Deficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
164% occupied
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 83
Deficiencies: 3
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with nursing staffing requirements and infection prevention and control practices at Edgewood Health and Rehab.
Findings
The facility failed to ensure a Registered Nurse worked at least 8 consecutive hours daily and that the Director of Nursing served as the RN in the facility. Additionally, the facility failed to ensure proper hand hygiene during meal service and perineal care, and failed to implement Enhanced Barrier Precautions for a resident with pressure ulcers.
Deficiencies (3)
Failure to ensure a Registered Nurse worked at least 8 consecutive hours a day and the Director of Nursing did not serve as the RN in the facility.
Failure to ensure staff performed hand hygiene during meal service and perineal care.
Failure to initiate Enhanced Barrier Precautions for a resident with pressure ulcers.
Report Facts
Facility census: 84
Facility census: 83
Residents sampled: 21
Residents affected: 1
Residents affected: 1
Inspection Report
Annual Inspection
Census: 84
Deficiencies: 2
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with nursing staffing requirements and infection prevention and control practices at Edgewood Health and Rehab.
Findings
The facility failed to ensure a Registered Nurse was on duty for at least 8 consecutive hours daily and that the Director of Nursing served as the RN in the facility. Additionally, the facility failed to ensure proper hand hygiene during meal service and perineal care, and failed to implement Enhanced Barrier Precautions for a resident with pressure ulcers.
Deficiencies (2)
Failed to ensure a Registered Nurse worked at least 8 consecutive hours a day, 7 days a week, and the Director of Nursing did not serve as the RN in the facility.
Failed to ensure staff performed hand hygiene during meal service and perineal care, and failed to initiate Enhanced Barrier Precautions for a resident requiring them.
Report Facts
Facility census: 84
Resident sample size: 21
Resident #12 BIMS score: 15
Resident #34 BIMS score: 11
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 8, 2023
Visit Reason
The inspection was conducted based on complaints regarding privacy violations during medication administration, unsanitary environment and torn furnishings, improper medication labeling and storage, inadequate food handling hygiene, and infection control practices.
Complaint Details
The visit was complaint-related addressing issues of privacy breaches, unsanitary conditions, medication storage and labeling errors, poor dietary hygiene, and infection control lapses. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to protect resident medical information privacy, unsanitary conditions and torn furnishings affecting residents' environment, failure to date insulin bottles and secure narcotic medications, dietary staff not following proper hand hygiene and food handling practices, and inadequate infection control during medication administration.
Deficiencies (5)
Failed to ensure personal medical information and privacy was protected during medication administration for 1 resident, potentially affecting 19 residents.
Failed to provide a sanitary environment and ensure furnishings were free of tears affecting 79 residents and 15 residents respectively.
Failed to ensure insulin bottles were dated after opening and narcotic medications were stored in a permanently affixed locked container, potentially affecting 13 and 79 residents respectively.
Failed to ensure dietary staff effectively washed hands before handling clean equipment or food items, potentially affecting 78 residents.
Failed to ensure appropriate infection control measures during medication administration to prevent transmission of infections for 1 blood glucose observation.
Report Facts
Residents affected: 19
Residents affected: 79
Residents affected: 15
Residents affected: 13
Residents affected: 78
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in privacy breach, medication labeling, and infection control findings |
| Director of Nursing | Director of Nursing | Confirmed findings related to privacy, medication labeling, and infection control |
| Maintenance Director | Maintenance Director | Interviewed regarding responsibility for furnishings and condition of chairs |
| Dietary Employee #1 | Dietary Employee | Observed failing to wash hands and change gloves during food preparation |
| Dietary Employee #2 | Dietary Employee | Observed failing to wash hands and change gloves during food preparation |
| Dietary Employee #3 | Dietary Employee | Observed failing to wash hands and change gloves during food preparation and serving |
| Dietary Employee #4 | Dietary Employee | Observed failing to wash hands and change gloves during food serving |
| Dietary Employee #5 | Dietary Employee | Observed failing to wash hands before handling clean equipment |
| Dietary Employee #6 | Dietary Employee | Observed failing to wash hands and improper glove use during food handling |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, sanitary environment, medication storage and labeling, dietary staff hygiene, and infection control practices.
Findings
The facility was found deficient in protecting resident medical information privacy, maintaining a sanitary and homelike environment, properly labeling and securely storing medications, ensuring dietary staff hand hygiene, and implementing infection control measures during medication administration. All deficiencies were noted to have minimal harm or potential for actual harm.
Deficiencies (5)
Failed to ensure personal medical information and privacy was protected during medication administration for 1 resident, with potential impact on 19 residents.
Failed to provide a sanitary environment and ensure furnishings were free of tears affecting 79 residents and 15 residents respectively.
Failed to ensure insulin bottles were dated after opening and refrigerated narcotic medications were stored in a permanently affixed, locked container, potentially affecting 13 and 79 residents respectively.
Failed to ensure dietary staff effectively washed their hands before handling clean equipment or food items, potentially affecting 78 residents.
Failed to implement appropriate infection control measures during medication administration to prevent transmission of infections for 1 blood glucose observation.
Report Facts
Residents affected: 19
Residents affected: 79
Residents affected: 15
Residents affected: 13
Residents affected: 78
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings related to privacy breach, medication labeling, and infection control failures |
| Director of Nursing | Director of Nursing | Confirmed policies and findings related to medication administration and privacy |
| Maintenance Director | Maintenance Director | Interviewed regarding responsibility for furnishings |
| Dietary Employee #1 | Dietary Staff | Observed failing to wash hands properly during food preparation |
| Dietary Employee #2 | Dietary Staff | Observed failing to wash hands properly during food preparation |
| Dietary Employee #3 | Dietary Staff | Observed failing to wash hands properly during food preparation |
| Dietary Employee #4 | Dietary Staff | Observed failing to wash hands properly during food preparation |
| Dietary Employee #5 | Dietary Staff | Observed failing to wash hands properly during food preparation |
| Dietary Employee #6 | Dietary Staff | Observed failing to wash hands properly during food preparation |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 17, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to implement residents' care plans for bathing and failure to provide safe and appropriate respiratory care, including proper administration of updraft treatments and infection control practices.
Complaint Details
The complaint investigation focused on failure to follow care plans for bathing and failure to provide safe respiratory care including proper administration of updraft treatments and infection control, with substantiation based on observations, interviews, and record reviews.
Findings
The facility failed to ensure residents received showers as per their care plans, affecting 2 sampled residents with potential impact on 79 residents. Additionally, the facility failed to properly administer updraft treatments, including lack of assessment before, during, and after treatment, failure to perform hand hygiene, and improper handling of nebulizer equipment, potentially affecting 6 residents with orders for updraft treatments.
Deficiencies (4)
Failure to ensure residents received showers as per their care plans to promote dignity and cleanliness.
Failure to provide safe and appropriate respiratory care by not assessing residents before, during, and after updraft treatments and not following infection control procedures.
Failure to provide pharmaceutical services ensuring safe administration of updraft treatments and maintaining sanitary conditions.
Failure to implement an infection prevention and control program, specifically failure to perform hand hygiene before, during, and after administering updraft treatments.
Report Facts
Residents potentially affected by bathing care plan failure: 79
Residents with orders for updraft treatments potentially affected: 6
Sampled residents for bathing deficiency: 2
Sampled residents for respiratory care deficiency: 14
Pulse oximetry readings: 83
Oxygen liters per minute applied: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in findings related to failure to assess resident lung sounds before and after updraft treatment, failure to perform hand hygiene, and improper handling of nebulizer equipment |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding proper procedures for updraft treatment administration and hand hygiene |
| Assistant Director of Nursing | ADON | Provided policies, lists of residents with updraft orders, and interviewed about expectations for staff compliance with procedures |
| Administrator | Administrator | Interviewed about facility procedures and expectations for care plan compliance and infection control |
| Certified Nursing Assistant #1 | CNA | Interviewed about shower schedules and responsibilities |
| Certified Nursing Assistant #2 | CNA | Interviewed about shower schedules and responsibilities |
| Licensed Practical Nurse #2 | LPN | Checked pulse oximetry on Resident #1 after nebulizer treatment |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 17, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care plan implementation, respiratory care, pharmaceutical services, and infection prevention and control related to resident care.
Findings
The facility failed to ensure residents received showers as per their care plans, failed to properly administer updraft treatments including lack of assessment before and after treatment, and failed to perform proper hand hygiene during treatment administration. These deficiencies had the potential to affect multiple residents and posed risks of harm and infection.
Deficiencies (4)
Failure to ensure residents' showers were implemented according to the plan of care to promote dignity and cleanliness.
Failure to ensure safe and appropriate respiratory care by not assessing residents prior to, during, and after updraft treatments and not following infection control procedures.
Failure to provide pharmaceutical services ensuring proper administration and sanitary conditions during updraft treatments.
Failure to implement an infection prevention and control program, specifically failure to perform hand hygiene before, during, and after administering updraft treatments.
Report Facts
Residents potentially affected by shower care deficiency: 79
Residents potentially affected by updraft treatment deficiencies: 6
Residents sampled for updraft treatment review: 14
Pulse oximetry reading: 83
Pulse oximetry reading: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in findings related to improper administration of updraft treatments and failure to perform hand hygiene. |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding proper procedures for updraft treatments and hand hygiene. |
| Assistant Director of Nursing | ADON | Provided documentation and interviewed regarding care plans, shower schedules, and updraft treatment procedures. |
| Administrator | Administrator | Interviewed regarding facility policies and responsibilities for ensuring care plan compliance. |
Inspection Report
Routine
Census: 73
Deficiencies: 5
Date: Jun 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, assistance with activities of daily living, food preparation, and food safety in a nursing home facility.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments, comprehensive care plans for anticoagulation therapy, adequate assistance with meals including cutting food and one-on-one feeding assistance, proper preparation of pureed food to a smooth consistency, and proper food storage practices including dating and sealing of food items.
Deficiencies (5)
Failed to ensure accurate Minimum Data Set (MDS) assessments for residents receiving Plavix and those with significant changes in condition.
Failed to develop and implement a comprehensive person-centered care plan addressing anticoagulation therapy needs for resident on Eliquis.
Failed to provide adequate assistance with meals, including cutting food and one-on-one feeding assistance as ordered.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize choking risk.
Failed to ensure foods stored in refrigerators, freezer, and dry storage were dated and sealed to prevent foodborne illness.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 71
Total census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding MDS assessment inaccuracies and care plan responsibilities | |
| Director of Nursing (DON) | Interviewed regarding care plan oversight and meal assistance policies | |
| Certified Nursing Assistant (CNA) #5 | Interviewed about meal delivery and food cutting for Resident #56 | |
| Dietary Manager (DM) | Interviewed about meal preparation and food cutting for Resident #56 | |
| Lead CNA | Interviewed about food cutting assistance for Resident #56 | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about food cutting assistance for Resident #56 | |
| Certified Nursing Assistants (CNA) #2 and #3 | Interviewed about feeding assistance for Resident #57 | |
| Registered Dietician (RD) | Observed and provided guidance on pureed food consistency and food storage | |
| Dietary Employee (DE) #1 | Observed preparing pureed beef patties |
Inspection Report
Routine
Census: 73
Deficiencies: 5
Date: Jun 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, meal assistance, food preparation, and food storage at Edgewood Health and Rehab.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments, comprehensive care plans for anticoagulant therapy, proper assistance with meals, preparation of pureed foods to appropriate consistency, and proper food storage and labeling. These deficiencies had the potential to affect multiple residents but were generally categorized as minimal harm or potential for harm.
Deficiencies (5)
Failed to ensure accurate MDS assessments for residents receiving Plavix and those with significant changes in condition.
Failed to develop and implement a comprehensive person-centered care plan addressing anticoagulant medication needs for Resident #36.
Failed to provide appropriate assistance with meals, including cutting food and one-on-one assistance, for Residents #56 and #57.
Failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize choking risk.
Failed to ensure foods stored in refrigerators, freezer, and dry storage were dated and sealed properly to prevent foodborne illness.
Report Facts
Residents affected: 14
Residents affected: 71
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided lists of residents affected and facility policies; interviewed regarding care plan and meal assistance |
| MDS Coordinator | MDS Coordinator | Interviewed regarding MDS assessments, medication coding, and care plan responsibilities |
| Dietary Manager | Dietary Manager | Interviewed regarding meal preparation and food storage practices |
| Registered Dietician | Registered Dietician | Observed food preparation and assessed food consistency and storage |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed regarding meal delivery and food cutting for Resident #56 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding food cutting assistance for Resident #56 |
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