Edgehill Health Center

In the surveyor’s words

From the most serious findings on record at Edgehill Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 6, 2022

  Based on observations, review of facility documentation and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary manner. The findings include: 1. Tour of the dry food storage area on 1/4/22 at 10:00AM identified live cockroaches observed on the ground in the dry food storage rooms. Further observation identified the floor had notable food debris and a large quantity of a red sticky substance noted on the floor in the corner in the dry food storage room. Also noted was a black box on the floor which was identified by the FSD as a roach trap. Interview with the FSD on 1/4/22 at 11:25AM identified the floors are swept every day and thoroughly cleaned every Sunday evening by the dishwasher. […]

• No harm, potential for more than minimal, patternF812May 29, 2024

  Based on observations during the tour of the kitchen, review of facility policy and staff interview, the facility failed to ensure expired food was discarded from the dry storage area and failed to date and label food items per facility policy. The findings included: Tour of the kitchen on [DATE] at 10:40 AM during the initial walk through with the Chef #1 identified the following: 1. The dry storage room had the following food item with no expiration dates: 3 boxes of Gold Medal Chocolate Cake Mix. The Cake mix was most recently dated [DATE], however, the expiration year indicated [DATE]. Interview with Chef #1 on [DATE] at 11:00 AM identified he and the dietary team are responsible for checking food items for expiration date weekly and disposing of expired items as needed. 2. […]

• No harm, potential for more than minimal, isolatedF842Feb 10, 2026

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #8) reviewed for falls, the facility failed to ensure that the resident's clinical record reflected complete and accurate information related to falls and frequent monitoring. The findings include:Resident #8 was admitted to the facility in June 2025 with diagnoses that included Parkinson's disease, dementia, and repeated falls. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition, was frequently incontinent of bowel and bladder and was dependent on staff for bathing, toileting, and transfers. The care plan dated 9/3/25 identified Resident #8 was at risk for falls due to Parkinson's disease, cognitive deficits, and history of falls. […]

• No harm, potential for more than minimal, isolatedF880Feb 10, 2026

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #7) reviewed for pressure ulcers, the facility failed to ensure a resident with a chronic wound was placed on enhanced barrier precautions (EBP), and for 1 resident (Resident #17) reviewed for transmission-based precautions, the facility failed to utilize Personal Protective Equipment (PPE) in accordance with policy and infection control standards of practice for a resident requiring contact precautions. The findings include: Resident #7 was admitted to the facility in May 2025 with diagnoses that included dementia, spinal stenosis, and ataxia. A physician's order dated 5/14/25 directed to admit Resident #7 to hospice level of care. […]

• No harm, potential for more than minimal, isolatedF678Mar 11, 2025

  Based on record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for change in condition, the facility failed to ensure staff had current Cardiopulmonary Resuscitation (CPR) certifications. The findings include: Resident #1 had a diagnosis of right hip fracture, anemia, hypertension (high blood pressure), cerebral infarction without residual deficits and chronic kidney disease. Nursing admission note dated [DATE] at 3:21 PM identified Resident #1 was alert and oriented, and was oriented to surroundings. The Resident Care Plan dated [DATE] identified Resident #1 had difficulty chewing or swallowing related to cerebral vascular accident. […]