Inspection Reports for
Edgewood Manor Health Care Center

The complaint investigation substantiated misappropriation of funds involving Resident #1 and Resident #2. Resident #1 gave $400 to the Social Worker Director for a recliner chair that was never purchased. Resident #2 gave money to CNA A, Housekeeper B, and Activity Assistant A for rent, utilities, and a car payment. Police were involved and staff members were terminated.

The facility failed to protect residents from misappropriation of their funds by staff members, including the Social Worker Director, Certified Nursing Assistant, Housekeeper, and Activity Assistant. Several residents gave money to staff for various purposes, but the funds were misused or not properly accounted for. The facility took corrective actions including staff termination, audits, and education.

The complaint investigation found that laboratory tests ordered for Residents #5, #8, and #10 were not completed. The facility was aware of issues with the laboratory service provider and had ongoing communication about the problem. The laboratory technician had recently come to the facility but did not complete all ordered tests. The issue was acknowledged by nursing and administrative staff.

The facility did not complete ordered laboratory tests for three residents (Resident #5, Resident #8, and Resident #10). Interviews revealed issues with the laboratory service provider not consistently drawing labs as ordered, resulting in missing lab results in the residents' medical records.

The complaint investigation was triggered by concerns about facility cleanliness and a resident-to-resident abuse incident on 5/29/25 where Resident #2 touched and struck Resident #1 inappropriately. The incident was substantiated, law enforcement was involved, and corrective actions including staff training and increased supervision were implemented.

The facility failed to maintain a clean, comfortable, and homelike environment with multiple areas noted as dirty, including resident rooms, bathrooms, dining areas, and common spaces. Additionally, the facility failed to protect one resident from physical abuse by another resident, with an incident involving inappropriate touching and striking.

The complaint investigation was triggered by an incident on 3/12/25 where Resident #1 was verbally and physically abused by LPN A and CNA A. Multiple staff witnessed the incident but did not intervene or report it. The facility started an investigation on 3/13/25, suspended and terminated the involved staff by 3/14/25. The abuse was confirmed by video footage and interviews. The facility failed to report the abuse timely and educate staff on behavioral interventions.

The facility failed to ensure Resident #1 was free from verbal and physical abuse by staff. Video evidence and interviews confirmed the abuse incident occurred on 3/12/25. Staff involved were suspended and terminated. The facility also failed to report the abuse timely and did not properly educate staff on behavioral de-escalation techniques.

The facility failed to maintain a legally licensed and properly maintained van for resident transport. The van had expired tags for four years, no title, was not inspected, and the lift was not inspected as required, posing potential safety risks to residents.

The complaint investigation found that the facility failed to notify the Ombudsman and residents or their representatives in writing about hospital transfers and bed hold policies for three residents. The Social Services Director position was vacant during August 2024, contributing to notification failures. Interviews with staff revealed unclear responsibilities and missing documentation.

The facility failed to provide timely written notification to residents, their representatives, and the Ombudsman about hospital transfers and discharges, including reasons for transfer and bed hold policies, for three sampled residents. Documentation and notification processes were inconsistent, and key staff responsible for notifications were either unclear or the positions were vacant during the relevant periods.

The facility had multiple deficiencies including failure to provide required Medicare notices, maintain a safe environment, notify residents and ombudsman of transfers, ensure accurate assessments and care plans, administer medications properly, maintain infection control practices, provide dental and hospice services, ensure proper staffing postings, and maintain food safety standards.

The complaint investigation revealed that a resident's wallet containing cash was found in the laundry and placed in the safe, but money was missing when retrieved. Multiple staff gave conflicting statements about the amount of money. The resident's bank withdrawals totaling $1100.00 were confirmed and reimbursed. Police were notified but could not fingerprint the wallet. The facility changed the safe code and limited access to prevent recurrence.

The facility failed to prevent the misappropriation of resident funds, with conflicting reports on the amount of money initially in the wallet. The resident's withdrawals totaling $1100.00 were verified and reimbursed by the facility. The investigation involved multiple staff interviews and police notification, and corrective actions included changing the safe code and limiting access.

The complaint was substantiated based on interviews and record review. The incident involved Agency CNA B slapping Resident #3's hand and making inappropriate comments during care. The resident was not physically harmed or scared. The facility administrator took immediate action by removing the agency CNA and educating staff.

The facility failed to preserve the dignity of one resident when an agency CNA slapped the resident's hand and made inappropriate comments. The facility administration responded by in-servicing all staff on abuse, neglect, resident rights, and dignity, and the deficiency was corrected promptly.

Complaint #MO 00231972 regarding Resident #5 eloping from the facility on 2/15/24 and the facility's failure to provide adequate supervision and timely notification to the guardian and family.

The facility failed to ensure adequate supervision and safety oversight for Resident #5, who left the facility by entering a door code and was missing overnight. The investigation found multiple staff failures including lack of proper face checks, failure to notify charge nurses, incomplete shift change reports, and failure to change door codes weekly as per policy.

The complaint investigation found that Resident #2 assaulted Resident #3 on 12/20/23 causing actual harm. Resident #2 had a psychotic break and was refusing medications. The assault was determined to be abuse by the facility and medical staff, though a Regional Nurse Consultant did not classify it as abuse due to lack of intent. The facility failed to send Resident #2 for psychiatric evaluation prior to the assault despite increased behaviors and a call to law enforcement on 12/18/23.

The facility failed to protect Resident #3 from abuse by Resident #2, who had a history of severe mental illness and medication refusal. The facility also failed to provide appropriate treatment and oversight for Resident #2, who exhibited increased aggressive behaviors and was not sent for timely psychiatric evaluation prior to the assault.

The complaint involved an allegation that CNA A struck Resident #1 after the resident threw coffee at CNA A. Multiple witnesses provided conflicting accounts. The incident occurred on 8/4/23 at 3:00 A.M. The abuse allegation was reported to the Administrator around 8:00 A.M. The facility failed to report the allegation to the State Agency and did not suspend CNA A during the investigation. The investigation was completed quickly based on verbal statements without thorough follow-up.

The facility failed to prevent potential abuse when an alleged incident was not reported immediately to the Administrator or designee, and CNA A continued to work during the investigation. The investigation lacked documentation of root cause, guardian and physician notification, and appropriate follow-up actions. The Administrator did not report the allegation to the State Agency and was unaware that CNA A had not been suspended pending investigation.

The complaint investigation found substantiated deficiencies related to fall investigation and dialysis care. The facility failed to initiate a fall investigation within 24 hours for Resident #6 and failed to ensure Resident #2 received dialysis treatments and transportation as ordered, resulting in missed dialysis appointments.

The facility failed to initiate a fall investigation for Resident #6 after a fall incident and failed to ensure Resident #2 received ordered dialysis treatments, including transportation to dialysis appointments. Multiple interviews and record reviews confirmed these deficiencies.

The facility was found deficient in multiple areas including failure to document reasons for resident transfers and discharges, failure to notify residents and representatives timely, failure to provide bed hold policy notices, incomplete PASRR screening and care planning for mental health diagnoses, inadequate individualized activity care plans and activity provision, lack of restorative range of motion services, incomplete fall investigations and care plan revisions, improper catheter care and lack of physician orders, inadequate dialysis site monitoring, failure to provide trauma-informed care, failure to post nurse staffing information, incomplete monthly medication regimen reviews, inadequate psychotropic medication monitoring, failure to provide dental services for residents with poor dentition, and food safety violations related to improper thawing, storage, and sanitation.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not using privacy bags for catheter bags, failure to manage resident funds properly, incomplete transcription of code status orders, environmental maintenance issues, verbal abuse by staff, incomplete care plans especially related to Foley catheter care and orthotic device use, improper use of mechanical lifts, inadequate respiratory care documentation and practices, improper medication storage temperatures, infection control lapses including improper hand hygiene and equipment storage, and pest control deficiencies.