Inspection Report
Renewal
Deficiencies: 3
Feb 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the Edgewood Helena Senior Living LLC facility to assess compliance with applicable health care standards and regulations.
Findings
The inspection identified deficiencies including staff not using clothes covers when handling laundry, incomplete resident charts missing final transfer or discharge information, and non-functioning call systems in resident bathrooms due to dead batteries.
Deficiencies (3)
| Description |
|---|
| Clothes covers are not being used by staff handling laundry and are not present in either of the laundry rooms. |
| Closed resident charts #1 and #2 did not include the date and circumstances of the resident's final transfer, discharge, or death, including notice to responsible parties and disposition of personal possessions. |
| Resident rooms 208 and 213 did not have working call systems in resident bathrooms; they were observed to be out of batteries and would not signal to staff. |
Inspection Report
Renewal
Deficiencies: 2
Feb 2, 2023
Visit Reason
The visit was conducted as a renewal inspection of the Edgewood Helena Senior Living LLC facility.
Findings
The inspection identified deficiencies including the lack of a written agreement for an off-site evacuation point and failure to provide residents or their legal representatives with copies of their service plans.
Deficiencies (2)
| Description |
|---|
| Facility does not have a written agreement for an off-site evacuation point. |
| No record of residents #1 - #6 or their legal representative being given a copy of their service plan. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Kelly | Administrator | Administrator of the facility during the inspection. |
| Brett Christian | Survey Team Leader | Led the renewal inspection survey. |
Inspection Report
Renewal
Deficiencies: 7
Feb 27, 2019
Visit Reason
The inspection was conducted as a renewal inspection of Edgewood Helena Senior Living LLC to assess compliance with assisted living facility regulations and standards.
Findings
The inspection identified multiple deficiencies including lack of physician orders for Category C level of care for some residents, failure to conduct timely reviews and updates of resident service plans and assessments at times of significant change, multiple medications not administered as prescribed with inadequate documentation, missing required information on medication administration records, housekeeping issues with uncovered garbage cans, and bathroom doors lacking single motion doorknobs.
Deficiencies (7)
| Description |
|---|
| Two of three Category C residents did not have physician orders for Category C level of care. |
| Five of nine residents did not have evidence of a 60 day review of their service plans; reviews were done at 90 days instead. |
| No review/update to service plan and Resident Needs Assessment conducted at times of significant change for residents admitted to hospice or transferred to memory care. |
| Multiple medications were not administered as prescribed and lacked notification to practitioners of missed or refused medications; documentation forms were not completed. |
| Residents #8, #10, and #11 did not have required information listed on their Medication Administration Records. |
| Three garbage cans in the facility kitchen did not have lids covering them. |
| Resident room bathroom doors do not have single motion doorknobs as required by NFPA 7.2.1.5.3. |
Report Facts
Residents without physician orders for Category C care: 2
Residents without 60 day service plan review: 5
Garbage cans without lids: 3
Residents missing MAR requirements: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tara Wooten | Survey Team Leader | Named as survey team leader for the renewal inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 17, 2018
Visit Reason
The inspection was conducted as a complaint investigation regarding missed medication doses and related resident care concerns.
Findings
The facility failed to administer the medication Entresto on September 1, 2, and 3, resulting in a resident being hospitalized for congestive heart failure. There was also a failure to notify the practitioner and no incident report or documentation of safeguarding steps.
Complaint Details
Complaint investigation related to missed medication doses leading to resident hospitalization; substantiation status not stated.
Deficiencies (3)
| Description |
|---|
| Medication (Entresto 24-26 mg tab) not given September 1, 2, & 3; CNA notified LPN, but LPN failed to notify practitioner; resident admitted to hospital. |
| Order for Entresto indicates no partial doses; medication not given September 1, 2, & 3 due to unavailability. |
| No incident report filed and no documentation of facility's steps to safeguard resident from adverse effects of missed doses. |
Report Facts
Medication missed days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Egebjerg | Survey Team Leader | Named as survey team leader for complaint inspection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 28, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns related to incident reports and medication administration at Edgewood Helena Senior Living LLC.
Findings
The inspection found deficiencies in documentation of corrective actions for incident reports, lack of family or practitioner notification for incidents, and multiple missed medication administrations without proper documentation or practitioner notification.
Complaint Details
Complaint inspection conducted by Survey Team Leader Tara Wooten. The complaint involved review of incident reports and medication administration records for Resident #1.
Deficiencies (3)
| Description |
|---|
| Three incident reports for Resident #1 did not have documentation of appropriate corrective action taken to avoid a reoccurrence. |
| Two of three incident reports for Resident #1 did not have indication of family or practitioner notification. |
| Multiple missed medication administrations for Resident #1 with no documentation of why medications were not given and no indication that the practitioner was notified. |
Report Facts
Incident reports reviewed: 3
Missed medication dates: 7
Inspection Report
Renewal
Deficiencies: 3
Feb 15, 2018
Visit Reason
The inspection was conducted as a renewal inspection of the Edgewood Helena Senior Living LLC facility.
Findings
The inspection identified deficiencies including resident agreements signed after admission dates, improper food storage with unlabeled and undated raw meats, and incomplete resident activity service plans lacking identification of residents' needs and interests.
Deficiencies (3)
| Description |
|---|
| Resident agreements were signed after the residents were admitted. |
| Food service observation found approximately 5 lbs. of hamburger and 5 to 10 lbs. of raw chicken breasts or pork chops stored unlabeled and undated in the refrigerator. |
| Resident activity service plans did not identify the activity needs and interests of residents #1 and #2. |
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