Eden Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF627Apr 13, 2026

  Based on record review, and staff, Friend #1, Friend #2, Family Member, Home Health Nurse, Adult Protective Services Social Worker, hospital Social Worker, Nurse Practitioner, and Primary Care Physician interviews, the facility failed to ensure a safe and orderly discharge for a resident that had severe cognitive impairment, incontinent of bowel and bladder, required assistance with all activities of daily living, and was not capable of managing her medications prescribed for diabetes, hypertension, hypothyroidism, pain and depression. Resident #1 was discharged to her apartment where she lived alone with friends (Friend #1 and Friend #2) who indicated they were unable to provide the 24-hour level of care the resident required. […]

• No harm, potential for more than minimal, patternF812Feb 19, 2026

  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… […]

• No harm, potential for more than minimal, patternF761Jul 27, 2023

  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. […]

• No harm, potential for more than minimal, patternF842Jan 13, 2022

  Based on observations, staff interviews and record review, the facility failed to maintain accurate documentation in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: On 01/13/22 at 8:30 AM Nurse #1 was observed administering medications to Resident #61. Nurse #1 was logged into the electronic health record (EHR), and in the resident's MAR, under Nurse #2's name. Review of Nurse #2's time clock information, provided by human resources (HR), revealed Nurse #2 had clocked out of her shift on 01/13/22 at 7:43 AM. An interview was conducted with Nurse #1 on 01/13/22 at 8:30 AM. The nurse stated she did not have a login due to a 30-day inactivity lockout rule for EHR access. […]

• No harm, potential for more than minimal, isolatedF745Apr 13, 2026

  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. […]