Edgehill Nursing and Rehab Cen

In the surveyor’s words

From the most serious findings on record at Edgehill Nursing and Rehab Cen, in the surveyor’s own words.

• Actual harm, isolatedF658Jan 21, 2021

  Based on review of clinical and hospital records, review of professional standards of practice, review of facility documentation and interviews with staff, it was determined that a registered nurse failed to meet professional standards of practice related to medication administration for one of four residents reviewed (Resident R1). This failure resulted in actual harm to one resident (Resident R1) who did not receive anticoagulant medication as ordered by the physician for eleven consecutive days, was subsequently transferred to the hospital via emergency services and admitted to the hospital with shortness of breath, [CONDITION(S)] (decreased oxygen level in the bloodstream) and worsening pulmonary emboli.(Resident R1). […]

• No harm, potential for more than minimal, widespreadF851Jul 24, 2026

  Based on review of facility documents, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal system for one of one quarter reviewed (Quarter 2). Findings Included:Review of the Payroll-Based Journal staffing data reports revealed that the facility failed to submit data for Quarter 2 (January 1, 2026, thru March 31, 2026).Interview with Administer E1 on July 23, 206 at 02:00 p.m. confirmed no further documented evidence of submission.28Pa Code 201.14(a) Responsibility of licensee

• No harm, potential for more than minimal, widespreadF801Aug 14, 2025

  Based on staff interviews and a review of employee personnel file, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employee E10).Findings include: Interview on August 11, 2025, at 12:24 p.m. with the Nursing Home Administrator, Employee E1, revealed the Registered Dietitian was employed by the facility part-time. Review of Food Service Directors, Employee E10, personnel file revealed the employee held the position of Director of Dining Services with a start date of October 3, 2024. Job responsibilities included oversight of ordering, receiving, storing, preparation and service of food. […]

• No harm, potential for more than minimal, widespreadF812Aug 14, 2025

  Based on review of facility documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include:Review of facility policy Refrigerator and Frozen Food Storage undated, and facility policy Dry Storage, undated, revealed all food items should be labeled, dated, and sealed.A tour of the main kitchen was conducted on August 11, 2025, at 9:27 a.m. with the Assistant Food Service Director, Employee E11, which revealed the following:Observations inside the reach in refrigerator revealed two opened containers of thickened juices that had no open date. Per the specifications on the boxes, the juices should be consumed within seven days of opening. […]

• No harm, potential for more than minimal, patternF880Oct 9, 2024

  Based upon observations, interviews and review of clinical records and facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of Multidrug-resistant organism (MDRO) transmission for one residents with indwelling medical devices (Resident R51) and two residents with wounds (Resident R32 and R39) of 14 residents records reviewed. […]