Edgewater Woods
EDGEWATER WOODS in ANDERSON, IN — inspection on August 29, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview, on 8/29/25 at 11:46 a.m., Activity Assistant 4 indicated the former
by the Activity Director.
The items had not been labeled with residents' names and had been used for all the residents as far as she knew.
The Activity Director had put names on the items in the refrigerator.
She had not noticed the Activity Director using anything that belonged to the residents.
The ISNP benefits card program was new to the facility.
During an interview, on 8/29/25 at 2:08 p.m., the Administrator indicated when a resident was eligible for ISNP benefits, they were enrolled, and they received a grocery benefits card.
The program was new to the facility.
The benefits were to be used for items the residents wanted, or if the resident was cognitively unable to make decisions, then the resident's representative could assist with spending those benefits.
The Business Office Manager kept the cards in her office for the residents' cards that were at the facility.
The Activity Director had taken the facility credit card to get supplies for activities that day.
Since she was buying items for the residents, she also took the residents' ISNP benefits cards to make purchases for those residents.
After the incident with the cards, the ISNP benefit cards were stored in the business office safe.
The cards must be signed out. An accounting for products purchased are required by the provision of a receipt.
She in-serviced all the staff on the abuse policy as a whole, then focused on resident purchases and misappropriation of property.
The staff were in-serviced on who to notify when a resident requests items.
Social Services and the Business Office Manager was permitted to purchase items for the residents.
The three residents affected were reimbursed.
The investigation file, provided by the Administrator on 8/28/25 at 2:26 p.m., contained copies of checks for Resident D for $83.39 and Resident E for $150.00. A petty cash withdrawal receipt for Resident F for $150.00 was provided with an account statement that showed the resident's account had been credited with a cash payment of $150.00. An in-service sign in sheet for abuse/neglect/misappropriation of property for 6/19/25 was included.
The in-service sheet contained 62 staff signatures.
During an interview, on 8/29/25 at 2:35 p.m., the Administrator indicated she had discussed the incident at the facility Quality Assurance and Performance Improvement (QAPI) meeting.
The facility had a QAPI meeting every other month A facility QAPI tool provided by the Administrator on 8/29/25 at 2:49 p.m., indicated under the Quality Assurance information for abuse prohibition measures - a misappropriation of property incident had been substantiated. No trends were identified.
All staff were educated on abuse/misappropriation of property policy.
The system for the ISNP benefit cares was discussed.
Social Services and the Business Office Manager were permitted to use the benefit cards for the residents.
The Business Office Manager tracked the receipts.
The representative for the Provider 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
- 3.1-28(a)
155066 08/29/2025
Edgewater Woods 1809 N Madison Ave Anderson, IN 46011
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)
155066 08/29/2025
Edgewater Woods 1809 N Madison Ave Anderson, IN 46011
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)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
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