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Deficiency Records for Edgemoor Hospital
View the most recent health deficiencies and inspection results for Edgemoor Hospital. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Edgemoor Hospital. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2026-02-27 | 2026-03-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2026-02-27 | 2026-03-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-02-27 | 2026-03-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2026-02-27 | 2026-03-23 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Ensure gas and vacuum piping is labeled. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-12-04 | 2026-01-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2025-12-04 | 2026-01-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-12-04 | 2026-01-09 | N |
| 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. | Health | 2025-12-04 | 2026-01-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-12-04 | 2026-01-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-02-05 | 2025-03-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-06 | 2024-10-18 | Y |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Use approved construction type or materials. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2024-07-25 | 2024-09-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-25 | 2024-08-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-07-25 | 2024-08-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-07-25 | 2024-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide activities to meet all resident's needs. | Health | 2024-07-25 | 2024-08-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-25 | 2024-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-25 | 2024-08-25 | N |
| Keep all essential equipment working safely. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-22 | 2021-12-02 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-22 | 2021-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-22 | 2021-12-02 | N |
| Keep all essential equipment working safely. | Health | 2021-10-22 | 2021-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-10-22 | 2021-11-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-22 | 2021-11-15 | N |