Eden Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 14, 2021

  Based on observation, interview, and record review, the facility failed to adequately supervise and prevent one (Resident 1) of eight sampled residents, from wandering outside the facility grounds near/onto a freeway overpass. The failure to supervise, resulted in Resident 1 eloping from the facility, which placed Resident 1 at risk for injury, serious harm from a potential fall, possible death by wandering into traffic, not receiving needed prescribed medications, and not having shelter, food or water. As a result, Resident 1 incurred a four-day hospitalization on the critical care unit after being found by the local authorities after 36 hours. An Immediate Jeopardy (IJ) situation was called on 2/5/21 at 3:00 p.m. […]

• Immediate jeopardy, isolatedF689Feb 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure one (Resident 2) of three sampled residents was provided one-to-one supervision as ordered for aggressive behaviors. The failure to provide Resident 2 with continual one-to-one supervision resulted in Resident 2 being unsupervised for six minutes and had the potential to result in serious injury to other residents. The Chief Nursing Officer (CNO), the Administrator (Admin), the Administrator In Training (AIT), the Quality Assurance Consultant (QAC), and the Minimum Data Set Consultant (MDSC), were notified of the Immediate Jeopardy (IJ, a situation in which a provider's noncompliance with one or more requirements of participation have caused or is likely to cause serious injury, harm, impairment, or death to… […]

• Immediate jeopardy, isolatedF600Jul 8, 2021

  Based on observation, interview and record review, for one of six (Resident 43) sampled residents who were reviewed for allegations of abuse, the facility failed to ensure Resident 43 was free from physical abuse when Hospitality Aide (HA) 5 punched Resident 43 in the face during an altercation. This failure resulted in Resident 43 sustaining a laceration (a tear, cut or opening in the skin caused by an injury) under the nose and above upper lip that had profuse bleeding and required hospitalization for suturing. Resident 43 returned from the hospital with two sutures below the nose and above the upper lip, and mild swelling on the area. […]

• Actual harm, isolatedF600Feb 6, 2024

  Based on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents from abuse when the facility roomed Resident 2, a resident with known angry outbursts and a potential for assaultive behaviors, with Resident 1, a bedridden, vulnerable resident. This failure resulted in Resident 2 physically assaulting Resident 1 within hours of being moved into a shared room with Resident 1. As a result of Resident 2's assault, Resident 1 required admission to the hospital for closure of a scalp laceration (cut) with staples (metallic staples to hold wound edges together until the wound is healed), a fractured (broken) cheek bone, and a concussion. (A brain injury that occurs when the head hits an object, or a moving object strikes the head. […]

• Actual harm, isolatedF689May 26, 2023

  Based on observation, interview, and record review, for one (Resident 1) of three sampled residents at risk of falls, the facility failed to implement an intervention to provide adequate supervision for Resident 1 when walking. The facility failed to implement the Interdisciplinary team (IDT, a group of healthcare professionals from various healthcare disciplines who collaborate to share expertise, knowledge, and skills to influence and improve patient care) intervention of, monitor whereabouts, recommended after Resident 1 fell on [DATE], by not ensuring there was a designated staff member to supervise Resident 1 when the assigned staff were all on a work break. […]