Center at Eden Hill, LLC

In the surveyor’s words

From the most serious findings on record at Center at Eden Hill, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF868Aug 13, 2021

  Based on interview and review of facility documentation, it was determined that the facility failed to ensure that the quality assessment and assurance committee (QAA) met at least quarterly and included all of the required members. Findings include: Review of the facility's undated QAPI (quality assurance and performance improvement) framework indicated the facility Will conduct quality assurance meetings on a monthly basis. Review of the facilities QAPI meeting sign in sheets revealed the facility conducted quarterly QAPI meetings on the following dates: 7/23/20, 10/20/20, and 4/16/21. […]

• No harm, potential for more than minimal, patternF880May 22, 2026

  Based on observation, interview, and record review, it was determined that for one (R63) out of six residents reviewed for infection control, the facility failed to use appropriate infection control practices. For R63 when cleaning/disinfecting reusable resident medical equipment. Findings include: Review of the facility's policy and procedure titled, C. diff Infection Precautions, last updated 4/15/26, documented, . equipment should be cleaned and disinfected according to facility policy using an appropriate disinfectant for C. diff .1. 4/17/26 - R63 was admitted to the facility.5/16/26 6:42 PM - A physician ordered to collect blood and stool to rule out Clostridioides difficile (C. […]

• No harm, potential for more than minimal, patternF550May 20, 2025

  Based on observation and interview, it was determined that for three (R16, R38, and R234) out of twenty-four (24) residents in the investigative sample, the facility failed to ensure residents were treated with respect and dignity. Findings include: 1. Review of R16's clinical record revealed: 4/24/25 - R16 was admitted to the facility. 5/12/25 10:42 AM - During an observation, E14 (PTA) knocked on R16's room door and entered the room without waiting for R16's response/permission to enter the room. 5/12/25 10:43 AM - During an interview, E14 (PTA) confirmed that the expectation is to knock and wait for a response to enter a resident's room. E14 confirmed that she did not wait for a response before entering R16's room. […]

• No harm, potential for more than minimal, patternF580Nov 19, 2021

  Based on clinical record review and interviews, it was determined that for one (R1) out of three residents reviewed for nutrition, the facility failed to notify F1 (R1's POA) when there were significant changes in R1's medical condition (clinical complications) and when there was a need to alter treatment significantly. Findings include: Cross refer to F657 and F692 R1's clinical record and admission paperwork revealed: 8/26/21 - R1 was admitted to the facility status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 8/26/21 - F1 (R1's POA) signed R1's admission paperwork as her Power of Attorney. F1 also signed the facility's form entitled HIPAA Communication Form. […]

• No harm, potential for more than minimal, patternF692Nov 19, 2021

  Based on clinical record review and interviews, it was determined that for one (R1) out of three residents reviewed for nutrition, the facility failed to have an effective system in place to ensure there was coordination of care among three physicians/one nurse practitioner, nursing and dietary with respect to managing R1's active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Cross refer F580, F657 and F770 R1's clinical record revealed: 8/26/21 - R1 was admitted to the facility after a hospitalization for pneumonia, bilateral pleural effusions and fluid overload requiring diuretic therapy. […]