially toileting assistance. The facility uses staffing ratios based on census rather than acuity, as determined by Corporate.

The complaint investigation found substantiated issues with low weekend staffing, confirmed by CMS PBJ Staffing Data Report for Quarter 3, 2024, and multiple resident and staff interviews describing insufficient staff and delayed care.

The facility failed to employ sufficient numbers of staff on weekends, with documented absences of Certified Nursing Aides and nurses on multiple shifts. Residents and staff reported inadequate staffing leading to unmet care needs, particularly in toileting assistance.

Complaint #124467-C was substantiated based on the investigation conducted during the annual recertification survey.

The facility was found to have insufficient nursing staff, particularly on weekends, failing to meet resident needs as evidenced by staff and resident interviews and staffing data reviews. The complaint was substantiated.

The complaint investigation found that Staff A did not prime the insulin pen before administering insulin to Resident #5. The Director of Nursing confirmed the expectation for proper priming. Staff B reported receiving training on insulin pen administration. The facility's Insulin Pen Competency and Novolog prescribing information both require priming with 2 units prior to dose administration.

The facility failed to prime the insulin pen with 2 units of insulin prior to administering the physician-ordered dose for Resident #5. Staff were observed and interviewed, confirming a lack of proper priming technique despite facility training and competency expectations.

The facility failed to prime the insulin pen with 2 units of insulin prior to administration for one resident, resulting in a deficiency related to meeting professional standards of care in comprehensive care plans and medication administration.

Facility reported incident #99977-I was not substantiated.

The facility failed to offer Bed Hold agreements to 2 of 2 residents who transferred to the hospital, and failed to hold routine quarterly Quality Assurance and Performance Improvement (QAPI) meetings in 2021 and 2022, including lack of Medical Director attendance at one meeting in 2021.