Edgemoor Hospital
EDGEMOOR HOSPITAL in SANTEE, CA — inspection on February 27, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
scheduled days off, leave, or paid time off will complete the education on the date of their return and prior to providing patient care.
This in-service describes the different types of abuse or neglect, risk factors, signs of abuse, protecting residents during an investigation, reporting requirements, and prevention practices. A thorough investigation of the allegations will continue to be conducted, including resident interviews, staff interviews, other witness interviews, employee personnel file review, resident record review, and other items as deemed necessary or that arise during the course of the investigation.
All results of the investigation will be submitted to CDPH within 5 days.
The ADM/Abuse Coordinator will review the abuse investigation protocols using the Abuse Investigation Checklist on 2/26/26 with the Assistant Administrator, DON, and ADON, and QA nurse, and, upon return from leave, the other ADON and the BHPC, before assuming direct patient care. On 2/27/26 at 3:48 P.M., the IJ was removed, and the ADM, DON, and Quality Assurance Nurse were notified after verifying the IJ removal plan while on-site.
055008 02/27/2026
Edgemoor Hospital 655 Park Center Drive Santee, CA 92071
stated Resident 1 then told her [CNA 2], stay here, stay here, don't leave, and observed the
me if you want something from me? while raising his voice. CNA 2 stated Resident 1 told her that
CNA 1's body language was intimidating and threatening. CNA 2 stated Resident 1 told her she felt fatigued, had refused to get up, and did not socialize after the incident. CNA 2 stated what happened to Resident 1 on 1/6/26 was abuse. CNA 2 stated she thought the nurse supervisors and the CN 1 who responded to the incident on 1/6/26 had appropriately reported the abuse allegation to the ADM.
CNA 2 stated if she had known that the facility was not treating the incident as an abuse allegation, she would have said something about it sooner.On 2/25/26 at 8:06 A.M., an interview with NS 1 was conducted. NS 1 stated she reported the incident that occurred between CNA 1 and Resident 1 to the ADM on speaker phone in the unit's medication room. NS 1 stated NS 4 and CN 1 were also present during the call. NS 1 stated she reported to the ADM what CNA 1 told her had happened. NS 1 stated CNA 1 went to get food for the resident and asked the resident her name. NS 1 stated CNA 1 told her Resident 1 replied to him that she did not have to tell him her name. NS 1 stated she reported to the ADM that CNA 1 did not engage in physical contact or raise his voice at Resident 1. NS 1 stated she did not tell the ADM Resident 1's statement of the incident. NS 1 stated she could not remember what Resident 1 told her. On 2/25/26 at 4:08 P.M., an interview was conducted with Social Worker (SW) 1.
SW 1 stated what Resident 1 experienced with CNA 1 on 1/6/26 caused emotional and psychosocial distress.A review of facility policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, indicated, I. POLICY.All [Facility] employees, contracted workers and volunteers are mandated reporters.It is the Policy of [Facility] to: Assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42CFR 483.12(c), .and other relevant laws, of known or suspected abuse and/or criminal activity directed against [Facility] residents.
Provide assistance to [Facility] staff in carrying out this responsibility.
The facility will facilitate the making of group reports, but will in no way impede an individual from making an individual report in compliance with the law.
Respond to concerns about abuse and investigate them thoroughly with a resident-centered approach that includes assessment.III PROCEDURES.A. ensure that effective measures are put in place to ensure that further potential abuse.does not occur while the investigation is in process.C.
External Reporting.c.
Time Frames Required: ii.
For all abuse.report to law enforcement ([local] Sheriff) by phone immediately.Then fax the SOC341 form to the Ombudsman and to CDPH.This shall be accomplished within 2 hours of the observation or report of the act.reporting withing a 24-hour window may be permitted.D.
Internal Reporting.a.
Evidence of, suspicion of, or witnessed or suspected abuse or criminal activity must be reported to the Administrator.supervisory Nurse.e.ii.
When staff are accused.the employee may be moved to another assignment or department if it is determined that there is risk to residents.
The staff member.generally should not have contact with the resident during the period in which the alleged abuse is being investigated.F.
Documentation a.
The employee who witnesses or hears about the abuse completes the Abuse Report of Suspected Dependent Adult Elder Abuse Form SOC341/SOC-341/SOC 341 with as much information as possible.J.
Prevention and Identification.c.
Identification, Tracking, & Trending: . staff are educated on how to identify .behavior which may indicate potential abuse.(i.e. increased fearfulness.).This policy was not implemented.
055008 02/27/2026
Edgemoor Hospital 655 Park Center Drive Santee, CA 92071
obligations and the names and phone numbers of where to make a report.
055008 02/27/2026
Edgemoor Hospital 655 Park Center Drive Santee, CA 92071
1/6/26.
The ADM stated she did not interview Resident 1.
The ADM stated she spoke to nurse
an internal complaint/grievance over asking the facility to report the incident to CDPH.
The ADM
3:40 P.M., a follow up interview with CNA 2 was conducted. CNA 2 stated she heard Resident 1 screaming her name, which prompted her to run out of a resident's room. CNA 2 stated Resident 1 then told her [CNA 2], stay here, stay here, don't leave, and observed the resident's body was tense and shaking. CNA 2 explained that Resident 1 reported asking CNA 1 for food from the refrigerator.
CNA 2 stated Resident 1 told her that CNA 1 said, Are you gonna say hi to me if you want something from me? while raising his voice. CNA 2 stated Resident 1 told her that when she did not say hi to CNA 1, his demeaner quickly changed. CNA 2 stated Resident 1 told her CNA 1's body language was intimidating and threatening. CNA 2 stated Resident 1 told her she felt fatigued, had refused to get up, and did not socialize after the incident. CNA 2 stated what happened to Resident 1 on 1/6/26 was abuse. CNA 2 stated she thought the nurse supervisors and the CN 1 who responded to the incident on 1/6/26 had appropriately reported the abuse allegation to the ADM. CNA 2 stated if she had known that the facility was not treating the incident as an abuse allegation, she would have said something about it sooner.On 2/25/26 at 8:06 A.M., an interview with Nursing Supervisor (NS) 1 was conducted.
NS 1 stated she reported the incident that occurred between CNA 1 and Resident 1 to the ADM on speaker phone in the unit's medication room. NS 1 stated NS 4 and CN 1 were also present during the call. NS 1 stated she reported to the ADM what CNA 1 told her had happened. NS 1 stated CNA 1 went to get food for the resident and asked the resident her name. NS 1 stated CNA 1 told her Resident 1 replied to him that she did not have to tell him her name. NS 1 stated she reported to the ADM that CNA 1 did not engage in physical contact or raise his voice at Resident 1. NS 1 stated she did not tell the ADM Resident 1's statement of the incident. NS 1 stated she could not remember what Resident 1 told her. A review of facility's staff assignment for 1/6/26 through 1/13/26, indicated CNA 1 provided resident care on 1/7/26 on Unit A and on 1/8/26 on Unit B during the PM shift (3 P.M. to 11:30 P.M.).A review of facility's census for Unit A and B combined on 1/7/26 and 1/8/26 indicated a total census of 63 residents.A review of the State Operations Manual revised 7/23/25, indicated, .In response to allegation of abuse.the facility must.Prevent further potential abuse.during the investigation.thoroughly collect evidence to allow the Administrator determine what actions are necessary .for the protection of residents.A review of facility policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, indicated, I. POLICY.Respond to concerns about abuse and investigate them thoroughly with a resident-centered approach that includes assessment.III PROCEDURES.A. ensure that effective measures are put in place to ensure that further potential abuse.does not occur while the investigation is in process.D.
Internal Reporting.a.
Evidence of, suspicion of, or witnessed or suspected abuse or criminal activity must be reported to the Administrator.supervisory Nurse.e.ii.
When staff are accused.the employee may be moved to another assignment or department if it is determined that there is risk to residents.F.
Documentation a.
The employee who witnesses or hears about the abuse completes the Abuse Report of Suspected Dependent Adult Elder Abuse Form SOC341/SOC-341/SOC 341 with as much information as possible.J.
Prevention and Identification.c.
Identification, Tracking, & Trending: . staff are educated on how to identify .behavior which may indicate potential abuse.