Eden Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Aug 8, 2024

  Based on review of facility policy, clinical records, facility investigation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision, assistance, and proper equipment to prevent injuries during a transfer for one of four residents reviewed (Resident R47). This failure resulted in Resident R47 having pain, bruising, and was transferred to the hospital and diagnosed with a fractured rib, which were sustained during an improper transfer. The facility failed to maintain resident Kardexes (a snapshot of resident care needs) and care plans to reflect accurate mobility transfer statuses. This failure created an Immediate Jeopardy situation for nine of 17 residents reviewed (Residents R47, R7, R21, R29, R33, R37, R51, R68, and R75). […]

• Actual harm, isolatedF686Jul 24, 2026

  Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of a pressure ulcer. This resulted in actual harm of the development of a facility-acquired Stage 3 (full thickness skin loss that extends into the subcutaneous fat) pressure ulcer for one of three residents (Resident R1).Findings include: Review of facility policy Prevention of Pressure Injuries dated 6/18/26, indicated the purpose of this procedure is to provide an overview of current standards of practice for pressure injury prevention. […]

• Actual harm, isolatedF656May 28, 2025

  Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan to meet resident care needs for two of four residents (Resident R1 and R2), which resulted in harm, when a resident was rolled out of bed without the correct level of assistance and sustained bilateral leg fractures (Resident R1). Findings Include: Review of Residents R1's admission record indicated the resident was admitted on [DATE], and readmitted [DATE], with diagnoses of anemia (a condition in which the number of red blood cells is lower than normal), renal failure (occurs when the kidneys are no longer able to filter waste products from blood effectively), and osteoarthritis (a degenerative joint disease that occurs when the cartilage that… […]

• Actual harm, isolatedF684May 28, 2025

  Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to provide appropriate care and treatment for one of four residents (Residents R1), which resulted in harm, and Resident R1 required a blood transfusion. Findings include: Review of the facility policy Falls-Clinical Protocol dated 3/4/25, last reviewed 5/19/25, indicated the staff, with the physician guidance, will follow up on any fall with associated injury until the resident is stable. […]

• Actual harm, isolatedF689May 28, 2025

  Based on review of facility policies, clinical records, and staff interviews it was determined that the facility failed to ensure the appropriate assistance for bed mobility was provided for one of four residents (Residents R1), which resulted in harm when Resident R1 rolled out of bed and sustained bilateral leg fractures. Findings include: Review of the facility policy Repositioning dated 3/4/25, reviewed 5/19/25, stated the purpose of the procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, and to promote comfort for all bed or chair bound residents. […]