Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
84 residents
Based on a November 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
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
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
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 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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