The county paid more than $67,000 in state and federal fines earlier this year after a state agency cited the Edgemoor skilled nursing facility for a resident’s startling interaction with a nursing assistant and taking days to report the incident.
A state Department of Public Health probe found that the officials failed to properly investigate and to within 24 hours report to the agency a certified nursing assistant’s “threatening and aggressive posturing” when a quadriplegic patient asked him for help in January. Edgemoor kept the now-former staffer on the job caring for more than five dozen other patients two days after the incident before beginning its own review of the encounter, according to the investigation.
The state investigation also found that other Edgemoor staffers had concerns about the nursing assistant’s attitude and interactions with other employees before the incident.
The county’s alleged failure to protect Edgemoor residents and properly respond to the incident cost taxpayers tens of thousands of dollars.
Though the county disputed some of the agency’s findings, county spokesperson Tim McClain wrote that the 192-bed facility implemented formal corrective action plans approved by the state. They include ensuring staff accused of abuse immediately stop caring for residents until they are cleared of wrongdoing, additional training and revised processes to quickly escalate potential abuse allegations.
Edgemoor agreed to these changes despite formally arguing to the state Department of Public Health that the resident involved in the incident never told staff at the facility that the nursing assistant had “charged at” her, leading them to not initially report the incident to the state. Edgemoor’s administrator wrote in a letter that the resident gave an “embellished, inconsistent statement” to the state investigator that didn’t match what she told Edgemoor staff.
The state agency earlier this month notified Edgemoor that state citations – and thus the state investigation’s conclusions – were upheld after an independent review.
The county ultimately paid $41,895 in civil penalties to the federal Centers for Medicare & Medicaid Services and another $25,200 for two state citations to the state Department of Public Health.
The early 2026 probe and fines came roughly a year and a half after a separate state investigation found that Edgemoor initially failed to properly flag and investigate facial bruising on a patient with Alzheimer’s disease and hearing loss to ensure she hadn’t been abused. State investigators separately documented health and building safety issues in 2024 and 2025 that records show the county has addressed.
The state reviews clash with Edgemoor’s sterling longtime reputation. For several years in a row, Newsweek named Edgemoor one of the top nursing homes in the state.
Cracks in that image have recently emerged for the facility serving San Diegans who need 24-hour care for complex health conditions and have been deemed ill-suited for traditional nursing homes.
Records obtained by Voice of San Diego last month after a records lawsuit showed that Edgemoor and its employees have the past few years grappled with racial tension, sexual harassment and sex tapes.
During a Board of Supervisors meeting earlier this month, two union members who work at Edgemoor urged the county’s top official Ebony Shelton and other county leaders to visit the facility to talk staff about concerns and potential solutions.
Several current and former Edgemoor employees who asked to remain anonymous because they fear retaliation separately told Voice that Edgemoor has been plagued by nepotism, racial friction and inappropriate relationships between staff and managers. They also described rumors of other repeated misconduct, including issues that they said went unaddressed by top-level management.
The county says Edgemoor takes abuse allegations seriously and has a policy barring county staff from supervising people with whom they have personal relationships. The policy calls for employees to disclose those relationships.
County spokesperson Tammy Glenn said county leaders are gathering input and taking steps to address issues at the nursing facility.
“Edgemoor is a safety net for some of the absolutely most vulnerable people in the county. The meaningful work on behalf of staff and residents is being shaped in a deliberate, thoughtful manner and includes high-level listening sessions and discussions with staff and residents,” Glenn wrote. “We are taking immediate action to identify gaps and gather input to drive significant improvements.”
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Last May, the county cheered its Edgemoor facility as a “source of county pride.”
The county noted in a press release that the facility mainly serves low-income residents with significant needs and yet “regularly rates as a five-star facility and has been named one of the top nursing homes in the state and nation for over a decade.”
The facility now has four stars on the Medicare care comparison website, which also features a “consumer alert” icon next to the facility’s name.
In fall 2024, Edgemoor was cited and ordered to pay $1,500 to the state after a Department of Public Health investigator showed up unannounced after receiving a complaint about a bruise on a resident’s face.
State records show an investigator noticed “dark purple discoloration” surrounding the resident’s right eye from the doorway of her room. The state investigator wrote that a certified nursing assistant suggested the resident “had a fall” but no one had witnessed it. The nursing assistant and a nurse told the investigator that it was often difficult to guess when she got injured since she often wore a large hat and her hair in a way that obscured her face. The resident was unable to say how she got the bruise.
The investigator wrote that an unnamed hospital reported the bruise to the Department of Public Health after the resident was sent to its emergency room to have the bruise evaluated almost two weeks before the state agency’s visit.
State and federal regulations require nursing facilities to proactively report injuries that could involve abuse or neglect.
“The facility failed to initiate their abuse policy and procedure related to an injury of unknown origin and placed (the resident) at risk for further abuse,” the state Department of Public Health wrote in its 2024 citation notice. “This failure also placed other residents at risk for abuse and delayed the abuse investigation process.”
A year and a half later, Edgemoor faced far more serious fines after another unannounced visit from an investigator.
According to a California Department of Public Health review, a resident who is quadriplegic told an investigator she asked a certified nursing assistant to retrieve her food from the refrigerator when he snapped at her at about 8:20 p.m. on Jan. 6.
“Are you gonna say hi to me if you want something from me?” the resident recounted the nursing assistant saying.
After the resident said she expressed confusion, the nursing assistant repeated himself. She reportedly replied, unsure if he was joking: “I don’t have to say hi to you if I don’t want to.”
The resident who was in a slow-moving electric wheelchair then reported that the nursing assistant startled her by replying that he wouldn’t help unless she said hi and “charged toward her with his chest out and aggressive arm movements” and in “a manner that it looked like he wanted to physically fight her.”
The resident later told an investigator that “she was worried she could not get away from him fast enough” though he ultimately left the room without getting her food.
Another Edgemoor resident who witnessed the incident confirmed the woman’s account to an investigator who spoke to the two residents together. Edgemoor’s administrator, however, later reported in a formal dispute that the witness separately told facility staff that she “witnessed no acts of aggression.”
After the incident, the resident who clashed with the nursing assistant told investigators that three nursing supervisors approached her to ask if she’d be willing to meet with the nursing assistant to discuss it. The woman said she told the supervisors she was “too scared” to talk to him.
Edgemoor staffers’ notes from the evening of the incident showed the resident “appeared to be in emotional distress.” Another nursing assistant who came to the resident’s aid immediately after the encounter said the woman was “very shaken about it, shaking and visibly in distress.”
The state investigation found that the nursing assistant remained on the job serving 63 patients for the next two days.
Meanwhile, the agency wrote that the resident that the nursing assistant clashed with described plans to report the incident to the police and ombudsman and later reportedly spent days in bed due to fear and concerns about more interactions with the nursing assistant.
Though a nursing supervisor said she reported the interaction to an administrator, the state probe found that two staffers failed to report the incident as “an allegation of abuse” and that the supervisor did not thoroughly investigate it.
Edgemoor apparently took three days to start its own investigation and report the abuse to the state Department of Public Health. A nursing supervisor said the facility ultimately reported the abuse allegation on Jan. 9, a day after the resident told a staffer she feared the nursing assistant.
In her rebuttal to the state agency, Edgemoor Administrator Erin Chancler wrote that the initial report met Edgemoor’s standard for a grievance report rather than abuse. She wrote that the facility immediately began its own review but escalated the report to the state within 24 hours of hearing the resident involved feared the nursing assistant.
She also wrote that Edgemoor removed the nursing assistant from the woman’s unit immediately after the incident – and that he recounted the incident differently.
In a statement included in Chancler’s formal dispute that she noted wasn’t included in the state review, the unnamed former nursing assistant recalled the woman he didn’t know asking if he could get her food for her and replying to ask her name.
“She replied ‘I don’t have to answer to you and get my food, rápido,’ the nursing assistant said using a Spanish term for hurrying up, according to the county rebuttal. “I said, ‘I will find your (nursing assistant)’ to make sure that it was done for her. I did this all at the nursing station, not even close to the resident, as I knew she was one that don’t like males caring for her.”
Chancler wrote that the nursing assistant “denied being aggressive, raising his voice or coming close.”
A handful of other staffers at Edgemoor told the state investigator they had already experienced problems with the nursing assistant, whose phone was disconnected when a state investigator tried to reach him in February. The investigator also obtained a list of three documented performance incidents involving the nursing assistant in November and December 2025 that did not involve residents.
Two staff development directors at Edgemoor told the investigator that the nursing assistant often failed to follow directions and started to show red flags during his October 2025 orientation. He reportedly “had a bad attitude” when he was late on his first day. He also reportedly took food from residents’ finished trays and stole other staffers’ food.
“The (directors) stated they could ‘totally’ imagine (the nursing assistant) acting aggressively toward (the resident)” and described the patient who clashed with him as “not the type of resident who would report abuse allegations indiscriminately,” according to the state investigation.
They also reported sharing details on the nursing assistant’s “misconduct and behavior” with at least one nursing supervisor within 10 days of noticing the behavior during his October 2025 orientation.
But in a separate interview, an assistant director of nursing told the state investigator that the nursing assistant’s behavior was not documented in an employee file because he was a probationary employee. He acknowledged that leadership at the facility discussed issues with the employee in an email thread but wouldn’t elaborate on any potential discipline against him.
State records provided by the county show that the county fired the nursing assistant on Jan. 13, a week after his interaction with the resident.
In its formal response plan later approved by the state, Edgemoor pledged to continue using a form it started using in March to track early performance issues involving new employees and to ensure that staff are evaluated after orientation. The facility also promised to either remove staffers with early performance issues from caring for residents so they can be further trained and assessed, or pair them with another staffer, among other changes.
The county then paid a $25,200 bill for a state citation for patient care violations and another for failing to report the alleged abuse within 24 hours, plus $41,895 in federal penalties.