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Health Inspection Summary

Edgewood Manor Health Care Center

11900 Jessica Lane

Raytown, MO 64138

(816) 358-7858

Deficiency Category	Inspection Date: 10/1/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 2/9/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 3/16/20 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	1	2	2
Quality of Life and Care Deficiencies	5	11	4
Infection Control Deficiencies	4	0	1
Resident Assessment and Care Planning Deficiencies	6	3	2
Nursing and Physician Services Deficiencies	2	1	0
Resident Rights Deficiencies	5	3	4
Nutrition and Dietary Deficiencies	1	1	0
Pharmacy Service Deficiencies	2	2	1
Environmental Deficiencies	0	0	2
Administration Deficiencies	1	0	0

Detailed result for inspection on 10/1/24

Date of last standard health inspection:	10/1/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	10/1/24Read the full report (PDF) 8/23/24Read the full report (PDF) 4/18/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	27
Average number of Health Deficiencies in Missouri:	12.2
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	8/23/24	8/23/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate foot care.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Provide safe, appropriate dialysis care/services for a resident who requires such services.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	10/1/24	11/14/24	3 - Actual harm	Few
Provide or obtain dental services for each resident.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement policies and procedures for flu and pneumonia vaccinations.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Many
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Many

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Ensure services provided by the nursing facility meet professional standards of quality.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Assess the resident when there is a significant change in condition	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Observe each nurse aide's job performance and give regular training.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Post nurse staffing information every day.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	4/18/24	4/18/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Many
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 2/9/23

Date of last standard health inspection:	2/9/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	2/27/24Read the full report (PDF) 12/26/23Read the full report (PDF) 8/30/23Read the full report (PDF) 5/25/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	23
Average number of Health Deficiencies in Missouri:	12.5
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	8/30/23	10/20/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	12/26/23	2/9/24	3 - Actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care or services that was trauma informed and/or culturally competent.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	2/27/24	2/17/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/25/23	5/29/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Few
Provide routine and 24-hour emergency dental care for each resident.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Few
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.	12/26/23	2/9/24	3 - Actual harm	Few
Provide activities to meet all resident's needs.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some
Provide safe, appropriate dialysis care/services for a resident who requires such services.	5/25/23	5/29/23	2 - Minimal harm or potential for actual harm	Few
Provide safe, appropriate dialysis care/services for a resident who requires such services.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
PASARR screening for Mental disorders or Intellectual Disabilities	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	2/9/23	4/6/23	2 - Minimal harm or potential for actual harm	Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	2/9/23	4/6/23	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Post nurse staffing information every day.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	2/9/23	4/6/23	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 3/16/20

Date of last standard health inspection:	3/16/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	2/9/23Read the full report (PDF) 12/5/22Read the full report (PDF) 11/17/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	16
Average number of Health Deficiencies in Missouri:	10.6
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	11/17/22	11/18/22	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	3/16/20	5/15/20	3 - Actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/17/22	11/17/22	4 - Immediate jeopardy to resident health or safety	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Many

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	11/17/22	11/18/22	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to manage his or her financial affairs.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	12/5/22	12/5/22	2 - Minimal harm or potential for actual harm	Few
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	3/16/20	5/15/20	2 - Minimal harm or potential for actual harm	Few

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	8/23/24	8/23/24	2 - Minimal harm or potential for actual harm	Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	10/1/24	11/14/24	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	4/18/24	4/18/24	2 - Minimal harm or potential for actual harm	Few
Respond appropriately to all alleged violations.	8/30/23	10/20/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	12/26/23	2/9/24	3 - Actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	2/27/24	2/17/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	2/9/23	3/15/23	2 - Minimal harm or potential for actual harm	Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/25/23	5/29/23	2 - Minimal harm or potential for actual harm	Few
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.	12/26/23	2/9/24	3 - Actual harm	Few
Provide safe, appropriate dialysis care/services for a resident who requires such services.	5/25/23	5/29/23	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	11/17/22	11/18/22	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/17/22	11/17/22	4 - Immediate jeopardy to resident health or safety	Few
Ensure services provided by the nursing facility meet professional standards of quality.	11/17/22	11/18/22	2 - Minimal harm or potential for actual harm	Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	12/5/22	12/5/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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