Edgewater Woods

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Partners Health Plan (PPHP) will come to the facility monthly and check the members' accounts.The deficient practice was corrected on 7/18/25 after the facility implemented a systemic plan that included the education of staff regarding the facility's abuse and misappropriation of property policy, interviewed and/or assessed other residents for abuse, completed an Interdisciplinary Team (IDT) review of the incident, and planned for Quality Assurance activities to mitigate reoccurrence of the deficient practice. A current facility policy, last revised 6/2023 and provided by the DON on 8/28/25 at 4:10 p.m., titled Abuse Prohibition, Reporting, and Investigation, indicated the following: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation.Misappropriation of Resident Funds or Property - Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. This citation relates to Intake 1630260. 3.1-28(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Edgewater Woods

1809 N Madison Ave Anderson, IN 46011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

from the nurse practitioner. The new order was received, and the catheter was placed at approximately 8:45 p.m. A nursing progress note, recorded on 7/30/25 at 3:04 a.m., dated 7/29/25 at 8:44 p.m., indicated the nurse went to see if the resident was ready to have his catheter anchored. He did not have any urinary output. An order for a 16 French 10 mL bulb catheter was ordered which was not available. The nurse practitioner was notified and gave an order for the resident to use an 18 French 10 mL bulb coude (type of catheter). The catheter was anchored with an immediate return of urine. The resident received an as needed pain medication at 8:12 p.m. prior to catheterization, had a fentanyl patch in place, and received routine acetaminophen to manage pain. The resident voiced no concerns. The physician's report, signed at 11:26 a.m., indicated the catheter was removed. The late entry nursing progress note, on 7/30/25 at 3:04 a.m., and the grievance report, on 7/29/25 at 8:25 a.m., indicated the catheter was re-anchored at approximately 8:45 a.m. The physician's order indicated to anchor a foley catheter if the resident did not void in six hours. The time between urinary catheter removal and re-anchoring of the urinary catheter was over nine hours. During an interview, on 8/29/25 at 11:05 a.m., RN 5 indicated when a urinary catheter was removed, the resident should go no longer than eight hours to void. She would follow the physician's orders

on what actions should be taken if the resident did not void. If the correct size of the catheter was not available, she would use a smaller size catheter and get an order from the physician. Catheter supplies were kept in the large storeroom or sometimes in the tiny storeroom where a few supplies are also stored.

The Scheduler was responsible for ordering and ensuring medical supplies were available. During an interview, on 8/29/25 at 11:51 a.m., the Unit Manager indicated when a resident had a foley catheter removed she would follow the physician's orders. She would expect the resident would need to have a catheter anchored in eight hours if the resident had not voided. During an interview, on 8/29/25 at 12:00 p.m., the Scheduler indicated she tried to keep one of every size of catheter in stock at the facility. They discussed in morning meeting when a new admission came in what needs the resident had such as sizes of catheters, feeding tubes, and tracheostomy supplies. During an interview, on 8/29/25 at 1:46 p.m., the DON indicated when a catheter was removed, per standard practice, the resident would need to be catheterized in eight hours or per the physician's orders if the resident did not void. The resident had declined the catheter earlier, and the nurse had to get a new order because she did not have the correct catheter size. She was uncertain if the nurse could not find the correct size catheter or if it was not available. During an interview, on 8/29/25 at 2:43 p.m., the DON indicated she had procedure steps for catheter care and emptying a urinary drainage bag. The facility did not have any additional policies for urinary catheters. According to the National Library of Medicine website from the National Institutes of Health (NIH) accessed on 8/29/25 at https://www.ncbi.nlm.nih.gov/books/NBK596722/, .When removing an indwelling urinary catheter, it is considered a standard of practice to document the time and track the time of the first void. This information is also communicated during handoff reports. If the patient is unable to void within 4-6 hours and/or complains of bladder fullness, the nurse determines if incomplete bladder emptying is occurring according to agency policy. The ANA [American Nurses Association] has made the following recommendations to assess for incomplete bladder emptying: The patient should be prompted to urinate. If urination volume is less than 180 mL, the nurse should perform a bladder scan to determine the post-void residual. A bladder scan is a bedside test performed by nurses that uses ultrasonic waves to determine the amount of fluid in the bladder. If a bladder scanner is not available, a straight urinary catheterization is performed. This citation relates to Intake 2582493. 3.1-41(a)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Edgewater Woods

1809 N Madison Ave Anderson, IN 46011

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was reviewed. The PRN (as needed) medications given as mentioned in the 7/23/25 note on the resident's admittance were not documented. The first documented given dose of PRN hydromorphone indicated the resident took the medication at 6:53 a.m. with a pain rating of 8 on a 1 to 10 scale. A narcotic count sheet indicated the hydromorphone was received on 7/24/25 at 12:50 a.m. and given at 2:30 a.m. The resident routinely took between four and six PRN hydromorphone daily to manage pain from 7/24/25 through 7/29/25. During a phone interview, on 8/28/25 at 11:09 AM, Resident C's representative indicated the resident had called the resident representative on the night he was admitted . The resident indicated he was in pain. He told the resident representative the facility did not have his medications, and no one would help him. He asked the resident representative to help him and bring his medications from home. During an interview, on 8/29/25 at 11:19 a.m., LPN 7 indicated when a resident was admitted , the orders were transcribed, and everything not in the emergency drug kit was ordered stat (immediately). She expected to get all medications within four hours. If the resident was in pain and the ordered pain medication was not available, she would call the physician to see if could get something else until the ordered medication was available. During an interview, on 8/29/25 at 11:28 a.m., RN 5 indicated for a newly admitted resident, she ordered from the pharmacy the medications that were not in the emergency drug kit. The medications were supposed to arrive within four hours after ordering. If the resident was requesting a pain medication and it was not in the emergency drug kit, then she would call the physician and get a temporary order for a different pain medication until the original ordered medication was available. During an interview, on 8/29/25 at 11:51 a.m., the Unit Manager indicated for a newly admitted resident, she utilized the emergency drug kit and then called the pharmacy for everything else to be sent stat. When the medications were ordered stat,

they came within four hours. If the ordered pain medication for the resident was requested and not available, she would call the nurse practitioner and get an alternative medication to give that was available

in the emergency drug kit. During an interview, on 8/29/25 at 1:56 p.m., the DON indicated when the facility received a new admission, anything that was in the emergency drug kit would not be sent out stat to the facility. Anything not in the emergency drug kit would be sent by the next morning. She did not believe the medications were received the night the resident was admitted . If the resident needed a pain medication,

she would call the pharmacy to have the pain medication sent stat. If the resident had another pain medication would try to use that first to see if the other pain medication would help. She indicated if the resident were on hydromorphone, she did not expect acetaminophen would be effective to manage the pain. The physician should be notified to see what should be done. A current facility policy, last revised 7/2024, provided by the DON on 8/29/25 at 12:17 p.m., titled Pain Management Policy, indicated the following: .It is the policy of American Senior Communities to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management.Residents are assessed for pain upon admission.Interviewable Resident - Pain medications will be prescribed and given based upon the intensity of the pain as follows using the verbal descriptive, numerical scale (1-10) or Wong-Baker FACES Scale.SEVERE = (6-8).Documentation of administration of ordered PRN pain medication will be documented on the Electronic Medication Administration Record (EMAR). This citation relates to Intake 2582493. 3.1-37(a)

Event ID:

Facility ID:

If continuation sheet