Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgewood Manor Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, agitation, impaired cognition, and a history of falls rolled off a raised bed while an CNA was providing incontinence care and turned to get supplies. The resident sustained a left eyebrow laceration requiring skin glue, plus facial swelling and hematoma, and was sent to the ER with a head injury and facial laceration. Staff documentation and interviews described the resident as high fall risk and dependent for bed mobility, with the fall occurring during bedside care when the CNA was momentarily away from the resident.
Insufficient dietary staffing delayed breakfast service when a dietary employee walked off the job and the DM was still en route, leaving only a dishwasher in the kitchen. Breakfast preparation did not begin on time, residents in the hall and dining room waited for hours, nursing staff served beverages while they waited, and the final hallway trays were not delivered until late morning. Interviews confirmed the department routinely operated short-staffed and staff were expected to handle multiple duties at once.
Failure to Verify Final Cooking Temperature of Hamburgers: During lunch prep, a BM acting as dietary staff moved cooked hamburgers from the grill directly to the steam table without checking or documenting the internal temp before hot holding. The DM confirmed the temp check was not done and acknowledged the facility policy required verification and documentation of the final internal cooking temp for potentially hazardous foods before service.
Meals were not served according to the facility’s posted schedule because breakfast ran late and lunch was delayed. The Administrator confirmed lunch would start later due to the delayed breakfast, and observation showed the lunch tray line did not begin until well after the revised start time, with hallway trays and dining room service following even later. The dietary manager stated staffing shortages caused staff to juggle multiple duties and delayed tray assembly and meal distribution.
Unsafe Food Handling and Cross-Contamination During Meal Prep: Non-dietary staff entered the kitchen and began food prep without hand hygiene, then handled raw foods, utensils, door handles, packaging, and ready-to-serve items with the same gloves. An LDM also handled raw chicken, fries, cheese, serving scoops, and plated food while touching her face, eyeglasses, body, and uniform without changing gloves or performing hand hygiene, and she acknowledged the observed practices were inconsistent with facility policy.
The facility failed to maintain the 100 Hall in a clean, sanitary, functional, and comfortable condition. Surveyors observed excessively sticky flooring, peeling cove base exposing broken and cracked drywall, chipped and peeling paint on the chair rail, and a buildup of dust, hair, and other debris near a fire door; an LPN confirmed these findings. The facility policy stated cleaning schedules are to be developed and implemented to keep each area safe, clean, and comfortable.
The facility failed to maintain dignity during meal service for two residents with severe cognitive impairment. A CNA was observed standing while feeding one resident seated with a bedside table in front of her and later standing while feeding another resident at a dining table. The CNA confirmed she assisted both residents and was standing during the meal assistance, contrary to the facility’s dignity policy.
A resident with multiple medical and psychiatric diagnoses, including DM2, anxiety, psychosis, and chronic pain, was observed with bed linens soiled throughout with unidentified brown and red substances. The resident stated dissatisfaction with personal hygiene, clothing, and bed, and an LPN confirmed the condition of the linens. Facility policy stated cleaning schedules are used to maintain a safe, clean, and comfortable environment.
Failure to Provide ADL Assistance: A resident with multiple diagnoses, including DM2, anxiety, psychosis, and chronic pain, was observed disheveled and poorly groomed, with a soiled shirt and dirty beard containing food residue and debris. The resident stated he had not received a shower or clothing change since admission and that a requested shower was not provided. An LPN confirmed the resident's condition, and the facility policy stated residents unable to perform ADLs independently are to receive needed assistance with grooming and hygiene.
Failure to secure indwelling Foley catheters for two residents. Two residents with intact cognition and indwelling catheters were observed with catheter tubing not secured by a leg strap/leg band, and a CNA confirmed the catheters were not stabilized per facility policy. One resident stated the Foley had not been secured to the leg since admission.
A resident receiving continuous oxygen with orders for 5 L/min via NC had a humidifier bottle that was observed empty and not humidifying the oxygen. Staff confirmed the bottle should have been changed when empty and that it was due to be changed on the prior Friday as part of the ordered oxygen set-up. The resident stated the empty bottle left his nose dry and irritated and made him uncomfortable.
A resident’s Incruse Ellipta inhaler was found lying on the bed with doses remaining and was readily accessible instead of being secured. The resident had COPD, intact cognition, and required staff help with all ADLs and continuous O2. The resident said the inhaler was routinely left in the room after administration, and an LPN confirmed there was no order for self-administration or self-storage. Facility policy required meds to be stored in a safe, secure manner.
Failure to Provide Routine Dental Services: A resident with severe cognitive impairment, dysphagia, DM2, and multiple psychiatric and neurologic diagnoses had a documented dental problem with missing, broken, and discolored teeth. Staff observed the resident’s teeth to be brown, black, broken, and missing, and the DSS stated there were no records of the resident being seen by a dentist since admission, despite dental consult orders and a facility policy stating oral healthcare and dental services would be provided to each resident.
EBP was not maintained for two residents with orders for gown and glove use during high-contact care. A CNA changed linens for one resident without an isolation gown, and another CNA assisted a resident off the bedpan without PPE despite EBP signage and orders. In a separate observation, a resident with an indwelling Foley catheter had the drainage bag resting on the floor instead of being secured below the bladder level.
A resident with a history of chronic illness and a recent hospital-treated toe wound infected with S. aureus was readmitted without timely wound care or dressing change orders in place for two days, despite hospital discharge instructions and facility policy. This lapse was confirmed by the Administrator and DON.
A resident admitted with a wound infection positive for S. aureus was not placed on appropriate isolation precautions until two days after admission, despite having positive lab results and ongoing antibiotic treatment. Staff failed to provide a waste receptacle for used PPE outside the resident's room, and an LPN entered the room without PPE, stating she was unaware of the isolation status. These actions were not in accordance with the facility's infection prevention and control policy.
A facility failed to provide timely incontinence care for a resident with multiple health issues, leading to a deficiency. Despite a care plan requiring checks every two hours, the resident was found heavily soiled, indicating a lapse in care. The resident had a history of UTIs, and staff interviews confirmed the failure to adhere to the care plan.
A resident was found with unattended medications at their bedside, which they forgot to take before breakfast. An LPN had administered the medications but did not verify their consumption, yet marked them as administered in the electronic record. The facility's policy requires medications to be administered safely and timely, with proper documentation.
A resident with cognitive impairment and multiple health issues fell and fractured her femur due to inadequate staff assistance during bed mobility. Despite requiring two-person assistance as per her care plan, only one staff member was present, leading to the fall. The facility's policy on fall prevention was not adhered to, resulting in the deficiency.
Two residents reported abuse by STNA #198, including verbal abuse, neglect, and rough handling. Despite consistent reports from the residents, the facility failed to substantiate the claims and did not conduct a thorough investigation, highlighting a deficiency in implementing abuse prevention policies.
A resident with a complex medical history and high fall risk fell out of bed while receiving care from a single STNA, despite requiring two-person assistance. The fall resulted in a left femur fracture, but the facility failed to report the incident as potential neglect to the state agency, contrary to its policies.
A facility failed to maintain proper infection control practices for a resident under Enhanced Barrier Precautions (EBP) due to a coccyx wound. Despite a sign indicating EBP, two STNAs provided incontinence care without the required PPE, believing the order had expired. Interviews confirmed the EBP order was active, and the facility's policy on EBP was not followed, resulting in a deficiency.
The facility did not maintain the required RN coverage for a minimum of eight hours a day on several occasions, potentially affecting all 65 residents. This was confirmed by the Administrator and was contrary to the facility's staffing policy, which mandates adequate staffing to meet residents' needs.
The facility's kitchen was found to be unsanitary, with excessive buildup and grime observed in various areas, including between and behind the fryer and stove, on a metal food cart, and under tables and appliances. The Regional Dietary Manager confirmed these observations, and pest control logs recommended cleaning the kitchen.
The facility failed to maintain cleanliness in the memory care unit, affecting 28 residents. Observations showed thick layers of dust and grime on the flooring in hallways and resident rooms. Housekeeping staff confirmed the issue and had just started deep cleaning. The facility's policy required cleaning schedules to ensure a clean environment, which was not followed.
A facility failed to report a resident's elopement and allegations of unlicensed staff administering unprescribed melatonin to residents. The resident, at high risk for elopement, left the facility through a window and visited local bars. Additionally, several residents were allegedly given melatonin without prescriptions. Despite these incidents, no Self-Reported Incidents were filed, violating the facility's policy on abuse investigation and reporting.
The facility failed to investigate an allegation of unlicensed staff administering unprescribed melatonin to four cognitively impaired residents, only one of whom had a prescription for the medication. Despite being notified, the DON and Administrator did not conduct a thorough investigation or file a self-reported incident, contrary to the facility's policy on abuse investigation and reporting.
A resident with chronic obstructive pulmonary disease was observed receiving three liters of oxygen per minute instead of the prescribed two liters. The resident, who was cognitively intact, confirmed the correct prescription. A nurse acknowledged the error, suggesting the concentrator control might have been accidentally adjusted.
The facility failed to discard expired insulin, affecting three residents with diabetes. During an observation, an LPN confirmed that expired insulin pens and a multi-dose vial were still stored in the medication cart. The facility's policies require that expired medications be discarded and expiration dates checked before administration, which was not followed in this instance.
A facility failed to complete a resident's HbA1c test as ordered by the physician, despite a recommendation to monitor it every three months for diabetes management. The resident, with a history of diabetes and other conditions, had not had the test since the previous year. The DON confirmed the oversight, which was against the facility's policy to follow physician orders for diagnostic services.
A resident in an LTC facility experienced verbal abuse from an STNA, who made derogatory remarks about the resident's incontinence. Despite witness statements and the resident's report, the facility did not substantiate the abuse but did suspend the STNA for one day. The resident was cognitively intact and required assistance with daily activities due to various health conditions.
A facility failed to prevent a resident's elopement and did not implement fall interventions for another resident. One resident, with cognitive impairment and identified as a flight risk, left the facility unsupervised and visited local bars. The staff was unaware of his absence until he returned. Another resident, at risk for falls, did not have a required safety mat in place next to the bed, as confirmed by staff observations and interviews.
Failure to Protect a Resident During Bedside Perineal Care
Penalty
Summary
The facility failed to ensure a resident’s safety during perineal care when one staff member was providing incontinence care and turned away to obtain supplies, allowing the resident to roll off the bed and strike the floor. The resident had diagnoses including brief psychotic disorder, dementia with agitation, anxiety, history of embolism, and abnormal posture, and was documented as having severely impaired cognition, impaired safety awareness, and a history of falls from bed. The resident’s care plan identified fall risk related to agitation, incontinence, decreased strength and endurance, generalized weakness, and impaired cognition. The incident resulted in a laceration to the left eyebrow that required skin glue, along with left periorbital soft tissue swelling and hematoma. The resident was sent to the emergency room and diagnosed with a fall, head injury, and facial laceration. The record also reflected prior falls and prior evaluations noting the resident overestimated and forgot her limits, was at high risk for falls, and required assistance with bed mobility. Facility documentation and staff interviews described the resident rolling out of bed while the CNA was completing check and change care with the bed in a raised position. The CNA stated she turned to reach for cleaning products and saw the resident rolling toward her before the resident fell to the floor, and she was unable to stop the motion. The facility also documented that the resident had been on an air mattress, though the mattress was later tested and found to be in proper working order, and the administrator confirmed there was no physician order or care plan specific to the air mattress.
Insufficient Dietary Staffing Delayed Breakfast Service
Penalty
Summary
The facility failed to ensure sufficient dietary staff were available to timely meet the dietary needs of residents. On 06/28/26 at 7:50 A.M., survey observation found an insufficient number of dietary staff to complete meal preparation, tray assembly, and meal distribution. Dietary [NAME] #119 could not be located by Dishwasher #170, and it was determined that the dietary staff member had walked off the job while the Dietary Manager #106 was en route to the facility to complete breakfast preparation. At 8:10 A.M., no one was preparing the breakfast meal, and the only dietary staff member present in the kitchen was Dishwasher #170. The posted breakfast schedule showed meal service times of 7:40 A.M. for South Front, 7:50 A.M. for South Back, 8:05 A.M. for North Front, 8:15 A.M. for North Back, and 8:30 A.M. for the Dining Room, but meal service was delayed beyond those times due to inadequate staffing. At 9:00 A.M., residents on the hall and in the dining room still had not received breakfast. At 9:15 A.M., random nursing staff served beverages to residents in the hallways and dining room while they continued waiting for breakfast. At 9:45 A.M., three random residents in the dining room received breakfast, and at 10:00 A.M. the final hallway trays were delivered. Interviews with Dishwasher #170, the Administrator, and DM #106 confirmed routine short staffing, recent dietary resignations, and that staff were required to perform multiple job responsibilities simultaneously because there were not enough employees scheduled.
Failure to Verify Final Cooking Temperature of Hamburgers
Penalty
Summary
The facility failed to ensure dietary staff verified the final cooking temperature of potentially hazardous food before placing it into hot holding. During lunch preparation, the facility’s business manager, acting as dietary staff, transferred cooked hamburgers directly from the grill to the steam table without obtaining or documenting the internal temperature of the hamburgers before they were placed in hot holding. The observation occurred during meal preparation for the facility’s 71 residents. During the observation, the Dietary Manager confirmed the hamburgers had not been temperature checked before being placed in the steam table and acknowledged the internal temperature should have been verified before service. The Dietary Manager also confirmed the facility policy required staff to verify and document the final internal cooking temperature of cooked potentially hazardous foods prior to placing them into hot holding. Review of the facility’s Food Handling policy, revised September 2021, stated that potentially hazardous foods will be cooked to the appropriate internal temperature and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms.
Delayed Meal Service Due to Staffing Shortages
Penalty
Summary
Meals were not served in accordance with the facility’s established meal schedules. Based on observation, staff interview, and policy review, the facility delayed lunch service because breakfast service had run late due to inadequate staffing. The Administrator confirmed that lunch would be pushed back to 12:45 P.M. because of the delayed breakfast times and stated that residents and staff would be notified. The facility’s posted lunch schedule listed staggered serving times for different dining areas, beginning at 11:40 A.M. and ending with the dining room at 12:30 P.M. Observation showed the lunch tray line did not begin until approximately 1:30 P.M., which was 45 minutes after the revised 12:45 P.M. start time. The last hallway trays did not arrive on the nursing floor until about 2:10 P.M., and dining room residents were served at 2:15 P.M. The dietary manager stated staffing shortages were a significant issue, that staff were required to perform multiple job responsibilities simultaneously, and that insufficient dietary staffing caused delays in tray assembly and meal distribution.
Unsafe Food Handling and Cross-Contamination During Meal Prep
Penalty
Summary
The facility failed to maintain sanitary conditions during food preparation and meal service. During observation of meal preparation and service, non-dietary staff, including the Business Office Manager and Regional Nurse, entered the kitchen/cooking area and were not observed performing hand hygiene before beginning food preparation tasks. They prepared tomatoes, onions, and lettuce while wearing gloves, and one staff member handled raw food products and then food utensils without removing gloves, performing hand hygiene, or changing gloves. The Business Office Manager’s clothing came into direct contact with food during meal preparation, and the same staff member was also observed touching door handles, carrying fruit cups, and touching the outside of hamburger bun packaging while wearing food service gloves before returning to food preparation without changing gloves or performing hand hygiene. Additional observations showed the Dietary Manager placing raw chicken into the deep fryer and then handling raw French fries with the same gloves without changing gloves or performing hand hygiene. The Dietary Manager also put frozen chicken tenders into the fryer, then handled frozen French fries, grabbed serving scoops with the same gloved hands, handled a block of cheese without hand hygiene or glove changes, placed the cheese on the outside of its wrapper rather than a clean food preparation surface, removed gloves and opened the garbage can before donning new gloves without hand hygiene, pressed food against her uniform while plating, wiped gloved hands on her forehead, and touched her face, eyeglasses, and body while continuing to handle food during tray line service. The Dietary Manager acknowledged these practices and confirmed staff are expected to change gloves and perform hand hygiene when gloves become contaminated, after touching environmental surfaces, after handling raw animal products, and before resuming food preparation.
Unsafe and Unclean Physical Environment on 100 Hall
Penalty
Summary
The facility failed to maintain the physical environment in a clean, sanitary, functional, and comfortable manner for residents outside of the memory care unit. During observation, the flooring throughout the 100 Hall was excessively sticky, the cove base in the common area of the 100 Hall was peeling away from the wall and exposing broken and cracked drywall, and the chair rail in the same common area had peeling and chipped paint. These conditions were confirmed by an LPN during the survey observations. In addition, the floor near the fire door on the 100 Hall was observed to have a substantial accumulation of debris, including dust, hair, and unidentified dirt and debris. An LPN confirmed this observation during interview. Review of the facility's undated Housekeeping/Environmental Services policy showed that cleaning schedules are to be developed and implemented to ensure each area of the facility is maintained in a safe, clean, and comfortable manner.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure respect and dignity were maintained during meal service for two residents. Resident #26 had diagnoses of dementia, dysphagia, Alzheimer's disease, and anxiety, and the MDS showed a BIMS score of 00 indicating severe cognitive impairment. Resident #32 had diagnoses of dementia, muscle weakness, and anxiety, and the MDS showed a BIMS score of three indicating severe cognitive deficit. During lunch observation, Resident #26 was seated in a chair with a bedside table in front of her while CNA #128 stood on the other side of the table and fed her. Later in the same meal service, Resident #32 was seated at a dining table while CNA #128 stood to the right of her and fed her. CNA #128 confirmed she assisted both residents with lunch and verified she was standing while doing so. The facility policy stated residents are to always be treated with respect and dignity.
Soiled Bed Linens and Unclean Resident Environment
Penalty
Summary
The facility failed to ensure the physical environment was maintained in a clean, sanitary, functional, and comfortable manner for Resident #79. The resident was admitted with diagnoses including major depressive disorder, Type II DM, anxiety disorder, psychosis, a history of suicidal behavior, atherosclerotic heart disease, prior TIA, polyneuropathy, urinary retention, acquired absence of other toes, and chronic pain, and the admission MDS indicated the resident was unable to complete the BIMS. On observation, the resident's bed linens were soiled throughout with unidentified brown and red substances. The resident stated dissatisfaction with the condition of personal hygiene, clothing, and bed. An LPN confirmed the bed linens were soiled with unidentified brown and red substances throughout. The facility policy stated cleaning schedules are developed and implemented to ensure each area of the facility is maintained in a safe, clean, and comfortable manner.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to ensure one resident received assistance with activities of daily living. Resident #79 was admitted with diagnoses including major depressive disorder, Type II diabetes mellitus, anxiety disorder, unspecified psychosis, personal history of suicidal behavior, atherosclerotic heart disease, personal history of transient ischemic attack, polyneuropathy, urinary retention, acquired absence of other toes, and chronic pain. The admission MDS noted the BIMS was not completed due to the resident's recent admission to the facility. On observation, the resident appeared disheveled and poorly groomed, with a shirt containing food residue, dry skin, and other debris, and a dirty beard with food residue and other debris. The resident stated he had not received a shower or had his clothing changed since admission and reported requesting a shower the prior evening, but it was not provided and he was not informed of the shower schedule. An LPN verified the resident appeared disheveled and that his shirt and beard were dirty. The facility policy stated residents unable to independently perform ADLs will receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Secure Indwelling Foley Catheters
Penalty
Summary
The facility failed to ensure that indwelling Foley catheters were secured for two residents. Resident #22 was admitted with diagnoses including benign prostatic hyperplasia, obstructive uropathy, urinary retention, sepsis, emphysema, and acute respiratory failure with hypoxia. His admission MDS indicated intact cognition and an indwelling catheter, and his care plan identified the Foley catheter as being in place due to impaired genitourinary status related to BPH, obstructive uropathy, and urinary retention. During observation, his urinary catheter tubing was found without a securement device, and a CNA confirmed the catheter was not secured and should have been stabilized with an appropriate securement device per facility policy. Resident #51 was admitted with diagnoses including neuromuscular dysfunction of the bladder, borderline personality disorder, bipolar disorder, and anxiety disorder. Her admission MDS indicated intact cognition and an indwelling catheter, and her care plan identified the Foley catheter as being in place due to urinary retention and neurogenic bladder. During observation, her urinary catheter tubing was also found without a securement device. The resident stated that her Foley catheter had not been secured to her leg since admission, and the CNA again confirmed the catheter was not secured and should have been stabilized using an appropriate securement device in accordance with facility policy, which required indwelling urinary catheters to remain secured with a leg strap or leg band.
Oxygen Humidifier Bottle Left Empty
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident who was receiving continuous oxygen therapy. The resident had diagnoses including COPD, acute respiratory failure, CHF, OSA, obesity, and generalized weakness, and had a physician order for oxygen at 5 L/min via nasal cannula. The resident also had an order for oxygen tubing and set-up to be changed every Friday on day shift, which included a 350 mL bottle of sterile water for inhalation used to humidify the oxygen. On observation, the resident’s oxygen condenser had a 350 mL bottle of sterile water for inhalation that was empty and not humidifying the oxygen. Staff interviews confirmed the bottle should have been changed when empty and that it should have been changed on the prior Friday. The resident stated the empty bottle had not been changed, and when it was empty his nose was dry and irritated and he was uncomfortable. The facility policy stated oxygen therapy is used to treat or prevent symptoms and manifestations of hypoxemia and noted possible complications of oxygen therapy include bacterial contamination associated with certain nebulizers and humidifiers.
Medication Left Unsecured in Resident Room
Penalty
Summary
Medications were not stored in a safe and secure manner when an Incruse Ellipta inhaler for Resident #21 was found lying on the resident’s bed with three doses remaining. Resident #21 was admitted with diagnoses including COPD, generalized muscle weakness, history of falling, abnormalities of gait and mobility, acute respiratory failure, obesity, GERD, CHF, OSA, depression, anxiety, hyperlipidemia, HTN, and insomnia. The most recent Quarterly MDS showed a BIMS score of 15, indicating cognition was intact, and also showed the resident required staff assistance with all ADLs and received continuous oxygen therapy. The inhaler was observed in the resident’s room and was readily accessible rather than secured. Resident #21 stated the facility routinely left the Incruse Ellipta inhaler in the room after administration. An LPN confirmed the inhaler was on the bed and confirmed the resident did not have a physician order authorizing self-administration or self-storage of the medication. The facility policy stated medications are to be stored in a safe, secure, and orderly manner and assigned to an individual cubicle, drawer, or other designated holding area to prevent medications from being mixed or accessed by other residents.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental care was provided for one resident reviewed for dental services. The resident was admitted with diagnoses including metabolic encephalopathy, dysphagia, psychosis, major depressive disorder, Alzheimer's disease, and Type Two Diabetes. The quarterly MDS assessment showed a BIMS score of 00, indicating severe cognitive deficit, and the resident required partial to moderate assistance with personal and oral hygiene. The revised care plan identified a dental problem related to several missing, broken, and black teeth, and physician orders included consultation with follow-up treatment as indicated for dental services. Observation of the resident in the dining area showed teeth that were brown, black, broken, and some missing. The Director of Social Services stated there were no records of the resident being seen by a dentist since admission, although the resident had been seen by podiatry, audiology, and visual health services. The same staff member stated the dental service was scheduled to be in-house on the day of the interview, but the resident was not on the list to be seen. The facility policy stated oral healthcare and dental services would be provided to each resident.
EBP Not Maintained and Urinary Drainage Bag Left on Floor
Penalty
Summary
Enhanced Barrier Precautions (EBP) were not maintained for two residents who had physician orders for EBP. Resident #5 was admitted with diagnoses including osteomyelitis, dysphagia, gastrostomy, sepsis, schizoaffective disorder, quadriplegia, and psychosis. The most recent MDS showed a BIMS score of 15 and that the resident required assistance with all activities of daily living. The resident had a physician order for EBP every shift related to a wound and Foley catheter, and signage outside the room instructed staff to use hand hygiene, gloves, and a gown for high-contact care activities. During observation, CNA #125 was seen changing Resident #5's bed linens without wearing an isolation gown. The CNA confirmed the resident was on EBP, verified the signage, and acknowledged changing the linens without wearing a gown. Resident #63 was admitted with diagnoses including Type Two Diabetes, cerebral infarction, and chronic obstructive pulmonary disease. The most recent MDS showed a BIMS score of 14 and a diabetic foot ulcer was present. The care plan and physician orders identified EBP related to the wound. During observation, CNA #160 opened the door and exited Resident #63's room after assisting the resident off the bedpan. The CNA stated she did not wear PPE because the resident did not have a bowel movement, and she confirmed the resident was on EBP. In addition, Resident #51 had an indwelling Foley catheter, and during observation the urinary drainage bag was lying directly on the floor rather than being secured to the bed frame below the level of the bladder. RN #157 confirmed the bag was on the floor and stated it should have been secured to the bed frame to prevent contamination and maintain proper infection prevention practices.
Failure to Provide Timely Wound Care Orders After Hospital Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including chronic kidney disease, osteoarthritis, and a recent hospital admission for a wound on the left great toe, was readmitted to the facility. Hospital records indicated the wound was positive for Staphylococcus aureus and included a physician's order for an antibiotic regimen, with eight doses remaining at discharge. The hospital discharge paperwork also contained laboratory results confirming the infection. Upon review of the facility's medical record, it was found that there were no orders for wound care or dressing changes for the resident's left great toe from the date of readmission through two days later. This lack of timely wound care was confirmed in an interview with the Administrator and the DON, who verified that no wound care or dressing change orders were in place during this period. The facility's own wound care policy, which aims to promote healing, was not followed in this instance.
Failure to Implement Timely and Adequate Infection Control Precautions
Penalty
Summary
The facility failed to implement adequate infection prevention and control practices for a resident who was admitted with a wound infection positive for Staphylococcus aureus. Upon admission, the resident's hospital discharge paperwork included laboratory results indicating the presence of S. aureus, and the resident was receiving antibiotic treatment for the infection. Despite this, there were no physician orders for isolation precautions until two days after admission, and the resident was not placed into appropriate isolation precautions until that time. Facility leadership confirmed that it is the responsibility of the admitting nurse to review laboratory results and ensure proper isolation measures are implemented as needed. Further observations revealed additional lapses in infection control practices. There was no waste receptacle available for discarding used PPE outside the resident's room, as verified by the DON and a registered nurse. Additionally, an LPN entered the resident's room without donning PPE and stated she was unaware that the resident was on isolation precautions. The facility's infection prevention and control policy requires the implementation of appropriate isolation precautions when necessary, but these procedures were not followed in this instance.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely interventions for a resident's incontinence patterns, which led to a deficiency in care. The resident, who was admitted with multiple diagnoses including cognitive communication deficit, hemiplegia, and polyneuropathy, was assessed as incontinent of bowel and bladder and at risk for pressure ulcers. Despite having a care plan that required incontinence care as needed and regular checks every two hours, the resident was found heavily soiled during an observation, indicating a lapse in the care plan's implementation. The resident had a history of urinary tract infections, with recent treatments for E.coli infections. The deficiency was confirmed through staff interviews, where it was acknowledged that the resident should have been checked every two hours. The Director of Nursing verified the resident's recent urinary tract infection and the requirement for regular incontinence checks, highlighting the facility's failure to adhere to the care plan and prevent further complications.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were maintained and administered securely, affecting a resident who was observed with medications unattended at the bedside. The resident, who had intact cognition and required partial to moderate assistance with activities of daily living, was found with a medication cup containing five different pills on the overbed table. The resident admitted to forgetting to take the medication before breakfast, which was approximately one hour prior to the observation, and was unable to identify the medications. An interview with the LPN responsible for administering the medication revealed that she had handed the medications to the resident before breakfast but was unaware that the resident did not take them. The LPN did not observe the consumption of the medications and had already initialed the electronic medication administration record as if the medications had been administered. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, with the individual administering the medication initialing the record only after giving the medication.
Failure to Follow Care Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident requiring two staff members for bed mobility was properly assisted, resulting in a fall and injury. Resident #65, who was moderately cognitively impaired and had a history of multiple health issues including dementia, chronic kidney disease, and generalized weakness, required two-person assistance for bed mobility as per her care plan. However, on the day of the incident, only one staff member, STNA #159, was providing care, which led to the resident falling from the bed and sustaining a supracondylar fracture of the left femur. The incident occurred when STNA #159 was changing Resident #65 by himself, contrary to the care plan that required two staff members for such tasks. During the care, the resident was rolled away from the STNA, and she inadvertently placed her legs off the side of the bed, causing her to slide off and fall to the floor. The fall resulted in the resident experiencing left leg pain, and she was subsequently diagnosed with a fracture that required a cast and pain management. The facility's policy on falls, dated September 2021, emphasized the need for staff to identify interventions related to specific risks to prevent falls and minimize complications. Despite this policy, the care plan for Resident #65 was not followed, leading to the fall and injury. The deficiency was identified during an investigation under Complaint Numbers OH00159072 and OH00159507.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect residents from abuse by staff, specifically involving two residents. Resident #14, who was admitted with multiple medical conditions including pneumonia, COPD, and PTSD, reported verbal abuse and neglect by STNA #198. The resident stated that the aide would ignore call lights, respond rudely, and once threw a pillow that damaged the resident's orchid. Despite these allegations, the facility unsubstantiated the verbal abuse claim. Resident #60, with a history of cerebral infarction and other medical issues, also reported rough treatment by a caregiver with a ponytail, later identified as STNA #198. The resident described being thrown against the bed railing and taunted from the hallway. Initially unable to identify the perpetrator, the resident later confirmed it was STNA #198. The facility's investigation into these incidents was inadequate, as the abuse was unsubstantiated despite the residents' consistent reports. The facility's policies on abuse prevention and investigation were not effectively implemented, as evidenced by the lack of thorough investigation and reporting of the incidents. The facility's response to the allegations was insufficient, with only minimal corrective action taken against the staff member involved. This deficiency was identified under Complaint Number OH00159507.
Failure to Report Potential Neglect Incident
Penalty
Summary
The facility failed to timely report an incident of potential neglect involving Resident #65 to the appropriate state agency. Resident #65, who had a complex medical history including dementia, chronic kidney disease, and a high risk for falls, was care planned to require two-person assistance for bed mobility and transfers. However, on the morning of 09/28/24, State tested Nursing Assistant (STNA) #159 provided care independently, without the required assistance of another staff member, leading to Resident #65 falling out of bed and sustaining a left femur fracture. The incident occurred when STNA #159 was rolling Resident #65 away from himself during incontinence care, and she placed her legs off the side of the bed, subsequently sliding off and falling to the floor. Despite the care plan specifying the need for two-person assistance, STNA #159 was unaware of this requirement at the time of the incident. The fall resulted in Resident #65 being sent to the emergency room, where she was diagnosed with a left femur fracture and returned to the facility with a cast. The facility's failure to report this incident as a potential neglect case was confirmed during interviews with the Administrator and the Director of Nursing (DON). The facility's policy on abuse prevention and reporting mandates that all incidents of potential abuse or neglect be promptly reported to the appropriate authorities, but no self-reported incident (SRI) was filed in this case. This oversight highlights a significant deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Maintain Infection Control Practices for Resident in Isolation
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident in isolation, specifically for Resident #54, who was under Enhanced Barrier Precautions (EBP) due to a wound on the coccyx. The resident had a complex medical history, including cellulitis, sepsis, heart failure, chronic ulcers, and chronic kidney disease, and was dependent on staff for all functional abilities. Despite the presence of a sign indicating EBP at the resident's room, two State Tested Nursing Aides (STNAs) entered the room to provide incontinence care without wearing the required personal protective equipment (PPE), which includes a gown and gloves. Interviews with the STNAs revealed that they were unaware that the EBP order was still active, mistakenly believing it had expired. Further interviews with the Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed that the EBP order was indeed active and had been placed for the resident's coccyx wound. The facility's policy on Enhanced Barrier Precautions, which mandates the use of gloves and gowns during high-contact care activities for residents with certain conditions, was not adhered to in this instance, leading to the deficiency.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the required Registered Nurse (RN) coverage, which had the potential to affect all 65 residents. A review of staff timesheets revealed that on several specific dates, the facility did not have an RN working a minimum of eight hours a day. This was confirmed during an interview with the Administrator, who verified the lack of RN coverage on those dates. The facility's policy, dated September 2021, states that adequate staffing must be maintained on each shift to ensure residents' needs and services are met, with licensed registered nursing and licensed nursing staff available to provide and monitor the delivery of resident care services.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, which had the potential to affect all 65 residents receiving meals from the kitchen. During an initial tour of the kitchen, excessive buildup and grime were observed between and behind the fryer and stove, as well as on the lower part of a metal food cart used for resident meal trays. Additionally, there was buildup and debris on the floor and along the edges of the walls surrounding the interior side of an exit door in the dry storage room, and excessive black-colored buildup under tables and appliances throughout the kitchen. The Regional Dietary Manager confirmed the presence of debris and buildup on the floors and meal cart. A review of the facility's pest control service logs from May and June indicated that the kitchen had been inspected and spot treated, with recommendations for cleaning. The Maintenance Director verified that the pest control logs noted the need for kitchen cleaning.
Failure to Maintain Cleanliness in Memory Care Unit
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the memory care unit, affecting 28 residents. Observations over several days revealed that the flooring along the edges of the hallways and in specific resident rooms had a thick layer of dust and grime. This was noted in the memory care unit and in the rooms of specific residents, where the flooring, particularly around the corners and edges, was unclean with a noticeable build-up of substances. Interviews with housekeeping staff confirmed the presence of dirt and debris in these areas. Housekeeping staff acknowledged the issue and mentioned that they had just begun deep cleaning, planning to clean two rooms per day. The facility's housekeeping policy, which lacked a date, indicated that cleaning schedules should be developed and implemented to maintain a safe, clean, and comfortable environment, but this was not adhered to, leading to the observed deficiencies.
Failure to Report Elopement and Unprescribed Medication Administration
Penalty
Summary
The facility failed to report an incident of elopement involving a resident who was at high risk for elopement. The resident, who had a history of cognitive impairment and was deemed appropriate for the memory care unit, managed to leave the facility through a window. The resident was found outside the facility after visiting local bars, consuming alcohol, and returning to the premises. Despite the severity of the incident, no Self-Reported Incident (SRI) was filed by the facility. Additionally, the facility did not report allegations of an unlicensed staff member administering unprescribed melatonin to several residents. This involved four residents who were either not prescribed melatonin or were cognitively impaired. The Director of Nursing was aware of the allegations but did not conduct further reporting, and the Administrator confirmed that no SRI was filed regarding this issue. The facility's policy on abuse investigation and reporting mandates that all reports of resident abuse, neglect, and other related issues be promptly reported to appropriate authorities. However, the facility did not adhere to this policy in the cases of the resident's elopement and the administration of unprescribed medication, leading to non-compliance with regulatory requirements.
Failure to Investigate Allegation of Unlicensed Staff Administering Unprescribed Medication
Penalty
Summary
The facility failed to investigate an allegation of unlicensed staff administering unprescribed melatonin to residents. This issue affected four residents, all of whom were cognitively impaired and included individuals with diagnoses such as dementia and Alzheimer's disease. The medical records revealed that only one of the four residents had a prescription for melatonin, while the others did not. Despite being notified of the allegation, the Director of Nursing (DON) only spoke with the nurse involved and reported the incident to the Administrator, without conducting a thorough investigation. The Administrator also failed to file a self-reported incident or investigate the allegation of abuse involving the administration of unprescribed medication by unlicensed staff. The facility's policy on Abuse Investigation and Reporting, dated September 2021, mandates that all reports of abuse, neglect, exploitation, and other related issues be reported and thoroughly investigated by facility management. This includes interviewing the resident and staff members involved in the alleged incident. The deficiency was investigated under Complaint Number OH00154857.
Oxygen Administration Error for Resident
Penalty
Summary
The facility failed to ensure that a resident received oxygen at the correct rate as prescribed by the physician. The resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease among other diagnoses, was supposed to receive two liters of oxygen per minute via nasal cannula. However, during an observation, it was noted that the oxygen concentrator was set to deliver three liters per minute. The resident confirmed that they were supposed to receive two liters per minute. A registered nurse acknowledged the discrepancy and suggested that the control for the oxygen concentrator might have been accidentally adjusted.
Expired Insulin Not Discarded
Penalty
Summary
The facility failed to properly manage the storage and disposal of expired insulin, affecting three residents diagnosed with diabetes mellitus type II. During an observation, it was found that insulin pens and a multi-dose vial were opened and expired, yet still stored in the medication cart. Specifically, a multi-dose vial of aspart insulin for one resident, a fiasp insulin pen for another, and a novolog insulin pen for a third resident were identified as expired. This was confirmed by an LPN during the observation. The facility's policy on medication storage mandates that all drugs and biologicals be stored safely and securely, and that discontinued, outdated, or deteriorated drugs should not be used. Additionally, the policy on administering medications requires checking the expiration or beyond-use date on medication labels before administration. The failure to adhere to these policies resulted in the presence of expired insulin in the medication cart, which was not discarded as required.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were completed according to the pharmacist's recommendation and physician's order for a resident. The resident, who was admitted with diagnoses including type II diabetes mellitus with diabetic polyneuropathy, obesity, muscle weakness, anxiety, and depression, was identified as cognitively intact. The plan of care for the resident included monitoring labs and diagnostic testing per physician order. However, the last Hemoglobin A1C (HbA1c) test was completed on 12/28/23, despite a pharmaceutical recommendation made on 05/24/24 to monitor HbA1c every three months for diabetes therapy. This recommendation was reviewed and an order was placed on 06/11/24 to monitor HbA1c every three months starting on the 12th. Despite the physician's order, the laboratory work completed on 06/12/24 did not include the HbA1c test. An interview with the Director of Nursing on 07/08/24 confirmed that the HbA1c test was not completed as ordered on 06/12/24, and the most recent HbA1c test for the resident was on 12/28/23. The facility's policy on requests for diagnostic services stated that orders for diagnostic services would be carried out as instructed by the physician's order, indicating a failure to adhere to this policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a State Tested Nurse Aide (STNA). The incident involved a resident who was cognitively intact and required assistance with activities of daily living due to conditions such as chronic obstructive pulmonary disease, muscle weakness, and incontinence. The resident reported that an STNA was verbally abusive, which was corroborated by witness statements from other staff members who observed the STNA cursing and belittling the resident about their incontinence. The incident was reported on the same day it occurred, and the STNA involved was immediately removed from the facility pending investigation. Despite the resident expressing shock and discomfort at the STNA's behavior, the facility's investigation concluded that verbal abuse was not substantiated. However, the STNA was disciplined with a one-day suspension for verbal abuse, indicating some acknowledgment of inappropriate behavior. Interviews with other staff members and the resident's daughter confirmed the STNA's inappropriate comments and actions, which included cursing and making derogatory remarks about the resident's urinary habits. The facility's administrator acknowledged the disciplinary action taken against the STNA but did not report the incident to the nurse aide registry. The resident expressed that the STNA had never behaved in such a manner before, and the STNA was not allowed to provide care for the resident following the incident.
Failure to Prevent Elopement and Implement Fall Interventions
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as Resident #54. This resident, who had a history of cognitive impairment and was deemed a flight risk, managed to leave the facility unsupervised. Despite being on a secure memory care unit, the resident was able to unscrew his window screen and exit the building. He then visited two local bars, consuming alcohol before returning to the facility. The staff was unaware of his absence until he was found outside the facility early in the morning. The resident's care plan had identified him as an elopement risk, but the necessary supervision and checks were not in place to prevent this incident. Additionally, the facility failed to implement fall prevention interventions for Resident #58, who was at risk for falls due to cognitive impairment and physical weakness. The care plan for this resident included the use of a mat on the floor next to the bed to prevent injury from falls. However, observations revealed that the mat was not in place on multiple occasions, and staff interviews confirmed that the mat had not been used as required. This oversight left the resident vulnerable to potential falls, as the necessary safety measures were not adhered to. These deficiencies highlight lapses in the facility's adherence to care plans and supervision protocols, which are critical for ensuring resident safety. The lack of proper monitoring and implementation of safety interventions contributed to the incidents involving both residents, indicating a need for improved compliance with established care procedures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 208 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Port Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Otterbein North Shore | 9.7 mi | ★★★★★ | 8 | 0 |
| Ottawa Co Riverview Nursing Ho | 10.8 mi | ★★★★★ | 26 | 0 |
| Providence Care Center | 12.2 mi | ★★★★★ | 8 | 2 |
| Countryside Manor Nursing And Rehabilitation Llc | 12.4 mi | ★★★★★ | 26 | 1 |
| Valley View Health Campus | 12.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Edgewood Manor Rehabilitation & Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.