Eden Rehabilitation and Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident with severe cognitive impairment, no established legal decision maker for financial or healthcare decisions, and no payor source when Medicare skilled benefit days were exhausted was assisted with pursuit of a legal decision maker (guardianship) and the completion of a Medicaid application for 1 of 3 residents reviewed for discharge planning (Resident #1).The findings included:Resident #1 was admitted on [DATE] with diagnoses that included anxiety, depression, communication deficit and dementia.Review of the clinical record did not specify a responsible party, guardian, or power of attorney for Resident #1. The admission Minimum Data Assessment (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired.Resident #1's care plan initiated on 3/20/26 did not include interventions addressing lack of a legal decision maker or assistance with completion of a Medicaid application.The discharge Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to label and date food and discard expired food from two nourishment refrigerators reviewed for food storage (400 hallway and 500 hallway nourishment refrigerators). These practices had the potential to affect food served to residents.Findings included:a. On 2/16/26, at 1:35 PM, an observation with the Dietary Manager of nourishment refrigerator #1 (400 hallway) revealed that the refrigerator contained a gallon-size clear plastic bag with a sandwich, a 4-ounce juice carton, and a snack bag with no name or date on them; a peanut butter and jelly sandwich in a plastic bag with no name or date; a takeout box containing pinto beans and seasoned rice with the date [DATE]th - 15th written on it; food wrapped in aluminum foil with no name or date; an opened 16-ounce soda bottle with no name or date; and a takeout 20-ounce coffee cup with no name or date. b. On 2/16/26, at 1:42 PM, an observation with the Dietary Manager of nourishment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, manufacturer instructions review, and staff interviews, the facility failed to date opened multi-dose pen injectors of insulin and failed to remove expired multi-dose pen injectors of insulin from 1 of 5 medication administration carts ( 500-hall).Findings Included: On 2/16/26 at 1:25 PM, an observation of the 500-hall medication cart with Nurse #1 revealed 2 open and undated multi-dose vials of Lantus insulin pens injectors. Review of the manufacturer's instructions indicated to discard Lantus insulin multi-dose vial 28 days after opening. In the second drawer of the 500-hall medication cart, there were: one opened Lispro insulin multi-dose pen injector, marked as expired on 2/10/26, one opened Aspart Flex insulin pen injector, marked as expired on 1/15/26, and one opened Glargine insulin multi-dose pen injector, marked as expired on 2/9/26.On 2/16/26 at 1:30 PM, during an interview, Nurse #1 indicated the nurses who worked on the medication carts were responsible for discarding open and undated multi-dose vials. She mentioned that per training/competency,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Legal Guardian, and staff interviews, the facility failed to communicate with the Resident's Legal Guardian regarding resident's abdominal pain and the resident's refusal to go to the hospital. This occurred for 1 of 3 sampled residents reviewed for the surrogate to exercise the resident's rights (Resident #1). Findings included: Resident #1 was admitted on [DATE] with diagnoses that included hypertensive heart disease with heart failure, diabetes mellitus type (2), dementia, and hypomagnesemia (a condition characterized by abnormally low levels of magnesium in the blood. Symptoms may include muscle cramps, weakness, and irregular heart rhythms). Review of Resident #1's facility face sheet dated 1/18/22 revealed a social worker from local Department of Social Services (DSS) was appointed as his Legal Guardian and included contact information. Resident #1's face sheet indicated the Legal Guardian was the Power of Attorney (POA) for the resident. During an interview on 6/10/25 at 10:28…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review the facility failed to secure the indwelling urinary catheter to reduce tension for 1 of 2 residents (Resident #200) reviewed for urinary catheter. Findings included: Resident #200 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder, and calculus of ureter. The physician order dated 11/08/24 was to use an indwelling catheter with closed drainage system due to neuromuscular dysfunction of bladder. The physician order dated 11/08/24 included to use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. The order included to rotate site of securement as needed and check the securement every shift. Documentation on his care plan noted 11/9/24 for the resident had Indwelling urinary catheter related to neurogenic bladder. The approaches included to position catheter bag and tubing below the level of the bladder and away from entrance room door and to place secure tape on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to (1a) remove expired medication from hall 3 medication cart, (1b) discard loose pills from hall 1,2, and 4 medication carts, and (1c) failed to date an open vial of lidocaine (local anesthetic) found in hall 4's medication cart for 4 of 5 medication carts reviewed for medication storage. The findings included: 1a. Observation of Hall 3 medication cart occurred on 11-15-24 at 10:31am with Nurse #3. The following item was found: -Bisacodyl (laxative) 5 milligrams (mg) bottle expired in [DATE]. During an interview with Nurse #3 on 11-15-24 at 10:33am, Nurse #3 stated she was unaware the medication had expired. She explained the night shift nurses were responsible for checking the medication carts for expired medication. b. Observation of the medication cart for halls 1 and 2 occurred on 11-15-24 at 10:48am with Nurse #4. The following item was found: - one small pink round pill was loose in the top drawer of the medication cart. Nurse #4 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, resident and staff interviews, the facility failed to provide adaptive eating utensils to a resident who required light weight utensils with a rubber grip. This occurred for 1 of 1 resident (Resident #28) reviewed for accommodation of needs. The findings included: Resident #28 was admitted to the facility on [DATE] with multiple diagnoses that included multiple sclerosis and muscle weakness. Physician order dated 4-9-24 revealed Resident #28 was to receive a divided plate, a special cup (a cup with 2 handles and a lid), and built-up utensils. Resident #28's care plan with a revision date on 7-21-24 revealed the resident had nutritional problems or the potential for nutritional problems related to multiple sclerosis. The goal for Resident #28 involved her maintaining adequate nutritional status. The interventions included Resident #28 having a lightweight fork with a rubber grip handle. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) when a nurse aide provided catheter care for Resident #200 and did not wear a gown for 1 of 1 staff members observed for infection control practices. Findings included: The facility policy for Enhanced Barrier Precautions dated 2024 read in part that they required the use of gown and gloves for high-contact resident care activities in the resident's room when doing device care or use of urinary catheter. The physician order dated 11/08/24 to use indwelling catheter with closed drainage system due to neuromuscular dysfunction of bladder. Another order included for enhanced barrier precautions related to indwelling catheter every shift and to provide catheter cleansing and perineal hygiene every shift and as needed if soiled. An observation for the urinary catheter care was done on 11/13/24 at 3:48 PM. NA #1 washed her hands in the bathroom and collected her water in a basin with soap and towels for the catheter care. She wore her gloves during the entire…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interviews the facility failed to monitor temperatures for 1 of 2 medication refrigerators (300/500 Hall medication refrigerator). The findings included: Review of the medication storage policy labeled Medication Storage in the Facility and last updated 5/1/22 read in part The facility should maintain a temperature log in the storage area to record temperatures at least once a day. An observation was conducted of the 300/500 Hall medication refrigerator on 07/25/23 at 03:25 PM. Review of the temperature log for the month of July revealed the temperatures had not been recorded for 7/3/23, 7/8/23, 7/9/23, 7/18/23, 7/21/23, 7/22/23, 7/23/23, 7/24/23. An attempt to conduct an interview on 7/26/23 with the night shift nurse was unsuccessful. An interview was conducted with the Director of Nursing on 07/27/23 at 11:20 AM. The DON stated the refrigerator temperature checks were assigned to the night shift nurse. An interview was conducted with the Administrator on 07/27/23 at 11:27 AM. The Administrator stated she expected that medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.