Eden Valley Care Center

In the surveyor’s words

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

• Actual harm, isolatedF678Jan 16, 2024

  Based on interview and record review, the facility failed to initiate cardiopulmonary resuscitation (CPR, a lifesaving technique consisting of chest compressions and often combined with artificial ventilation used in emergencies to treat persons with ineffective heart pumping/beating and compromised breathing to improve blood perfusion throughout the circulatory system to vital organs, especially to the brain) for one of 2 sampled Residents (Resident 1) when Resident 1 was found unresponsive. […]

• Actual harm, isolatedF622Sep 26, 2023

  Based on interview and record review, the facility failed to safely discharge one of three residents (Resident 1) when Resident 1 was discharged , due to non-payment, while the facility's business office actively sought a payor source for Resident 1's stay in the facility and when the resident's Medi-Cal (California's health care program which covers most medically necessary care) eligibility was pending. Resident 1 cried because she did not want to be discharged and was being discharged to a shelter against her wishes. Resident 1 was hysterical, crying with anxiety, and having a mental breakdown when Resident 1 was taken in the facility van to Shelter A on 4/11/23. […]

• Actual harm, isolatedF742Sep 26, 2023

  Based on interview and record review, the facility failed to provide appropriate mental and psychosocial (involves the interaction between a person's thoughts and behaviors with a social environment) treatment and care for one of three residents (Resident 1), who had a history of trauma and/or post-traumatic stress disorder (PTSD, a mental health condition that's triggered by a terrifying event, either experiencing it or witnessing it), from childhood trauma, from being sexually assaulted, and from the loss of her son, when: 1. There was no assessment of Resident 1's PTSD and PTSD triggers; 2. Resident 1 did not have a PTSD related care plan to outline the resident's problem, goals, monitoring, plan for care, treatment, and evaluation; 3. […]

• Actual harm, isolatedF692Jul 12, 2023

  Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) monitored the residents' weights, identified the residents who had unplanned weight loss, assessed and discussed the cause of unplanned weight loss, updated the care plan with a measurable goal and interventions, and provided necessary and timely interventions to maintain acceptable weights of the residents, for three of three sampled residents (Residents 1, 2, and 3). 1. For Resident 1, in 12/2022, the resident had a 7.6 pounds (lbs) weight loss (4.9% in 30 days) and the IDT recommended weekly weights to monitor. […]

• No harm, potential for more than minimal, patternF658Oct 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for 10 of 12 sampled residents when: 1. For Resident 9 and 21 pacemakers were not monitored; 2. For Resident 230, her oxygen inhalation order was not followed; 3. For Resident 14, the nursing staff did not carry out the physician's order for labs; 4. For Residents 14, 15, 26, 128, 12, 22, 25 and also 230, staff did not document the systolic blood pressure (amount of pressure in the arteries during the contraction of the heart muscle) between lying and/or standing/siting positions when completing the Fall Risk Evaluation. […]