| Edgewood Health & Rehabilitation | |
| 205 Byram Parkway, Byram, Mississippi 39272 | |
| (601) 362-5394 | |
| Name | Edgewood Health & Rehabilitation |
|---|---|
| Location | 205 Byram Parkway, Byram, Mississippi |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 119 |
| Occupancy Rate | 91.26% |
| Medicare ID (CCN) | 255103 |
| Legal Business Name | Hinds County Nursing &rehabilitation Center, LLC |
| Ownership Type | For Profit - Corporation |
| NPI Number | 1598749210 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Hinds County Nursing &rehabilitation Center LLC |
| Address | 3454 Albermarle Road, Jackson, MS 39213 |
| Phone Number | 601-362-5394 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 5.36 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.4 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.29 | 0.86 |
| Nurse aide hours per resident per day | 3.67 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 4.33 | 3.42 |
| RN hours per resident per day on the weekend | 0.15 | 0.48 |
| Physical therapist hours per resident per day | 0.05 | 0.07 |
| Total nursing staff turnover | 59.8% | 45.8% |
| Registered nurse turnover | 71.4% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | Yes |
| Number of Fines | 8 |
| Total Amount of Fines in Dollars | $148,438 |
| Number of Payment Denials | 1 |
| Total Number of Penalties | 9 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Mar 2, 2026 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Immediate jeopardy, isolated | Corrected by Mar 25, 2026 |
| Mar 2, 2026 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Immediate jeopardy, isolated | Corrected by Mar 25, 2026 |
| Mar 2, 2026 | Respond appropriately to all alleged violations. F0610, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Immediate jeopardy, isolated | Corrected by Mar 25, 2026 |
| Mar 2, 2026 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. F0835, Administration, Complaint inspection | Immediate jeopardy, isolated | Corrected by Mar 25, 2026 |
| Jan 13, 2026 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Feb 10, 2026 |
| Jan 13, 2026 | 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. F0761, Pharmacy Service, Complaint inspection | Potential for harm, isolated | Corrected by Feb 10, 2026 |
| Oct 29, 2025 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Complaint inspection | Actual harm, isolated | Corrected by Nov 26, 2025 |
| Oct 29, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Actual harm, isolated | Corrected by Nov 26, 2025 |
| Oct 29, 2025 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. F0726, Nursing and Physician Services, Complaint inspection | Potential for harm, isolated | Corrected by Nov 26, 2025 |
| Jun 19, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Immediate jeopardy, isolated | Past non-compliance (already corrected) |
| Jun 19, 2025 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657, Resident Assessment and Care Planning, Complaint inspection | Potential for harm, isolated | Corrected by Jul 22, 2025 |
| Jun 19, 2025 | Ensure services provided by the nursing facility meet professional standards of quality. F0658, Resident Assessment and Care Planning, Complaint inspection | Potential for harm, isolated | Corrected by Jul 22, 2025 |
| Mar 20, 2025 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Apr 15, 2025 |
| Mar 20, 2025 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Complaint inspection | Potential for harm, isolated | Corrected by Apr 15, 2025 |
| Mar 20, 2025 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. F0676, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Apr 15, 2025 |
| Mar 20, 2025 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. F0804, Nutrition and Dietary, Complaint inspection | Potential for harm, isolated | Corrected by Apr 15, 2025 |
| Nov 26, 2024 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. F0623, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Dec 19, 2024 |
| Aug 1, 2024 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Complaint inspection | Actual harm, isolated | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Complaint inspection | Actual harm, isolated | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Actual harm, isolated | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Provide safe, appropriate pain management for a resident who requires such services. F0697, Quality of Life and Care, Complaint inspection | Actual harm, isolated | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. F0604, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, pattern | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. F0561, Resident Rights, Standard inspection, Complaint inspection | Potential for harm, isolated | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Aug 28, 2024 |
| Aug 1, 2024 | Have a plan that describes the process for conducting QAPI and QAA activities. F0865, Administration, Standard inspection | Potential for harm, isolated | Corrected by Aug 28, 2024 |
| Jun 24, 2024 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656, Resident Assessment and Care Planning, Complaint inspection | Immediate jeopardy, isolated | Corrected by Jul 17, 2024 |
| Jun 24, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Immediate jeopardy, isolated | Corrected by Jul 17, 2024 |
| Jun 24, 2024 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580, Resident Rights, Complaint inspection | Potential for harm, isolated | Corrected by Jul 17, 2024 |
| Jun 24, 2024 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Jul 17, 2024 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.96 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 8.22 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.83 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 0.75 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 1.2 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.72 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.36 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.74 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.84 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.1 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.42 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.32 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.22 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 4.51 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.17 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 27.33 | 15.38 |
Willow Creek Retirement Center Location: 49 Willow Creek Lane, Byram, Mississippi 39272 Phone: (601) 863-4201 |