Inspection Reports for EdenHill Communities

The inspection was conducted due to a complaint investigation regarding failure to immediately notify the resident's physician and responsible party about a worsened wound on Resident #1.

The facility failed to notify Resident #1's physician and responsible party of a worsened wound to the sacrum, which could delay decision making and negatively impact quality of care. Interviews and record reviews confirmed the wound deterioration and lack of proper notification.

The complaint investigation found that the facility did not notify Resident #1's physician or responsible party about a worsened wound, despite policy requiring notification. The failure was confirmed through interviews with nursing staff, the Director of Nursing, the resident's responsible party, and the Nurse Practitioner.

The inspection was conducted due to a complaint investigation regarding a mechanical lift transfer incident involving Resident #1, which resulted in a displaced fracture of the resident's right humeral neck.

The facility failed to ensure that Resident #1 was transferred using a mechanical lift by two staff as required, resulting in an immediate jeopardy situation due to injury from improper transfer. The facility corrected the noncompliance before the survey began and implemented staff training and audits to prevent recurrence.

The complaint investigation revealed that on 01/19/2025, CNA A transferred Resident #1 alone using a gait belt instead of a mechanical lift with two staff, resulting in a displaced fracture of the resident's right humeral neck. CNA A was suspended pending investigation and later resigned. The facility provided remedial training and implemented corrective actions including audits, staff training on abuse and neglect, and transfer procedures.

The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, abuse reporting, accurate assessments, PASARR coordination, and comprehensive care planning at Eden Home nursing facility.

The facility failed to ensure residents' rights regarding DNR orders, timely reporting of suspected abuse, accurate resident assessments, coordination with PASARR for mental health diagnoses, and development of comprehensive care plans reflecting residents' psychiatric needs. These deficiencies affected multiple residents and could result in inappropriate care or harm.

The inspection was conducted due to a complaint regarding the facility's failure to coordinate assessments with the pre-admission screening and resident review (PASARR) program for residents diagnosed with mental illnesses.

The facility failed to refer two residents diagnosed with Major Depressive Disorder and Post Traumatic Stress Disorder to the designated PASARR authority, potentially resulting in residents not receiving needed care and services for identified psychiatric problems.

The complaint investigation found that the facility did not refer Resident #48 and Resident #73 to the PASARR program after diagnoses of Major Depressive Disorder and Post Traumatic Stress Disorder were identified. Interviews with staff confirmed the importance of PASARR referrals which were not completed.

The inspection was conducted to assess compliance with the requirement that each resident's assessment is updated at least once every 3 months, specifically reviewing quarterly MDS assessments.

The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for Resident #1 with an Assessment Reference Date (ARD) of 10/10/2024, which was still in progress at the time of the survey. This delay could lead to residents not receiving necessary, complete, or correct care due to lack of current information for care plans.

The inspection was conducted following a complaint investigation triggered by a choking and subsequent death of Resident #16 due to failure to provide the correct mechanical soft diet as recommended by the Speech Language Pathologist (SLP).

The facility failed to follow the SLP's recommendations to provide ground meat for Resident #16's mechanical soft diet and instead served a ham sandwich with thinly sliced ham, which led to choking, CPR, hospitalization, and death. The facility was found to be in immediate jeopardy but removed the IJ after corrective actions were implemented, including removal of thinly sliced meats from mechanical soft diet options and staff in-service training.

The complaint investigation was substantiated. Resident #16 choked on a ham sandwich served contrary to the mechanical soft diet order, leading to respiratory arrest and death. Immediate Jeopardy was identified on 06/23/2024 and removed on 06/27/2024 after corrective actions.

The inspection was conducted to assess compliance with regulations regarding the proper storage and administration of medications in the facility.

The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls and that only authorized personnel had access to the keys. Specifically, Resident #2's medications were found unsecured, posing a risk of medication misuse and diversion.

The inspection was conducted to assess compliance with regulatory requirements related to care planning, resident safety, and food service in the nursing home.

The facility failed to ensure comprehensive care plans were accurately revised for residents, maintain safe water temperatures in resident bathrooms, and properly cover food items during meal service, posing risks of inadequate care, potential burns, and foodborne illness.

The inspection was conducted to assess compliance with regulatory requirements related to care planning, resident safety, and food service safety at Eden Home nursing facility.

The facility failed to ensure comprehensive care plans were accurately revised for residents, maintain safe water temperatures in resident bathrooms, and properly cover food items during meal service, posing risks of inadequate care, potential burns, and foodborne illness.

The inspection was conducted to assess the facility's infection prevention and control program, specifically related to COVID-19 quarantine and isolation procedures.

The facility failed to maintain an effective infection prevention and control program by allowing a staff member (LVN B) to remove PPE gowns from a quarantine area and hand them to another staff member outside, risking cross contamination. Interviews and observations confirmed this breach of protocol and highlighted misunderstandings about quarantine and isolation procedures.

The inspection was conducted to assess compliance with advance directive requirements, specifically reviewing the accuracy and validity of Do Not Resuscitate (DNR) orders for residents.

The facility failed to comply with 42 CFR part 489, subpart I (Advance Directives) for 1 of 56 residents reviewed, as Resident #2's out of hospital DNR form lacked a physician's signature, rendering it invalid and potentially placing the resident at risk of not receiving basic life support in an emergency.

The inspection was conducted to assess the facility's compliance with professional standards for food service safety, specifically focusing on kitchen sanitation.

The facility failed to ensure that items stored in the refrigerator, freezer, and dry storage were properly labeled and dated, which placed residents at risk of food borne illnesses or contamination.