Edgehill Nursing and Rehab Cen

Inspectors wroteBased 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

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process. Finding Included:Review of the facility's facility assessment, dated April 23, 2026, revealed there was no indication that the facility involved direct care staff, input from residents, resident representatives, and/or family members. Interview with Director of Nursing E2, on July 24, 2026, at approximately 11:00 a.m., confirmed there was no direct care staff, resident representatives, and/ or family members included in the facility assessment. 28 Pa. Code 201.18(b)(3) Management.

Inspectors wroteBased 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).

Inspectors wroteBased 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. Further observations inside the reach in refrigerator revealed two black serving trays being used to store milk. [...]

Inspectors wroteBased on review of facility documentation, review of facility policy and interview with resident, it was determined that facility did not ensure to report the results of all investigations within 5 working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency) for one of one resident reviewed. (Resident R38)

Inspectors wroteBased on review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for two of three hospitalizations reviewed (Resident R9 and R5). Findings Include: Review of Resident R9's clinical record revealed a nursing progress note dated April 25, 2025, that indicated the resident was experiencing weight loss and dysphagia (difficulty swallowing) and was subsequently transferred to the local hospital for evaluation. Review of Resident R5's clinical record revealed a nursing progress note dated June 17, 2025, that indicated the resident had abnormal lab results was transferred to the local hospital for evaluation. [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff and resident interviews it was determined that the facility failed to develop and implement a person-centered comprehensive care plan for two of 24 residents reviewed related to activities of daily living and pressure ulcers (Resident R4 and R15).

Inspectors wroteBased on review of clinical records and staff and resident interviews it was determined that the facility failed to ensure care was provided in accordance with physician orders related to ACE wraps and cholecystostomy care for two of 24 residents reviewed (Resident R8 and R61). Findings Include:Review of Resident R8's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated July 3, 2025, revealed the resident was admitted to the facility on [DATE], was deemed cognitively intact, and had a diagnosis of heart failure. Review of Resident R8's comprehensive care plan revised July 17, 2025, revealed the resident was on diuretic (helps the body get rid of excess fluid) therapy for lower extremity edema (fluid retention). [...]

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of four residents observed during medication administration (Residents R2, and R29).

Inspectors wroteBased on observation, review of policies, procedures, and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with the cleaning techniques for medical equipment on two of two residents observed during Medication Administration review (Resident R51 and Resident 29).

Inspectors wroteBased 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.

Inspectors wroteBased on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for 10 of 10 months of antibiotic stewardship program data reviewed. (January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024 and September 2024). Findings Include: A review of CDC (Centers for Disease Control and Prevention) guidelines, The core element of Antibiotic Stewardship for Nursing Homes, revealed that Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. 1. [...]

Inspectors wroteBased on review of personnel files and staff interviews, it was determined that the facility failed to ensure that nurse aides received their at least 12 hours of continued education per year as required for three of four personnel files reviewed. (Employee E10, E12, E13) Findings Include: Review of four nurse aide records revealed the facility did not ensure nurse aides completed their required twelve hours of training for the calendar year of 2023-2024. Nurse aide Employee E10's chart revealed the nurse aide was hired at the facility on November 7, 2022. Review of Employee E10's training records revealed only 10 hours of training was completed from October 10, 2023 to the current date. No other trainings were completed between March 1, 2024 to the current date. [...]

Inspectors wroteBased on observation, review of clinical records and facility policies and interviews with staff, it was determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice and physician orders, to promote healing of pressure ulcers for two of two residents reviewed for pressure ulcer. (Resident R39 and R32) Findings Include: Review of facility policy titled Pressure Injury Management Program Evaluating Risk, Prevention, Support Planning, Treatment, And Monitoring dated October 2021, revealed that Goal-Residents admitted with pressure ulcers receive the care and services necessary to promote healing. Interventions are multi-factorial. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to identify, implement, monitor, and modify interventions consistent with resident needs to maintain acceptable parameters of nutritional status for three of five residents reviewed for nutrition (Resident R2, R12, R39). Findings Include: Review of undated facility policy Weighing of Residents revealed the facility must monitor the resident's weight to detect significant weight loss or gain to ensure that the resident maintains acceptable parameters of nutritional status, taking into account the resident's clinical condition or other appropriate intervention, when there is a nutritional problem. Per the facility policy, residents should be weighed monthly and subsequently should be documented in the medical record. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for one of one resident reviewed (Resident R54). Findings Include: Review of facility policy Central Vascular Access Device (CVAD) Dressing Change revised January 15, 2004, revealed a CVAD includes peripherally inserted central catheter (PICC). The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Assessment of the vascular access site is performed upon admission and during dressing changes, at least once every shift when not in use, and routinely for signs and symptoms of infusion related complications. [...]

Inspectors wroteBased on clinical record review, facility policy and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for two of five residents reviewed for nutritional risk (Resident R12 and Resident R39).

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility failed to ensure required yearly performance reviews for two out of the four nurse aides reviewed. (Employee E10 and E13). nurse aides. Findings Include: Review of facility records revealed nurse aide Employee E10 was hired on November 7, 2022 and did not have a yearly review completed in the year 2023. Review of facility records revealed nurse aide Employee E13 was hired on hire date March 5, 2009 and did not have a yearly review completed in the year 2023 or 2024. Interview held with Employee E9 from Human Resources on October 9, 2024 at 10:35 a.m. confirmed that two out of the four staff did not have yearly reviews. She stated they have been through several Director of Nursing which may be why she cannot find them. 28 Pa. Code: 211.12(d)(1) Nursing services 28 Pa. [...]

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure the identified pharmacy review irregularities were implemented for one of five residents reviewed (Resident R32). Findings Include: Review of Resident R117's Consultant Pharmacist review report dated August 1, 2024, by consultant pharmacist, revealed a recommendation to increase resident's medication order Clindamycin (It can treat various types of infections, including skin and vaginal infections.) dose to increase 300 mg every 6 hours due to resident's . Further review of the consult revealed that the recommendation was approved by the physician. Review of Resident R32's medication administration record (MAR) revealed that the resident was ordered for Clindamycin 300 mg tablet three times daily on July 25, 2024, for 10 days. [...]

Inspectors wroteBased 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 E6).

Inspectors wroteBased on the review of Quality Improvement Program (QAPI) plan, review of facility policy, review of facility documentation, and interview with staff, it was determined that the facility failed to demonstrate and maintain an effective Quality Improvement Program with systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators.

Inspectors wroteBased on review of facility policies and interviews with staff, it was determined that the facility failed to designate one or more individuals as the infection preventionist who work at least part time at the facility with specialized training infection prevention and control as required.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to timely develop and implement a person-centered care plan to meet one resident's current needs for the use of a colostomy for one of three resident records reviewed (Resident R1). Findings including. Review of Resident R1's quarterly MDS (minimum data set, an assessment of resident's needs) dated June 21, 2024, revealed the resident was diagnosed with coronary heart disease, dementia, depression, anxiety and Parkinson's Disease (a progressive brain disorder), was incontinent of urine and used a colostomy for bowel elimination. The same MDS indicated the resident was cognitively impaired and dependent (helper does all of the effort) for toileting bathing, dressing and personal hygiene. [...]

Inspectors wroteBased on observations, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to provide care to maintain grooming and personal hygiene for one of three residents reviewed (Resident R2).

Inspectors wroteBased on review of clinical records and interviews with staff, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice when a changed of condition occurred for one of three resident records reviewed (Resident R1)