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37/100EDGEWOOD HEALTH & REHABILITATION Inspection Report, Violations & Safety Grade (Byram, Mississippi)
205 Byram Parkway, Byram, Mississippi 39272
Phone: 6013625394
CMS Overall:1/5
Overview & Bed Count
Certified Beds
119
Avg Residents/Day
110.1
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Hinds
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Icon
Yes
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Mississippi Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.35 | 0.63 | -0.28 |
| Total Nurse Hours per Resident per Day | 5.04 | 4.20 | +0.85 |
| CMS Staffing Rating | 3/5 | 3.8/5 | - |
| Nursing Staff Turnover | 73.0% | 44.4% | - |
Health Citation History
49 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-23 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-07-23 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2026-07-23 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | D – Moderate Harm Potential |
| 2026-07-23 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2026-07-23 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-07-23 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-03-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J – Immediate Jeopardy |
| 2026-03-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | J – Immediate Jeopardy |
| 2026-03-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | J – Immediate Jeopardy |
| 2026-03-02 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | J – Immediate Jeopardy |
| 2026-01-13 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-01-13 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-10-29 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | G – Actual Harm |
| 2025-10-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-10-29 | Nursing and Physician Services Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-06-19 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-06-19 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2025-06-19 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-03-20 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-03-20 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-03-20 | Quality of Life and Care Deficiencies | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D – Moderate Harm Potential |
| 2025-03-20 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D – Moderate Harm Potential |
| 2024-11-26 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2024-08-01 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-08-01 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | E – Moderate Harm Potential |
| 2024-08-01 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2024-08-01 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-08-01 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | D – Moderate Harm Potential |
| 2024-08-01 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | G – Actual Harm |
| 2024-08-01 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | G – Actual Harm |
| 2024-08-01 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2024-08-01 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | G – Actual Harm |
| 2024-06-24 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | J – Immediate Jeopardy |
| 2024-06-24 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-06-24 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-06-24 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-04-23 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-04-03 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | G – Actual Harm |
| 2024-02-06 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | D – Moderate Harm Potential |
| 2023-07-27 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | G – Actual Harm |
| 2023-07-27 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2023-07-27 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E – Moderate Harm Potential |
| 2023-07-27 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2023-07-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2023-07-27 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2023-07-27 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2023-07-27 | Quality of Life and Care Deficiencies | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | D – Moderate Harm Potential |
| 2023-07-27 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2023-07-27 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
0 fire safety citations on record
No fire safety citations on record.
Total Penalties & Fines
$136,131
Total Fine Amount (CMS)
8
Number of Fines
9
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-03-02 | Fine | $22,858 | - |
| 2025-10-29 | Fine | $6,435 | - |
| 2025-10-29 | Fine | $6,500 | - |
| 2025-06-19 | Fine | $12,428 | - |
| 2024-08-01 | Fine | $7,278 | - |
| 2024-08-01 | Fine | $7,279 | - |
| 2024-06-24 | Fine | $10,036 | - |
| 2024-04-03 | Fine | $63,317 | - |
| 2024-04-03 | Payment Denial | - | 21 days starting 2024-05-01 |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Byram area at no cost.
Find Safe, Vetted Facilities Near Byram
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.