Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgehill Health Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, and repeated falls had incomplete and inaccurate fall monitoring documentation. The record showed multiple unwitnessed falls, but 15-minute check forms did not match the resident’s actual location after one fall and failed to document checks after later falls, with no checks recorded until the next morning after one event. The DNS stated there was confusion about who should complete the monitoring forms and that the resident’s falls on one date were documented in the wrong location.
Failure to Use EBP and Contact Precaution PPE: A resident with chronic wounds was not placed on EBP, and wound care was performed without gowns during a high-contact activity. In a separate case, a resident on contact precautions for C-diff had multiple staff enter the room without the required PPE, including a housekeeper, a program coordinator, and a private duty nurse aide who resumed care without replacing PPE after using the bathroom.
A resident with multiple health conditions became unresponsive during dinner, and CPR was initiated by staff. However, it was discovered that the LPN's CPR certification had expired, and the NA lacked certification. The facility failed to ensure staff had current CPR certifications, and the DNS could not explain the lapse in certification maintenance.
The facility failed to follow its food storage policy, leading to expired and unlabeled food items in the kitchen. Observations revealed that the dry storage room had boxes of cake mix without expiration dates, and the salad fridge contained a half bottle of blueberry sauce without a label or 'use by' date. The chef confirmed that the dietary team is responsible for checking expiration dates and labeling food, as required by facility policy.
Incomplete and inaccurate fall monitoring documentation
Penalty
Summary
The facility failed to ensure that Resident #8’s clinical record contained complete and accurate information related to falls and frequent monitoring. Resident #8 was admitted in June 2025 with Parkinson’s disease, dementia, and repeated falls. The quarterly MDS identified severely impaired cognition, frequent bowel and bladder incontinence, and dependence on staff for bathing, toileting, and transfers. The care plan identified the resident as at risk for falls due to Parkinson’s disease, cognitive deficits, and a history of falls, with interventions including floor mats on both sides of the bed, the bed in the lowest position, monitoring out of bed activity, and visual checks every 15 minutes. The record showed multiple unwitnessed falls and inconsistent monitoring documentation. After an unwitnessed fall on 10/27/25, the A&I report stated the resident was found kneeling on a floor mat in the room with an arm stuck in a bedrail, while the 15-minute check form documented the resident in the dining room at 8:00 AM, 8:15 AM, 8:30 AM, and 8:45 AM. A second unwitnessed fall the same day was documented as the resident sitting on a floor mat leaning against the bed, and an immediate needs care plan directed checks every 15 minutes for 3 days. On 11/20/25, two additional unwitnessed falls were documented at 10:35 PM and 11:10 PM, with immediate care plans directing 15-minute checks for 3 days, but the 15-minute check forms failed to show any checks after either fall and did not document checks until 7:30 AM the next day after the second fall. The DNS stated there was an issue with documentation on the monitoring forms, confusion among staff about who should document, and that the resident’s falls on 10/27/25 occurred in the room rather than the dining room as documented.
Failure to Use EBP and Contact Precaution PPE
Penalty
Summary
The facility failed to ensure a resident with chronic wounds was placed on enhanced barrier precautions (EBP). Resident #7 was admitted with diagnoses including dementia, spinal stenosis, and ataxia, and had severely impaired cognition, dependence for transfers and rolling, and pressure injury risk. The resident had a stage 4 facility-acquired pressure ulcer to the left heel and an unstageable pressure injury to the right foot. The care plan addressed wound treatment and monitoring, but it did not identify that the resident was on EBP, and the physician orders for wound care did not include an order for EBP. Observations showed no signage or PPE outside the resident’s room indicating EBP on 2/8/26 and 2/9/26. During wound care, an LPN and an NA performed dressing removal, wound cleansing, application of ordered treatments, and new dressing application to the resident’s left heel and right foot without wearing gowns. The facility’s Nurse Consultant stated she would have expected the resident to be on EBP and staff to wear a gown and gloves during wound care. The current DNS/Wound Nurse later stated the resident was just placed on EBP and that staff should wear PPE, including a gown and gloves, during chronic wound dressing changes. The facility also failed to use PPE in accordance with contact precaution requirements for a resident with C-diff. Resident #17 had diagnoses including enterocolitis related to C-diff, was severely cognitively impaired, and required assistance with bed mobility, transfers, and toileting. The care plan identified active C-diff infection with sepsis, and a physician’s order directed contact isolation precautions. Observations showed a housekeeper entered the room and swept the floor wearing gloves and a mask but no isolation gown, a program coordinator entered the room without PPE, and a private duty nurse aide assisted the resident with breakfast without PPE after using the bathroom and not replacing PPE. The facility’s IP stated that a disposable isolation gown and gloves were to be put on prior to entering the room for a resident on contact precautions, including for staff without direct contact, and the facility policies directed staff and visitors to wear a gown and gloves before room entry.
Failure to Maintain Current CPR Certifications Among Staff
Penalty
Summary
The facility failed to ensure that staff members had current Cardiopulmonary Resuscitation (CPR) certifications, which led to a deficiency in providing basic life support to a resident. The resident, who had a diagnosis of right hip fracture, anemia, hypertension, cerebral infarction without residual deficits, and chronic kidney disease, was identified as a full code, meaning CPR should be administered if necessary. During a dinner, the resident became unresponsive, and the family present indicated a possible choking incident. Despite the Heimlich maneuver being performed, no food was expelled, and CPR was initiated by staff members. However, it was later found that the LPN's CPR certification had expired six months prior, and the NA did not have any CPR certification. The facility's documentation and interviews revealed that the Staff Development nurse was responsible for ensuring CPR certifications were current, but the Director of Nursing Services (DNS) was unable to confirm if the facility provided CPR education for NAs. The DNS acknowledged that staff providing CPR should have current certifications but could not explain why the certifications for the involved staff were not up to date. The facility also failed to provide a CPR policy for review, further highlighting the deficiency in ensuring staff readiness to provide life-saving measures.
Expired and Unlabeled Food Items Found in Kitchen
Penalty
Summary
The facility failed to adhere to its food storage policy, resulting in expired and unlabeled food items being present in the kitchen. During a tour of the kitchen, it was observed that the dry storage room contained three boxes of Gold Medal Chocolate Cake Mix without expiration dates, with the most recent date being noted but the expiration year indicating a past date. Additionally, a half bottle of blueberry sauce in the salad fridge was found without a label or 'use by' date. Interviews with the chef revealed that the dietary team is responsible for checking expiration dates weekly and disposing of expired items, and that all food should be labeled with an opening date and a 'use by' date as per facility policy. The facility's policy requires that dry food removed from original packaging be labeled with a 'use by' date and that all refrigerated food be covered, labeled, and dated.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stamford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ark Healthcare & Rehabilitation At St. Camillus | 2.1 mi | ★★★★★ | 14 | 0 |
| Civita Care Center At Long Ridge | 2.3 mi | ★★★★★ | 1 | 0 |
| Stamford Care Center | 2.6 mi | ★★★★★ | 18 | 0 |
| Nathaniel Witherell, The | 3.1 mi | ★★★★★ | 3 | 0 |
| Villa At Stamford, The | 5.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.