Edgemoor Hospital

In the surveyor’s words

From the most serious findings on record at Edgemoor Hospital, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 27, 2026

  Based on interview and record review, the facility failed to ensure Resident 1 (who resided on Unit C) was protected from mental abuse and intimidation and 63 other residents on two units (Unit A and Unit B) were protected from potential abuse when: 1. Certified nursing assistant (CNA) 1 responded to Resident 1's request for assistance with a raised voice, angry demeanor, and threatening and aggressive posturing on 1/6/26.2. Charge Nurse (CN) 1 and CNA 2 failed to report the incident between CNA 1 and Resident 1 as an allegation of abuse to the facility's administrator.4. The facility did not investigate and report the allegation of abuse to the state agency (California Department of Public Health, CDPH) for three days.5. […]

• No harm, potential for more than minimal, patternF607Feb 27, 2026

  Based on interview and record review, the facility failed to implement its written abuse policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, in accordance with required procedures when:1. The facility did not identify, report, or investigate an allegation of abuse in a timely manner.2. The facility did not thoroughly investigate the allegation at the time of its report. 3. The facility did not assess the risk to other residents when CNA 1 was assigned to provide resident care for two days after an abuse allegation was made.4. […]

• No harm, potential for more than minimal, patternF610Feb 27, 2026

  Findings:On 1/9/26, the state agency (California Department of Public Health, CDPH) received a faxed SOC 341 (standardized abuse reporting form) from the facility dated 1/9/26. The SOC 341 indicated the facility was reporting an incident of psychological/mental abuse and verbal aggression that allegedly occurred between CNA 1 and Resident 1 on 1/8/26 7:00 PM. The SOC 341 further indicated, .On 10/6/26 [sic] resident reported to the charge nurse that [CNA 1] was aggressive to her because she did not say Hi to him when she asked him to get something from the fridge. […]

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based on observation, interview, and record review, the kitchen failed to ensure safe food handling practices during tray line, of pureed diets (when food has been ground, and strained to a soft, smooth consistency, like a pudding), served to 16 of 157 residents. This failure had the potential for residents on pureed diets to experience foodborne illnesses. Findings: An observation of lunch puree diet preparation was conducted with [NAME] 1 (CK 1) on 12/3/25 at 8:30 A.M. CK 1 stated they had 16 residents receiving puree diets, but they prepare 18 servings for request of extra-large potions. […]

• No harm, potential for more than minimal, patternF558Jul 25, 2024

  Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one of 32 residents (Resident 136) reviewed for call light accessibility. As a result, Resident 136 was not able to reach the call light to call for assistance in order for staff to address the resident's needs in a timely manner. Findings: Resident 136 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body), per a Record of Admission. During an interview with Resident 136 conducted on 7/23/24 at 8:36 A.M. inside the resident's room, Resident 136 stated he sometimes received help when he needed it, and sometimes he did not. […]