Edgewood Manor: Staph Infection Precautions Ignored - OH
Nobody put him in isolation.
The resident, identified in inspection records only as Resident #53, had been admitted to Edgewood Manor on August 9, 2025. His hospital discharge paperwork included the laboratory results confirming the S. aureus wound culture. He was actively being treated for the infection at the time he arrived. According to the Director of Nursing and the Administrator, it was the admitting nurse's responsibility to review those lab results and order the appropriate precautions. That did not happen.
Two days passed. Then, on the morning of August 11, a federal inspector arrived at the facility as part of a complaint investigation. By 10:04 that morning, signage outside the resident's door showed he had been placed in enhanced barrier precautions. By 2:17 that afternoon, the sign had changed to contact precautions. The medical record showed the first isolation order was entered at 9:40 a.m. on August 11, roughly 44 hours after the resident had walked in the door with a confirmed staph infection.
When inspectors sat down with the Director of Nursing and the Administrator that same afternoon, both confirmed the timeline. The resident had arrived with the positive culture results in hand. He had been receiving wound treatment since admission. And for two days, no isolation precautions had been ordered.
The problems did not stop at the delayed order.
At 2:28 p.m. on August 11, inspectors walked through the resident's room with the Director of Nursing and a registered nurse. There was no waste receptacle anywhere near the room's exit, meaning staff leaving the room had nowhere to discard their used personal protective equipment before stepping back into the hallway. Both the Director of Nursing and the registered nurse confirmed what inspectors could see for themselves: the bin simply wasn't there.
The following morning, at 9:59 a.m. on August 12, a licensed practical nurse entered Resident #53's room without putting on any PPE at all. Interviewed two minutes later, she said she hadn't known the resident was on isolation precautions.
That answer, on its own, captures the full chain of failure. A resident arrives with a documented infection. The precaution order doesn't get written for two days. When it finally does, there's no place to throw away contaminated gloves and gowns on the way out. And a nurse, working the floor the morning after inspectors flagged the missing trash can, still had no idea the room required any precautions at all.
Resident #53 is cognitively intact, with a mental status assessment score of 14 out of 15 recorded just six days before inspectors arrived. He had been admitted in late April with a long list of serious diagnoses, including chronic kidney disease, COPD, cellulitis, and cerebral infarctions, conditions that leave little margin for an additional infection spreading unchecked through a shared care environment.
Edgewood Manor had 62 residents at the time of the inspection. The report noted the infection control failure had the potential to affect all of them.
The facility's own infection prevention policy, dated September 2022, lists implementing appropriate isolation precautions as a core component of the program. The inspection was conducted August 13, 2025, two days after inspectors first observed the precaution signage and four days after the resident had been discharged from the hospital to Edgewood Manor's care.
Resident #53 spent those first two days in a room with no isolation order posted on the door, in a facility where the nurse who would eventually enter his room without protection had no reason to know she needed any.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edgewood Manor Rehabilitation & Healthcare Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
EDGEWOOD MANOR REHABILITATION & HEALTHCARE CENTER in PORT CLINTON, OH was cited for violations during a health inspection on August 13, 2025.
The resident, identified in inspection records only as Resident #53, had been admitted to Edgewood Manor on August 9, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.