Edgemoor Hospital

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. The facility did not identify Resident 1's increased fearfulness as a behavior which may indicate potential abuse. As a result, this failure placed Resident 1 and 63 other residents at risk for potential abuse. Cross reference F600, F609, and F610.

Inspectors wroteFindings: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. She said that she felt defenseless because her wheelchair is slow and did not know what to do. [...]

Inspectors wroteBased 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 and ensure that all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation was made when:1. Charge Nurse (CN) 1 and Certified Nursing Assistant (CNA) 2 failed to report the incident between CNA 1 and Resident 1 as an allegation of abuse to the facility's administrator.2. The facility did not thoroughly investigate the allegation of abuse at the time of its report. As a result, this failure caused a delay in reporting the abuse allegation to the state agency (California Department of Public Health, CDPH) for three days. Cross reference F600, F609, and F610.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and label Resident 54's pain medication. As a result, the facility could not ensure medications were safely stored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food brought in from the outside and stored in the designated resident refrigerator was discarded in a timely manner, for two of five resident refrigerators (Santa [NAME] and [NAME]), when reviewed for safe food storage,This failure had the potential for resident's personal food to be unsafe if consumed after the expiration date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent possible cross contamination (where microorganisms are unintentionslly transferred from one object to another) when a urinary catheter (a bag that contained urine which is draining from the bladder via a tube) was in contact with the floor for one of seven residents (Resident 159), reviewed for urinary catheter care. This failure had the potential for Resident 159 to obtain a transmitted urinary infection from the dirty floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) reviewed for feeding assistance and weight loss was supervised during meals. This failure placed Resident 1 at risk for aspiration (inhaling food particles into the lungs), choking, and weight loss.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to identify an injury of unknown origin as possible abuse for one resident (Resident 1), and failed to report the allegation of abuse to the California Department of Public Health. As a result, the facility failed to initiate their abuse policy and procedure related to an injury of unknown origin and placed Resident 1 at risk for further abuse. This failure also placed other residents at risk for abuse and delayed the abuse investigation proces.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the Food and Nutrition Services department when: 1. A food services worker could not correctly operate the dishwashing machine. 2. A food services worker could not properly demonstrate how to calibrate a food thermometer. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. The ice machine had black debris inside the ice making parts of the tray and curtain. 2. Two (2) large onions in the refrigerator had mold on them. 3. Three (3) floor sinks had piping without an air gap of at least 1 (inch) between the pipe and drain. 4. Two (2) green cutting boards with deep cuts and food stains were stored in the clean area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBPs, an infection control intervention using protective gowns and gloves) were implemented for 26 of 29 residents, and, 2. A Licensed Nurse (LN 1) used appropriate Personal Protective Equipment (PPE - gloves, gown, masks and other equipment used to control the spread of infection) when administering tube feeding (a replacement food source, administered through a tube directly into the stomach or intestines) to Resident 88, whose room was posted as requiring EBP. These failures had the potential to result in the spread of Multiple Drug Resistant Organisms (MDROs, microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was in safe operating condition according to standards of practice when: 1. A dishwashing machine had temperatures below the sanitation level. 2. A reach-in refrigerator and a reach-in freezer had condensation. This failure had the potential to place residents at risk of developing foodborne illness.

Inspectors wrote2. Resident 126 was admitted to the facility on [DATE] with diagnoses which included weakness, per a Record of Admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool used to guide resident care) was accurately coded for one of 31 sampled residents (Resident 134) when the resident's diagnosis was not reflected on the initial MDS assessment and three consecutive MDS assessments. This failure had the potential for Resident 134's needs to be unmet.

Inspectors wrote2. 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. Inside Resident 136's room an interview with Resident 136 was conducted on 7/23/24 at 8:36 A.M. Resident 136 stated he sometimes received help when he needed it, and sometimes he did not. Resident 136 stated, he uses the call light to ask for help. Resident 136 stated, he needed assistance to set up meals, get changed, or get on the wheelchair. During a concurrent observation and interview on 7/23/24 at 4:20 P.M. with Resident 136, Resident 136 was seen in his room. Resident 136's call light was placed beyond his reach. Resident 136 stated, They left the call light so far away that I can't call to ask for a drink. Resident 136 stated, he also needed to be cleaned. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an activity program to meet a resident's (31) preferences for one of one residents reviewed for activities. This failure had the potential to not support Resident 31's psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure one of 31 sampled residents, (Resident 18), received the prescribed tube feeding volume according to facility policy. This failure had the potential to result in further functional and physical decline and increase the risk of infections, pressure sore, and death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication was administered as ordered by the physician for one of seven residents (Resident 13) reviewed during medication administration observation. This failure had the potential to result in adverse outcomes for Resident 13, who was diagnosed with iron deficiency anemia (low red blood cell count due to low iron levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were competent on the food cool-down process (bring food temperature down to 41 degrees °F [Fahrenheit] or below) for potentially hazardous foods [PHF] and the use of a cool-down log when preparing egg salad. This failure had the potential to place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed when: 1. Prepared egg salad was not cooled-down to ensure food safety. 2. Spoiled produce items were not removed from the refrigerated storage area. 3. Food items were not labeled and dated. 4. Washed food storage containers were stacked and stored wet. In addition, one of the food storage containers had a crack through it. These failures to mitigate potential food contamination may result in food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure E-Kits (emergency kits) contained Ativan (medication used for epilepsy control and anxiety emergencies) to provide safe and timely administration in the event of an emergency. Multiple E-Kit containers had a label indicating Ativan as part of the contents but were not available in the designated unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained in a safe operating and fully functioning manner when, the salad [NAME] had a chipped lid and the mechanical crank handle was held together with blue tape. This failure had the potential to impact the ability of dietary staff to prepare food in a safe and sanitary manner.