Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Edgewood Centre (the) during CMS and state inspections, most recent first.
A resident's request for a physical therapy evaluation due to right shoulder pain, made by their DPOA during a care meeting, was not communicated to the Rehabilitation Manager or acted upon by the Unit Manager, resulting in no referral or assessment for PT services.
The facility did not ensure complete and accurate medical records for three residents, including missing documentation of enteral feeding amounts and lack of post-fall nursing assessments after unwitnessed falls and hospital transfers. These deficiencies were confirmed by nursing leadership.
Two residents were not documented as being offered or educated about the next recommended dose of the COVID-19 vaccine after receiving their initial dose, despite being eligible according to CDC guidelines and facility policy. This was confirmed by record review and staff interview.
The facility failed to store controlled medications in locked compartments and improperly disposed of medications during administration. Controlled substances were found in unlocked refrigerators, and medication carts were left unattended. Nurses disposed of dropped medications in open trash barrels instead of using the designated disposal system.
The facility failed to make a Level II PASARR referral for a resident with a newly evident mental disorder. A resident was admitted without a serious mental illness diagnosis, but a later psychiatric evaluation revealed PTSD. The Director of Social Services confirmed that a new Level I PASARR should have been submitted to reflect the new diagnosis, as per the facility's policy.
A facility failed to conduct a PASARR screening for a resident with a known diagnosis of bipolar disorder. The initial screening incorrectly indicated no severe mental illness, leading to a failure to refer the resident for further evaluation. The Director of Social Services confirmed the oversight.
The facility failed to provide adequate staffing on the South Unit to assist residents with breakfast in a timely manner. Observations and staff interviews revealed that meal trays often remained on the meal truck and residents received breakfast late, sometimes after 10:00 a.m., despite facility policies requiring prompt meal service.
The facility failed to maintain accurate records for controlled substances, with missing staff signatures on the East and West Unit Narcotic/Controlled Substance Logs. This deficiency was confirmed through observations and interviews with LPNs, despite existing policies requiring accurate shift counts.
The facility failed to monitor side effects for two residents on antipsychotic medications. One resident on Seroquel had not had an AIMS test since before the medication was prescribed, and another on Abilify had not had an AIMS test in over six months. The facility lacked a policy to ensure regular AIMS testing.
The facility failed to follow infection prevention procedures for residents with catheters and those requiring transmission-based precautions. A resident with a Foley catheter had an uncovered bag and tubing improperly placed, and another resident with clostridioides difficile had equipment cleaned with ineffective disinfectant wipes. Additionally, a resident with VRE was not placed on necessary precautions.
The facility failed to ensure that two residents were offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza vaccination. The Infection Preventionist confirmed that the residents had not been offered or educated on these vaccines, despite the facility's policy requiring such actions.
The facility failed to post the daily nurse staffing data for one of the two days observed. The Staff Development Coordinator stated that the data was posted in two locations, but observations revealed outdated data in both locations. Staff G confirmed these observations.
Failure to Address Resident's Request for Physical Therapy Evaluation
Penalty
Summary
The facility failed to address a resident's request for rehabilitation services related to right shoulder pain. The resident's Durable Power of Attorney (DPOA) requested a physical therapy (PT) evaluation during a meeting attended by the resident, a family member, the facility administrator, a nurse manager, and social services, as documented in a social/psychosocial note. Despite this request, the Rehabilitation Manager was not made aware of the need for a PT evaluation, and the Unit Manager, who attended the meeting, did not initiate a referral for PT services. As a result, the resident's request for a PT evaluation was not acted upon or assessed for necessity or appropriateness.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident, review of the Medication Administration Record (MAR) showed missing documentation of the amount of enteral nutrition administered on multiple dates, despite physician orders specifying the required feeding regimen. This omission was confirmed by the Assistant Director of Nursing/Infection Preventionist. Another resident's medical record lacked documentation regarding the reason and time of transfer to the hospital following an unwitnessed fall, and there was no post-fall nursing assessment recorded. Similarly, a third resident experienced a fall, but the medical record did not contain a status post-fall nursing assessment, even though a physician note referenced the incident. These documentation gaps were confirmed by facility nursing leadership during interviews.
Failure to Document COVID-19 Vaccine Education and Offer for Eligible Residents
Penalty
Summary
The facility failed to ensure that residents were offered and educated about the COVID-19 vaccine in accordance with CDC guidelines and facility policy. Specifically, for two of five residents reviewed for immunizations, there was no documentation that they were offered or educated about the next recommended dose of the 2024-2025 COVID-19 vaccine after receiving their initial dose. Record review showed that one resident received the vaccine in November 2024 and another in October 2024, but neither had documentation of being offered or educated about the subsequent dose when they became eligible. An interview with the Assistant Director of Nursing/Infection Preventionist confirmed that both residents had been eligible for their next dose but had not been documented as offered or educated regarding it. Facility policy required administration of the COVID-19 vaccine as per CDC recommendations, which was not followed in these cases.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure controlled medications were stored in a separately locked, permanently affixed storage compartment in two medication rooms. Observations revealed that controlled substances, specifically Lorazepam Intensol Oral Concentrate, were stored in unlocked medication refrigerators in both the West and East Unit Medication Rooms. Additionally, a medication cart on the West Unit was left unlocked and unattended for 10 minutes in a resident hallway. Interviews with staff confirmed these findings, and a review of the facility's Medication Storage Policy indicated that controlled medications should be stored separately in a locked drawer or compartment designated for that purpose. The facility also failed to ensure that medications were appropriately disposed of during medication administration. During observations, two registered nurses were seen disposing of dropped medications (Colace and a Multivitamin) in open trash barrels attached to the medication carts instead of using the designated Drug Buster disposal system. Interviews with the nurses and the Assistant Director of Nursing confirmed these practices, which were contrary to the facility's policy on the disposal of medications and medication-related supplies. The policy mandates that pharmaceutical waste be deposited in appropriately labeled containers and that staff be trained on proper disposal procedures upon hire and annually.
Failure to Update PASARR for New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to make a Level II Pre-Admission Screening and Resident Review (PASARR) referral for a resident with a newly evident mental disorder. Resident #26 was admitted without a diagnosis of a serious mental illness, and the initial Level I PASARR form indicated no mental illness, intellectual disability, or related condition. However, a psychiatric evaluation later revealed a new diagnosis of Post-Traumatic Stress Disorder (PTSD) and the resident was started on new medication for tremors, anxiety, and PTSD. The Director of Social Services confirmed that a new Level I PASARR should have been submitted to reflect the new diagnosis, as per the facility's policy.
Failure to Conduct PASARR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) screening was conducted for a resident with a known diagnosis of bipolar disorder. Upon review of the resident's medical record, it was found that the initial PASARR screening incorrectly indicated that the resident did not have a severe mental illness. This error led to the facility not referring the resident to the appropriate state-designated authority for further evaluation and determination. The Director of Social Services confirmed the oversight during an interview. The facility's policy requires the Admissions Liaison to review potential admissions for mental illness or intellectual disabilities and to provide a Level 1 form to the Office of Medical Services for confirmed or probable cases, which was not followed in this instance.
Inadequate Staffing for Breakfast Assistance
Penalty
Summary
The facility failed to ensure adequate staffing to provide assistance with breakfast on the South Unit. Observations and interviews revealed that the breakfast meal arrives at approximately 8:15 a.m., but there are not enough staff to assist all residents in a timely manner. On multiple occasions, meal trays remained on the meal truck and were not given to residents promptly. Staff interviews confirmed that it was not uncommon for residents to receive breakfast after 10:00 a.m., which is close to the start of lunch at 12:00 p.m. This delay in meal service was observed on different days, with several residents still in bed and meal trays untouched for extended periods. Staff members reported that the South Unit typically has four Licensed Nursing Assistants (LNAs) to assist with breakfast, but this number is insufficient to meet the needs of all residents requiring total assistance or cues during meals. The facility's policies on timely meal service and dining experience were reviewed and found to be inconsistent with the observed practices. The policies stated that meals should be delivered promptly and residents should be assisted in a timely manner, which was not adhered to in practice. This deficiency highlights the facility's failure to provide adequate staffing to meet the residents' needs during breakfast time.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs in sufficient detail to enable accurate reconciliation. This deficiency was identified through observations and interviews on the East and West Unit Medication Carts. Specifically, the East Unit Narcotic/Controlled Substance Log had missing staff signatures on multiple dates, including 1/8/24, 1/24/24, 1/28/24, 2/14/24, 2/27/24, 2/28/24, 3/3/24, 3/7/24, and 3/12/24. Staff P, an LPN, confirmed these findings during an interview. Similarly, the West Unit Narcotic/Controlled Substance Log also had missing staff signatures on several dates, including 1/13/24, 1/14/24, 2/11/24, 3/1/24, and 3/9/24. Staff Q, another LPN, confirmed these findings during an interview. The facility's policy titled 'Change of Shift Counts Policy,' dated 07/23, was reviewed and it outlined the responsibilities of licensed staff to complete shift counts to maintain compliance with regulations, prevent drug diversion, and ensure medication accountability. Additionally, a review of the 'Fundamentals of Nursing' textbook emphasized the nurse's responsibility to follow legal provisions when administering controlled substances. Despite these policies and guidelines, the facility failed to maintain accurate records, leading to the identified deficiencies in the narcotic logs for both the East and West Units.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure that residents on antipsychotic medications were monitored for side effects. Specifically, Resident #12, who was prescribed Seroquel for Major Depressive Disorder with delusional/agitation, had not had an Abnormal Involuntary Movement Scale (AIMS) test since 8/21/23, despite the medication order starting on 9/21/23. The Assistant Director of Nursing confirmed that AIMS tests should be completed every six months for residents on antipsychotic medications, but the facility lacked a policy to enforce this schedule. Similarly, Resident #42, who had an order for Abilify starting on 9/13/23, had not had an AIMS test since 3/26/23. The Director of Nursing confirmed this oversight. The National Institute of Health recommends that AIMS tests be administered every three to six months to monitor for tardive dyskinesia, a potential side effect of long-term neuroleptic medication use. The facility's failure to adhere to these guidelines resulted in the identified deficiencies.
Infection Control Deficiencies
Penalty
Summary
The facility failed to adhere to established infection prevention procedures for residents with catheters and those requiring transmission-based precautions. Resident #174 was observed with an uncovered catheter bag and tubing resting on the floor and hanging from a heating unit, which was confirmed by a Licensed Practical Nurse. The facility's policy clearly states that the drainage tube should never touch the floor to prevent bacteria from traveling back up into the bladder. Additionally, Resident #172, diagnosed with clostridioides difficile, had a hoyer lift used in their care that was cleaned with disinfectant wipes not effective against clostridioides difficile, posing a cross-contamination risk. This was confirmed by the Director of Nursing and contradicted the facility's policy requiring thorough disinfection of equipment before reuse. Furthermore, Resident #75, who had a physician's order for Linezolid to treat a urinary tract infection caused by vancomycin-resistant enterococci (VRE), was not placed on transmission-based precautions. Observations and interviews with staff, including a Licensed Nurse Assistant, Nurse Practitioner, and Infection Preventionist, confirmed that the resident should have been on such precautions. The facility's policy mandates the use of gowns and gloves for interactions involving contact with affected areas for residents with VRE, which was not followed in this case.
Failure to Offer and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that two residents were offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza vaccination. Resident #29 was admitted to the facility and had not received an influenza vaccination, although they had received Pneumovax 23 prior to admission. An interview with the Infection Preventionist revealed that Resident #29 had not been offered or educated on the risks/benefits of the Influenza vaccine or any additional pneumonia vaccines. Similarly, Resident #107 was admitted to the facility and had not received a pneumonia vaccine. The Infection Preventionist confirmed that Resident #107 had not been offered or educated on the risks/benefits of additional pneumonia vaccines. The facility's policy mandates that all new residents must be assessed for pneumococcal, influenza, and COVID-19 vaccine status, and that permission must be obtained to administer these vaccines. However, this policy was not followed for the two residents in question.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to post the daily nurse staffing data for one of the two days observed. On 3/13/24, the daily nurse staffing data was not posted as required. During an interview on 3/14/24 at 7:37 a.m., the Staff Development Coordinator (Staff G) stated that the daily nurse staffing data was posted in two locations: on the bulletin board in the hallway leading into the [NAME] Unit and in the window at the entrance of the facility. However, observations on 3/14/24 revealed that the bulletin board displayed data dated 3/12/24, and the entrance window displayed data dated 3/11/24. Staff G confirmed these observations during interviews conducted shortly after the observations.
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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 Portsmouth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Healthcare Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Webster At Rye | 4.1 mi | ★★★★★ | 14 | 0 |
| Durgin Pines | 4.7 mi | ★★★★★ | 0 | 0 |
| Saint Ann Rehabilitation And Nursing Center | 7.3 mi | ★★★★★ | 3 | 0 |
| Oceanside Skilled Nursing And Rehabilitation | 8.7 mi | ★★★★★ | 6 | 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.