Inspection Report
Complaint Investigation
Deficiencies: 22
Jul 15, 2025
Visit Reason
State-compiled facility profile showing 23 inspections from August 1, 2021 through July 31, 2025 with deficiency history and enforcement actions.
Findings
Across 23 inspections, Eden Heights had 29 violations with multiple complaint surveys and other surveys showing deficiencies primarily related to resident services, medication management, records and reports, admission standards, and environmental standards. Several inspections resulted in no violations.
Complaint Details
Multiple complaint surveys are included, with violations noted in several complaint investigations throughout the date range.
Deficiencies (22)
| Description |
|---|
| 1001.10 (i) (5-8) — Resident services: Failure to provide ongoing information and referral, coordination with service providers, formal mechanism for identifying changes in resident condition, and maintaining accurate personal records. |
| 487.7 (d) (8) — Resident services: Failure to properly notify next of kin, local authorities, and submit required reports upon resident death. |
| 485.11 (b) — Records and reports: Failure to supply and provide access to required information and records as determined by the department. |
| 487.7 (f) (5) — Resident services: Failure to establish a system for proper medication dosage administration and observation. |
| 485.5 (f) — Operating certificates: Unauthorized changes or modifications to facility or services without prior written approval. |
| 487.4 (a) — Admission standards: Admitting or retaining individuals requiring services beyond those permitted by law and regulation. |
| 487.7 (d) (12-13) — Resident services: Failure to maintain incident reports and include resident's version of events. |
| 487.9 (a) (3) — Personnel: Failure to conduct initial orientation and in-service training for employees and volunteers. |
| 487.11 (k) (1-3) — Environmental standards: Failure to maintain facility, building, grounds, equipment, and furnishings in clean, orderly, and good repair condition. |
| 1001.7 (g)(1-3) — Admission and retention standards: Failure to conduct pre-admission evaluation of prospective residents. |
| 1001.7 (h) (1) — Admission and retention standards: Failure to obtain medical evaluation including history, medication regimen, and assistance needs. |
| 1001.7 (k) (5) — Admission and retention standards: Failure to review and revise Individualized Service Plan every six months or as ordered. |
| 1001.10 (l)(1) — Medication management: Failure to perform medication acquisition, storage, disposal, and assistance with self-administration per standards. |
| 1001.10 (l) (4-7) — Medication management: Failure to review PRN medication orders, observe or consult licensed staff, and limit use of PRN medications for persons with dementia. |
| 487.4 (c) (5) — Admission standards: Accepting or retaining persons who repeatedly behave in a manner impairing well-being or safety of residents or facility operation. |
| 487.7 (d) (1) (x) — Resident services: Failure to investigate incidents involving resident endangerment, injury, reportable incidents, or death. |
| 1001.10 (i) (1) — Resident services: Failure to identify and evaluate resident needs, interests, strengths, and facility capability prior to admission and annually. |
| 1001.10 (i) (2) — Resident services: Failure to oversee and coordinate a written Individualized Service Plan for each resident. |
| 487.10 (e) (1) (i) — Records and reports: Failure to file Annual Financial Statement timely and with required information. |
| 486.5 (a) (4) (v) — Civil penalties: Failure of systemic practices and procedures evidenced by pattern of violations or inability to bring specific area into compliance. |
| 1001.10 (j) (1) — Resident services: Failure to provide necessary personal care to maintain hygiene, activities of daily living, health, and participation in residence activities. |
| 1001.11 (b) — Personnel: Failure to ensure sufficient staff in number and qualifications to conduct required functions. |
Report Facts
Inspections on page: 23
Total violations: 29
No-violation inspections: 8
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