Inspection Report Summary
The most recent inspection on May 1, 2025, found the facility in substantial compliance with no deficiencies. Earlier inspections are not listed in the available reports, so no broader pattern of compliance or issues can be determined. No complaint investigations or enforcement actions were noted in the available information. There were no fines, immediate jeopardy findings, or license actions reported. This suggests the facility met regulatory requirements at the time of the latest survey.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 0
Date: May 1, 2025
Visit Reason
A Standard Recertification Survey and Abbreviated Survey was conducted to assess compliance with 42 CFR subpart B.
Findings
The facility was found to be in substantial compliance with no deficiencies issued related to the provider numbers listed.
Report Facts
Sample Size: 18
Supplemental Residents: 1
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 1, 2025
Visit Reason
The document is an annual inspection report for Edmonson Nursing and Rehabilitation Center conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 12, 2020
Visit Reason
The inspection was conducted due to a complaint alleging abuse of Resident #54 by a staff member, specifically that a State Registered Nurse Aide (SRNA) put her hand over the resident's mouth and nose and used profane language.
Complaint Details
The complaint involved an allegation by SRNA #2 that SRNA #1 put her hand over Resident #54's mouth and nose and used profane language on 01/12/2020. The allegation was not reported immediately to supervisory staff as required, and the facility failed to report the incident to State Agencies within the required two-hour timeframe. The alleged perpetrator continued to work for two days after the incident before suspension.
Findings
The facility failed to implement its abuse policies, including timely reporting and thorough investigation of the alleged abuse incident involving Resident #54 on 01/12/2020. The alleged perpetrator continued to provide care for two days after the incident before suspension. The facility later implemented corrective actions including staff re-education, resident and staff interviews, audits, and policy reinforcement.
Deficiencies (3)
Failure to ensure abuse policies were implemented, including timely reporting and investigation of abuse allegations.
Failure to timely report alleged abuse to State Agencies within two hours.
Failure to initiate a thorough investigation of alleged abuse within 24 hours.
Report Facts
Number of residents sampled: 18
Resident BIMS score: 5
Staff re-education count: 74
Total staff count: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA #1 | State Registered Nurse Aide | Alleged perpetrator who put hand over resident's mouth and nose and used profane language |
| SRNA #2 | State Registered Nurse Aide | Witness to alleged abuse, delayed reporting |
| LPN #1 | Licensed Practical Nurse | Assigned nurse who was notified of the allegation |
| ADON | Assistant Director of Nursing | Conducted initial interviews, failed to identify abuse allegation timely |
| CED | Center Executive Director | Facility administrator involved in investigation and reporting |
| SRNA #3 | State Registered Nurse Aide | Informed by SRNA #2 and relayed information to SRNA #4 |
| SRNA #4 | State Registered Nurse Aide | Reported allegation to LPN #1 |
| LPN #2 | Licensed Practical Nurse | Completed head to toe assessment of Resident #54 |
| SSD | Social Service Director | Interviewed Resident #54 and conducted resident interviews |
| CRC | Clinical Reimbursement Coordinator | Updated resident care plan and provided staff education |
| NPE | Nurse Practice Educator | Provided staff education and audits |
| Interim DON | Interim Director of Nursing | Conducted interviews and acknowledged failures in investigation and reporting |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 22, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, treatment, infection control, medication management, and care planning at Edmonson Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide timely assistance to residents, inadequate call light accessibility, incomplete and untimely care planning, improper wound care and hand hygiene practices, failure to label medications properly, and inadequate infection prevention and control practices. Several residents were affected by these deficiencies, with minimal harm or potential for actual harm noted.
Deficiencies (8)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, demonstrated by Resident #28 sitting in a puddle of urine for 15 minutes after requesting assistance.
Failure to reasonably accommodate the needs and preferences of Resident #4 by not ensuring the call light was within reach at all times.
Failure to develop and implement a complete care plan for Resident #28 that meets all needs with measurable goals and timetables, specifically related to bladder continence.
Failure to review and revise care plans by the interdisciplinary team after assessments for Residents #1, #48, #51, and #54, including lack of updates after falls.
Failure to provide appropriate treatment and care according to orders and professional standards for Residents #3 and #15, including improper hand hygiene and wound care practices by RN #1.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #3, including contamination of wounds and failure to follow wound care policies.
Failure to ensure drugs and biologicals stored in medication carts were labeled with opening dates and appropriate instructions, including undated eye drops, inhalers, and Normal Saline bottles.
Failure to provide and implement an infection prevention and control program, including multiple breaches in hand hygiene, glove changes, wound care, and trash handling for Residents #3, #15, and #58.
Report Facts
Residents sampled: 25
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in findings related to failure to follow hand hygiene and wound care policies for Residents #3 and #15 |
| RN #2 | Registered Nurse | Named in findings related to failure to follow hand hygiene and wound care policies for Resident #58 |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding expectations for care planning, hand hygiene, wound care, and medication labeling |
| Administrator | Administrator | Provided interview regarding resident wait times for assistance and call light expectations |
| MDS Coordinator | MDS Coordinator | Mentioned in relation to care plan updates but unable to provide information |
| Infection Control Nurse | Infection Control Nurse | Provided interview regarding staff education and infection control expectations |
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