Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgewater Woods during CMS and state inspections, most recent first.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy: A resident with liver cancer, altered mental status, and malnutrition was sent to the ER after being found lethargic and difficult to rouse, then admitted to the hospital. The record lacked documentation that the resident or representative received written transfer/discharge notice and the bed hold policy, and the notice provided during survey did not include the bed hold policy.
PASRR screening was not updated after a resident received a new major mental health diagnosis. The resident had schizoaffective disorder, bipolar type, with behavioral symptoms documented in the care plan, but the SSD confirmed the last PASRR Level I submission did not include the diagnosis and no later screen was provided after the new diagnosis was received.
Failure to review dialysis communications led to a duplicate pneumococcal vaccination for a resident receiving dialysis. The resident had CKD with heart failure, acute kidney failure, and hypertensive heart disease, and dialysis records showed Prevnar 20 was given at dialysis, but the facility later documented another Prevnar 20 in the resident’s chart. Staff interviews indicated the dialysis binder was not being consistently reviewed by the UM, IP, or bedside nursing staff, and the resident’s immunization history was not available in the clinical record.
The facility failed to complete pharmacy recommendations in a timely manner for several residents. A pharmacist identified irregularities involving PRN meds, daily cetirizine use, and cyclobenzaprine, and also noted that a resident on amiodarone lacked ongoing TSH monitoring in the chart. The DON said she was new to the pharmacy review process and that recommendations were routed to the provider by email and paper, while the corporate nurse consultant said the goal was 30 days or by the next review, with some items taking longer based on urgency.
A resident with hypertensive heart disease, CKD with HF, and AKI received Prevnar 20 at dialysis, but the facility later documented another Prevnar 20 dose in the resident’s chart. The record lacked prior immunization history, and interviews showed the dialysis communication binder was not consistently reviewed by the UM, IP, or clinical staff before the vaccine was documented, leading to duplicate pneumococcal vaccination documentation.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate. These failures resulted in a deficiency related to resident care.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
The facility did not ensure that representatives of two cognitively impaired residents were invited to participate in care plan meetings, as required by policy. Documentation and staff interviews confirmed that invitations were not consistently sent or recorded, and a resident's representative reported not being invited. Both residents had severe cognitive impairment and required representative involvement in care planning.
A resident with multiple chronic conditions missed a scheduled stent placement procedure because the facility's transport driver did not report to work and there was no backup transportation plan in place. Staff were unable to arrange alternative transport in time, resulting in the appointment being missed and rescheduled.
The facility failed to follow infection prevention and control practices during laundry delivery and for residents requiring enhanced barrier precautions (EBP). Laundry attendants did not perform hand hygiene, and staff did not adhere to EBP protocols for residents with indwelling catheters or feeding tubes. This affected multiple residents and posed a risk of infection transmission.
A facility failed to monitor and report urinary output and abnormalities for a resident with a urinary catheter. The resident, with a history of dementia and chronic kidney disease, had cloudy and thick urine, which was not reported to the provider. The facility did not consistently document urinary output as ordered, and a CNA was observed improperly handling the catheter drainage bag. The DON confirmed the lack of documentation and policy on urinary catheter maintenance.
The facility failed to ensure proper infection control practices during medication administration. An RN was observed preparing medications with bare hands and not sanitizing her hands between administrations. Facility policies on medication administration and infection prevention were not followed.
Failure to Provide Transfer/Discharge Notice and Bed Hold Policy
Penalty
Summary
The facility failed to provide written notice of transfer/discharge and the bed hold policy to the resident and/or the resident's representative for one resident reviewed for hospitalization. The resident had diagnoses including liver cancer, altered mental status, and malnutrition. On 1/29/26, a nurse's note documented that a Nurse Practitioner found the resident lethargic and difficult to rouse and ordered the resident sent to the emergency room. Later that day, another nurse's note documented that the resident was admitted to the hospital. A transfer/discharge notice dated 1/29/26 was provided by the DON during the survey, but it lacked an attached bed hold policy. The clinical record did not contain documentation that the resident and/or representative was given a written copy of the transfer/discharge form or the bed hold policy. During interviews, RN 7 stated that when a resident is sent to the ER, paperwork including the notice of transfer/discharge with bed hold policy is provided to the resident before leaving, or reviewed and signed by the representative if the resident is unstable or not cognitively intact, with documentation entered in a progress note. The DON stated that residents sent to the ER are sent with a face sheet, continuing care document, and bed hold policy, and if admitted, the paperwork is mailed to the family.
PASRR Screening Not Updated After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a required PASRR Level I screening assessment to determine whether a Level II assessment was needed after a resident received a new major mental illness diagnosis. Resident 11’s record showed a diagnosis of schizoaffective disorder, bipolar type, added in July 2024, while a prior PASRR Level I outcome from 6/6/24 stated that a Level II assessment was not required and that a new screen must be submitted if changes occurred or new information refuted the findings. The resident’s care plan, initiated 7/11/24, documented behavioral symptoms including delusions, tangential thoughts, agitation, grandiose thoughts, restlessness, and impulsivity related to schizoaffective disorder. A 4/13/26 quarterly MDS assessment indicated the resident was cognitively intact and listed schizophrenia among active diagnoses. During interview, the Social Services Director stated she was responsible for PASRR submissions and confirmed the last screening was submitted on 6/6/24 without the major mental diagnosis; she was unable to provide any later PASRR submission after the schizoaffective disorder diagnosis was received and believed it had been overlooked.
Failure to Review Dialysis Communications Led to Duplicate Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure communications with the dialysis provider were reviewed to prevent duplicate pneumococcal vaccinations and to maintain continuity of care for a resident receiving dialysis. The resident had diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure, and had an order for dialysis on Monday, Wednesday, and Friday. The resident’s March 2026 dialysis communication binder showed that Prevnar 20 was given at dialysis in the left deltoid, but the facility’s clinical record also showed a Prevnar 20 vaccination was administered in the facility later that month in the left deltoid. The clinical record lacked historical data of previous immunizations, and the resident’s quarterly MDS indicated moderate cognitive impairment. During interviews, the DON stated the dialysis communication binder was supposed to be reviewed by the UM or IP, but there was a time when the facility had neither position filled. The Corporate Nurse Consultant stated the clinical staff should have reviewed the communication binder and documented the Prevnar 20 given at dialysis in the resident’s clinical record. RN 4 stated that when a resident returned from dialysis, the nurse assigned to the hall should review the communication binder and document important information in the resident’s record. The IP stated the resident’s clinical record should be reviewed before giving any vaccination, and the facility followed CDC guidelines for all vaccinations. The facility policy on Dialysis Care stated the nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident and that the facility will use a method of communication between the facility and the dialysis center to relay changes in condition and response to treatment.
Delayed Follow-Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure pharmacy recommendations were completed in a timely manner and in accordance with facility policy for 3 of 5 residents reviewed for unnecessary medications. The record review showed that a licensed pharmacist completed monthly medication regimen reviews and identified irregularities, but the recommendations were not consistently acted on within the time frame described in the facility policy. The policy stated that pharmacy recommendations should be reviewed with physician follow-up within 30 days of the facility receiving them. For one resident with COPD, type 2 diabetes mellitus, and morbid obesity, discontinued PRN orders included ipratropium-albuterol, ondansetron, and polyethylene glycol 3350. The pharmacy review dated 1/7/26 recommended discontinuing these PRN medications because they had not been used within the previous 60 days. The provider signed the recommendation on 3/10/26 and indicated to discontinue the PRN orders. For another resident with COPD, coronary artery disease, and peripheral vascular disease, cetirizine 10 mg daily was discontinued on 4/14/26 after the pharmacy review dated 1/7/26 recommended discontinuation because daily long-term use should be limited to the allergy season to avoid adverse events. For a third resident with chronic atrial fibrillation, hypertensive heart disease with heart failure, and hemiplegia and hemiparesis following cerebrovascular disease, the record showed current amiodarone 100 mg daily and a TSH order once on 3/12/26, but no future TSH orders every 6 months were present in the chart. The pharmacy review dated 1/7/26 recommended discontinuing cyclobenzaprine due to lack of use within the previous 60 days and also recommended monitoring TSH every six months because amiodarone may affect thyroid function. The provider signed the recommendation on 3/10/26 and ordered a TSH for 3/12/26. During interview, the DON stated she was new to the pharmacy review process, received recommendations by email, printed them, and handed them to the provider, while the corporate nurse consultant stated the facility aimed for 30 days or by the next review per regulation, with some recommendations taking longer depending on urgency.
Duplicate Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to ensure pneumococcal vaccinations were provided in accordance with CDC guidelines and facility policy to prevent duplication of administration for 1 of 6 residents reviewed for immunizations. Resident 2 had diagnoses including hypertensive heart disease, chronic kidney disease with heart failure, and acute kidney failure. The resident’s dialysis communication binder showed that Prevnar 20 was administered in the left deltoid at dialysis on 3/2/26, but the facility’s clinical record also documented a Prevnar 20 vaccination in the left deltoid on 3/26/26. The clinical record lacked historical data of any previous immunizations, and the resident’s quarterly MDS indicated moderate cognitive impairment. During interviews, the DON stated the Unit Manager or Infection Preventionist was responsible for reviewing the dialysis communication binder, but there was a period when the facility had neither position filled. The Corporate Nurse Consultant stated there was no UM or IP to review the binder when the resident would have received the vaccine at dialysis, and the clinical staff should have reviewed the binder and documented the dialysis vaccination in the resident’s record. RN 4 stated that when a resident returned from dialysis, the nurse assigned to the hall should review the communication binder. The IP (Float) stated the resident’s clinical record should be reviewed before giving any vaccination.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for this resident, indicating that the required services were not adequately provided as needed.
Failure to Notify Resident Representatives for Care Plan Meetings
Penalty
Summary
The facility failed to ensure that resident representatives of cognitively impaired residents were invited to participate in the care plan process for two out of three residents reviewed. Both residents had diagnoses including severe cognitive impairment, as indicated by their quarterly MDS assessments. For each care plan meeting reviewed, documentation showed that the residents were listed as attending, but there was no evidence that their representatives were invited or present. Progress notes for both residents lacked any record of notification or invitation to the responsible parties for care plan meetings over several months. Interviews with facility staff confirmed that the process for inviting resident representatives was not consistently followed or documented. The Social Services Director stated that invitations were documented in progress notes and that representatives were contacted by phone if not sent a written invitation, but this was not reflected in the records. The Director of Nursing acknowledged that there should be documentation of notification or attendance by the resident representative, especially for residents who are cognitively impaired. Additionally, a resident's representative reported not being invited to any care plan meetings. Facility policy requires that residents or their representatives be invited to care plan reviews, but this procedure was not followed in these cases.
Missed Medical Appointment Due to Lack of Transportation Backup
Penalty
Summary
The facility failed to provide transportation for a resident to attend a scheduled medical procedure, resulting in the resident missing the appointment. The resident, who had multiple diagnoses including emphysema, hemiplegia, atherosclerotic heart disease, diabetes with neuropathy, peripheral vascular disease with arterial ulcers, and hypertension, was cognitively intact and required substantial to maximum assistance with mobility and personal care. The resident was scheduled for a stent placement to treat peripheral vascular disease, with transportation to be provided by the facility bus. On the day of the appointment, the assigned transport driver did not report to work or notify the facility, and multiple attempts to contact the driver were unsuccessful. The facility did not have a backup transportation plan in place, and staff were unable to arrange alternative transportation in time for the appointment. As a result, the resident missed the scheduled procedure and the appointment had to be rescheduled for a later date. Facility policy indicated that transportation should be provided for residents to medical appointments when no other option is available, but in this instance, the lack of a backup driver led to the deficiency.
Infection Control Deficiencies in Laundry and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to utilize proper infection prevention and control practices during laundry delivery, affecting 69 of 70 residents who received facility laundry services. Observations revealed that laundry attendants did not perform hand hygiene when entering and exiting residents' rooms while delivering clean laundry. This was confirmed by interviews with the laundry attendants, the Infection Preventionist, and the Laundry Supervisor, who all acknowledged the requirement for hand hygiene during the laundry delivery process. The lack of hand hygiene posed a potential risk for the transmission of infections, especially given the presence of residents with COVID-19, Influenza A, and Clostridium difficile. The facility also failed to implement enhanced barrier precautions (EBP) for residents at higher risk of infection due to indwelling urinary catheters or feeding tubes. For instance, Resident 8, who had a suprapubic catheter, did not receive proper catheter care as the spigot of the urinary catheter drainage bag was not cleansed after touching the urinal. Additionally, the CNA did not wear a gown during high-contact care activities, despite the presence of an EBP sign. Similar deficiencies were observed with Resident 10, whose urinary catheter bag was allowed to touch the floor, and Resident 9, where a nurse administered medication via a feeding tube without donning a gown. Interviews with staff, including CNAs and the Infection Preventionist, revealed a lack of understanding and adherence to EBP protocols. The facility's policies and procedures for infection prevention and control, including hand hygiene and EBP, were not consistently followed, leading to potential risks of infection transmission among residents. The facility was unable to provide a policy regarding urinary catheter maintenance, further highlighting the gaps in infection control practices.
Failure to Monitor and Report Urinary Output and Abnormalities
Penalty
Summary
The facility failed to ensure proper monitoring and reporting of urinary output for a resident with a urinary catheter. The resident, who had a history of dementia, neuromuscular dysfunction of the bladder, and chronic kidney disease, was observed with milky-white and cloudy yellow urine in the catheter drainage tube on multiple occasions. Despite the presence of cloudy and thick urine, which are potential signs of a urinary tract infection, these abnormalities were not reported to the provider as required. The resident's care plan indicated a risk for infection due to a supra-pubic urinary catheter and required staff to report signs of urinary tract infections. However, the facility did not consistently document urinary output every shift as ordered by the physician. Specific dates in January and February were noted where urinary output was not recorded, and there was no documentation of any diagnostic urine testing during the period of observed abnormalities. During observations, a CNA was seen improperly handling the catheter drainage bag, allowing the spigot tip to touch the urinal walls without cleansing it afterward. The CNA acknowledged the requirement to report urine abnormalities to the nurse, but failed to do so. The DON confirmed the lack of documentation and was unable to provide a policy on urinary catheter maintenance or outputs, highlighting a systemic issue in monitoring and reporting urinary conditions.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration on the [NAME] Lane Unit. During an observation, RN 2 was seen preparing medications by punching six capsules from the medication card into her bare hand and opening each capsule with bare hands before emptying the contents into a medication cup. RN 2 did not sanitize her hands following the administration of these medications. Additionally, RN 2 prepared and administered an as-needed pain pill to a resident without sanitizing her hands. It was only after a conversation with LPN 3 that RN 2 performed hand hygiene using an alcohol-based hand rub. The facility's current policies on medication administration and infection prevention and control, revised in 2023, were not followed by RN 2. The policies clearly state that medications should be opened without contamination and that an infection prevention and control program should be maintained to provide a safe and sanitary environment. RN 2 acknowledged that she should have sanitized her hands between preparing medications and that gloves should have been worn when opening capsules to administer medications ordered to be crushed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Anderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northview Health And Living | 0.2 mi | ★★★★★ | 19 | 0 |
| Beaumont Rehabilitation And Healthcare Center | 0.3 mi | ★★★★★ | 27 | 0 |
| Envive Of Anderson | 2 mi | ★★★★★ | 9 | 0 |
| Bethany Pointe Health Campus | 2.9 mi | ★★★★★ | 4 | 1 |
| Countryside Manor Health & Living Community | 3.2 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.