Edgewater Health and Rehabilitation

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Resident Rights Deficiencies

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. Fire panel in trouble heat detector in boiler room. 2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling CodeThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101 and NFPA 80.Kitchen fire door does not shut. When the door closer is released.NFPA 80 5.2.14.1 Self-closing devices shall be kept in working conditionat all times.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance director at the exit conference. Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1and NFPA 54, 7.9.2.1. This was evidenced by the following:Gas orifice on dryer rated for 0-2000 feet in elevation in the laundry room.NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011) Rm 14 corroded sprinkler head2) Missing escutcheon Room 13, hole in drywall around head 3) Missing escutcheon in room 124)Storage needs to be 18" below sprinkler heads In Maintenance room, maintenance storage and kitchen. NFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 13 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space ar.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V(111), wood framed structure with a partial lower level used for support services. The residents have routine access to the lower level; however, resident rooms are not located in the lower level. The lower level has two exits at grade to the exterior.The facility is protected throughout by an automatic fire sprinkler system and is classified as Fully Sprinklered. The facility was constructed in 1972. The 70 bed facility was surveyed on March 5, 2024 using the National Fire Protection Association, (NFPA)101 Life Safety Code (20..

A recertification survey with Incident #30757 was completed on 2/12/24 to 2/14/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 2/12/24 to 2/14/24. No deficiencies were cited. Based on observation, record review and interviews, the facility failed to ensure that residents were kept free from significant medication errors for two (#54 and #47) of six residents out of 26 sample residents.Specifically, the facility failed to:-Ensure an antipsychotic medication for Resident #54 was obtained and administered according to physician' s orders;-Notify resident #54' s physician that the resident' s antipsychotic medication was not refilled which resulted in the resident missing administration of the medication three days;-Ensure Resident #47 received all ordered doses of her prescribed antibiotic medication; and,-Notify Resident #47' s physician when the resident did not receive the anti.. Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of two nourishment refrigerators. Specifically, the facility failed to:-Ensure thawed nutritional supplements and thickened liquids were dated appropriately;-Ensure food was labeled and dated in the nourishment refrigerators; and,-Ensure expired food was discarded in the nourishment refrigerators.Findings include:I. Professional referenceThe (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf., retrieved o.. Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries.Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on 5/13/22 without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility fai.. Based on record review, and observations, the facility failed to ensure six of seven residents out of 36 sample residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician orders, and the resident' s care plan.Specifically, the facility failed to ensure the puree textures produced were consistent with the International Dysphagia Diet Standard Initiative (IDDSI) level four puree texture (PU4) for residents prescribed a puree diet.Findings include:I. Professional standardThe International Dysphagia Diet Standard Initiative (IDDSI) effective July 2019 and retrieved 2/15/24 from https://iddsi.org/IDDSI/me..

A licensure survey was completed on 2/12/24 to 2/14/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries.Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on 5/13/22 without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility failed to conduct a skin assessment between the dates of 10/6/23 and 10/18/23. On 10/18/23, multiple pressure wounds were noted to Resident #31' s left foot. The wounds included an unstageable left lateral malleolus (outside ankle) wound which later evolved to reveal a stage 3 pressure injury, an unstageable lateral (outside) left heel wound, an unstageable lateral left foot wound which later evolved to reveal a stage 4 pressure injury, and an unstageable left fifth metatarsal head (joint between the foot and the small toe) deep tissue injury (DTI). The left fifth metatarsal wound resolved on 11/28/23 and reemerged as a DTI on 1/8/24. On 1/18/24, the left fifth metatarsal wound evolved into an unstageable pressure wound.On 10/22/23, the resident developed an unstageable pressure injury to his left hip. The facility had initiated a skin integrity care plan for the resident on 5/27/22, however, interventions, such as implementing a specialty air mattress and repositioning the resident, were not implemented until after Resident #31 developed the pressure injuries to his left hip and left foot.As a result of the facility' s failures to implement timely pressure injury interventions, Resident #31 developed multiple advanced pressure injuries to his left foot and left hip. Findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure..