Eden Healthcare Center

Inspectors wroteBased on observation and interview, the facility failed to ensure resident's personal and medical information was communicated in a way that protects personal privacy and confidentiality for four out of four sampled residents (Resident 1, 2, 3, 4) when Resident 1's medical information, Resident 2's personal information, Resident 3 and Resident 4's first and last name were communicated via a group messaging system involving nursing staff's personal smart phone (a mobile phone that performs many of the functions of a computer, typically having a touchscreen and internet access). This failure resulted in violation of residents' right to a secure and confidential personal and medical information. During a phone interview on 5/28/26 at 10:31 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care item was cleaned and disinfected (objects treated with chemicals to kill germs, bacteria, and viruses, reducing the risk of infection) according to manufacturer's instructions for one of one sampled resident (Resident 1) when Resident 1's urine collection canister was not fully submerged in a dish soapy solution for cleaning and in 70% isopropyl alcohol (IPA) for disinfection for a minimum of ten minutes. This failure had the potential for Resident 1 to be exposed to infections. [...]

Inspectors wroteBased on interview and record, the facility failed to ensure two out of six sampled Residents (Resident 2 and 4), were free from abuse, when Residents 2 and 4 had a physical altercation. Resident 2 had multiple skin tears with bleeding and Resident 4's right index finger was bitten. This failure resulted in pain and injuries on residents. During a review of facility's admission Record (AR) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included dementia with other behavioral disturbance. Resident 2's Minimum Data Set (MDS - resident assessment tool) dated 05/28/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 05, (BIMS score of 0 - 7, suggest severe cognitive impairment). [...]

Inspectors wroteBased on interview and record review, the facility failed to identify that a licensed nurse (Assisted Director of Nursing, ADON) increased a dose of medication without a physicians ' order. This failure resulted to Resident 1 ' s Seroquel ' s (Quetiapine -medication used to treat illness that affects thoughts and behavior) dose was increased to 50 milligram (mg) tablets given two times a day from 12/2024 through 4/2025 without indication.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), Resident 1 ' s rights were not protected when Seroquel (Quetiapine -medication used to treat illness that affects thoughts and behavior) dosage was increased without physician ' s orders, indication, and no informed consent. Resident 1 ' s Seroquel ' s dose was increased to 50 milligram (mg) tablets given two times a day. This failure resulted in Resident 1 ' s right being violated due to unnecessary increase of medication dose.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff practiced safe patient handling for one of three sampled residents (Resident 1) when Resident 1 was left on a hoyer lift (a mechanical device used to lift and transfer residents from one place to another) unsupervised for 30 minutes and had only one staff member assist Resident 1 during a hoyer lift transfer. This failure resulted in Resident 1's discomfort during a hoyer lift transfer and had the potential for falls which could lead to injury or death.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food served to residents had an appetizing taste and failed to ensure pureed bread was prepared in accordance with the facility's recipe and in a manner to conserve nutritive value. These findings had the potential to affect all 116 residents receiving meals from the dietary department, including 18 residents with orders for pureed diets.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure foods brought in by visitors were stored in a sanitary manner. Specifically, the facility failed to ensure 1 of 1 refrigerator used on the units for residents' food items was clean. Additionally, the facility failed to ensure resident food items brought to the facility by visitors were labeled with a date prior to storage in the resident refrigerator. These failures had the potential to affect all 116 residents who resided in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure safe and sanitary disposal of refuse. Specifically, the facility failed to ensure the dumpster was closed to prevent the attraction of vermin. This had the potential to affect all 116 of 116 residents who resided in the facility at the time of the survey.

Inspectors wroteBased on interview, facility document review, and facility policy review, the facility failed to consistently complete infection surveillance checklists as indicated in the facility's antibiotic stewardship program for residents identified with infections that received prescribed antibiotic therapy. This deficient practice had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to: 1) complete a smoking assessment for Resident #79, 2) provide supervision for Resident #91, a resident who was assessed to require supervision while smoking, and 3) ensure a safety intervention for smoking was implemented for Resident #10. These failures affected 3 (Residents #10, #79, #91) of 5 sampled residents reviewed for smoking. The facility further failed to ensure staff did not leave medications at the bedside for 2 (Resident #58 and Resident #82) of 24 sampled residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure medications were labeled and stored properly in medication carts located on 2 (South 2 Unit and North 1 Unit) of 4 units in the facility. Specifically, the South 2 Unit medication cart contained loose pills, and a topical medication and nebulizer solution were not stored separately from medications to be given by mouth, in accordance with the facility's policy. The North 1 Unit medication cart contained a bottle of guaifenesin oral solution (cough medicine) with an illegible expiration date.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the physician was notified when blood sugar levels were 350 milligrams per deciliter (mg/dL) or higher in accordance with the facility's Hypoglycemia [low blood sugar levels]/Hyperglycemia [high blood sugar levels] Management policy for 1 (Resident #11) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to ensure each resident had a safe and homelike environment by ensuring rooms were free of damage for 2 (Resident #112 and Resident #82) of 24 sampled residents.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected whether 1 (Resident #12) of 3 sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) requirements was considered by the state Level II process to have a serious mental illness, intellectual disability, or a related condition.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 3 residents reviewed for preadmission screening and resident review (PASARR) requirements was referred to the state-designated authority for a Level II PASARR evaluation following a positive Level I PASARR screening.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medication orders specified the intended dosages for 1 (Resident #32) of 4 residents whose physician's orders were reconciled during the medication administration task. Additionally, the facility failed to ensure nursing staff contacted the physician to obtain order clarifications for Resident #32's incomplete orders.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure 1 (Resident #39) of 4 residents reviewed for advance directives had a physician's order that was consistent with the resident's Physician Orders for Life Sustaining Treatment (POLST) form, which indicated the resident elected do not resuscitate (DNR)/no cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record for 1 (Resident #22) of 24 sampled residents. Specifically, the facility failed to document accurate skin assessment information for Resident #22.

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 (Resident #22) of 2 residents reviewed for pressure injury/ulcer.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the responsible party/conservator for 1 (Resident #113) of 5 residents reviewed for vaccinations were educated and provided the opportunity to consent for a pneumococcal vaccination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain medication for one of three sampled residents (Resident 1) when Fosamax (a medication used to prevent and treat osteoporosis [thinning of the bone]) was not available for administration to Resident 1. The failure to obtain and administer ordered medication had the potential to result in ineffective treatment and pain.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and clean environment for two of six sampled residents (Resident 1 and Resident 6) when: 1. Resident 4 went into Resident 1's room and urinated on the curtain next to Resident 1's bed; and 2. Resident 4 went into Resident 6's room and urinated on the floor. These failures resulted in Resident 1 and Resident 6 experiencing emotional distress, feeling mad, and being upset.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents from abuse when the facility roomed Resident 2, a resident with known angry outbursts and a potential for assaultive behaviors, with Resident 1, a bedridden, vulnerable resident. This failure resulted in Resident 2 physically assaulting Resident 1 within hours of being moved into a shared room with Resident 1. As a result of Resident 2's assault, Resident 1 required admission to the hospital for closure of a scalp laceration (cut) with staples (metallic staples to hold wound edges together until the wound is healed), a fractured (broken) cheek bone, and a concussion. (A brain injury that occurs when the head hits an object, or a moving object strikes the head. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to promote the right of privacy for one (Resident 3) of three sampled Residents, when the facility allowed Resident 3 to remain without clothing from the waist down in the rehabilitation room (rehab room). This failure resulted in Resident 3 being exposed to other residents and staff members and made Resident 3 feel helpless, exposed, and disrespected.

Inspectors wroteBased on record review and interview, the facility delayed reporting one of two abuse incidents to the California Department of Public Health for over 11 hours. This failure prevented oversight of the facility and delayed investigation of an assault of Resident 1 by Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 2) of three sampled residents was provided one-to-one supervision as ordered for aggressive behaviors. The failure to provide Resident 2 with continual one-to-one supervision resulted in Resident 2 being unsupervised for six minutes and had the potential to result in serious injury to other residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the potential need for one-to-one supervision of residents with mental or physical conditions requiring close supervision to prevent injury to themselves or others, and consequently failed to establish training and competency guidelines for staff members who provided one-to-one supervision of residents. This failure resulted in use of an untrained, non-nursing staff member (Hospitality Aide 1) to provide one-to-one supervision of a resident (Resident 2) at risk of harming others. Hospitality Aide 1 left Resident 2 unsupervised for six minutes, which had the potential to result in harm to the other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain a full-time qualified social worker (SW) for the 121 bed facility when the facility ' s full time SW went out on maternity leave without a replacement SW, and had no estimated return date for the current SW. This placed residents of the facility at risk for their psychosocial needs to go unnoticed and unmet.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an effective Pest Control Program when there were numerous fruit flies in the Rehabilitation Room (Rehab room). This failure created a nuisance for residents receiving rehabilitation services in the rehabilitation room, and had the potential to result in transfer of diseases such as salmonella, e.coli, and listeria (bacteria known to cause food-borne illness).

Inspectors wroteBased on observation, interview, and record review, for one of two sietters, the facility failed to develop and implement a training program for a one-to-one sitter (1:1, one sitter assigned to only one resident) prior to the sitter being assigned supervision of Resident 2, an abusive resident known for angry outbursts and assault. The failure to adequately train the sitter had the potential to result in inadequate supervision and placed residents of the facility at risk for injury and assault See also F 689.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete documentation of medical records for one of two residents (Resident 1) involving: 1. nebulizer treatment on medication administration record (MAR) on 8/12/23 at 10:00 p.m. 2. bathing records for seven out of nine days in September 2023. This failure resulted in Resident 1 having incomplete and inaccurate medical records which potentially may affect Resident 1's care and well-being.

Inspectors wroteBased on observation, interview and record review, for one of six (Resident 43) sampled residents who were reviewed for allegations of abuse, the facility failed to ensure Resident 43 was free from physical abuse when Hospitality Aide (HA) 5 punched Resident 43 in the face during an altercation. This failure resulted in Resident 43 sustaining a laceration (a tear, cut or opening in the skin caused by an injury) under the nose and above upper lip that had profuse bleeding and required hospitalization for suturing. Resident 43 returned from the hospital with two sutures below the nose and above the upper lip, and mild swelling on the area. HA 5's physically assault towards Resident 43 had the potential to cause Resident 43 to lose balance and fall on the concrete floor that could likely cause serious head injury and possibly death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the individual needs of one of 27 sampled residents (Residents 87) when Resident 87 was slumped in his bed and needed assistance and did not have his call light within reach. This failure resulted in Resident 87 being in an uncomfortable position with no access to his call light.

Inspectors wroteBased on interview and record review the facility failed to provide one of 23 (Resident 32) sampled residents the use of his electric wheelchair once the COVID 19 restrictions of movement about the facility were lifted. The facility's failure resulted in Resident 32's restriction to his room and prohibited his mobility on the unit causing psychological and emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one of one medication storage rooms had no expired medications accessible for use. This failure had the potential to result in administration of ineffective medications. 2. Ensure two of two treatment carts were locked/supervised when not in use. This failure had the potential to result in loss or misuse of antibiotic creams (creams used to treat skin infections) in the cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when several food items in the Resident's refrigerator and freezer were not labeled, not dated and had no use by date. These failures had the potential to cause food contamination or food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented policies and procedures designed to prevent and control spread of infection for three of 27 sampled residents (Resident 65, 86, and 32) when: 1. Certified nursing assistant 9 (CNA 9) failed to perform hand hygiene between care provision of two residents (Resident 65 and 86). 2. Resident 32 had an unlabeled urinal at his bedside. Findings- During an observation and interview, on 6/28/21, at 12:07 p.m., in Resident 65 and 86's shared room, Resident 65 and Resident 86 were in their respective beds. CNA 9 wore gloves, and held both of Resident 65's hands while she examined them. CNA 9 stated Resident 65's fingernails were long and had dirt beneath them. CNA 9 then removed Resident 65's socks and held and examined both feet. CNA 9 stated Resident 65's toenails were long. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 11 of 12 sampled employees (Hospitality Aid 1, Hospitality Aid 2, Hospitality Aid 3, Hospitality Aid 5, Dietary Aid 1, Dietary Aid 2, Medical Record, Certified Nurse Assistant 5, Certified Nurse Assistant 12, Certified Nurse Assistant 13, Certified Nurse Assistant 14) completed annual training for recognition of activities that constitute abuse and resident abuse prevention. This failure had the potential to place residents at risk for harm when staff were not trained in the prevention of resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services for activities of daily living for one (Resident 17) of 27 sampled residents when: Resident 17 did not receive requested toileting assistance for 40 minutes. The failure to provide toileting resulted in Resident feeling uncomfortable, helpless and embarrassed, while she lay in a urine soaked bed. This also had the potential to result in skin irritation and breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (Resident 70 and 87) of 27 sampled residents received proper treatment to maintain hearing and vision capabilities when: 1. Resident 70 did not receive treatment or hearing aids to maintain hearing ability. This failure resulted in Resident 70 not hearing staff during teaching and care provision. 2. Resident 87's eyeglasses were broken for one month with white adhesive tape applied around the lenses to hold the lenses inside the frame. This failure resulted in Resident 87 being unable to see things clearly, read, or watch television.

Inspectors wroteBased on interview and record review the facility failed to ensure three of three sampled nursing assistants (CNA 5,7,8) received annual performance evaluations. This failure had the potential for a lack of training for any potential deficiencies identified during the performance evaluation process.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' personal belongings were protected when one (Resident 32) of 32 sampled residents had personal items missing from the facility's locked storage shed. This deficient practice has the potential to emotionally distress residents and cause them to feel unsafe.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately assess the need and provide supervision for three of sixteen (Residents 8, 40, and 84) resident smokers. This deficient practice had the potential to place residents at risk for fire related injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute, and serve food under sanitary conditions when four cutting boards were well worn, knives were stored wet, spoiling onions were stored in the dry food storage area and when a resident's (83) snack was stored overnight at the resident's bedside. These deficient practices had the potential to cause foodborne illnesses to residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for four (Resident 52, 100, 14 and 45) of 32 sampled residents when their Oxygen (O2) tubing and Nebulizer (device for producing a fine spray of liquid, used for inhaling a medicinal drug) face mask were not labeled, outdated and were exposed to air at the bedside. This failure had the potential for Resident 52, 100, 14 and 45 to develop avoidable infections.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a doctor's order or determine if one of 32 sampled residents (Resident 312) was able to self-administer medications, when Resident 312 had a bottle of Nystatin (antifungal antibiotic topical treatment) powder at the bedside. This deficient practice had the potential to result in Resident 312 using the topical powder against safe dosing recommendations. It also had the potential to result in the use of the medications by other residents, who could potentially come into the room and obtain the treatment from the bedside table where it was stored.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate three of 32 sampled residents' (Residents 97, 312 and 17) needs when: 1. Residents 97 and 312 did not have a call light within reach. 2. Residents 17 was not able to sleep and rest well during night time, when the roommate (Resident 60) was yelling and cursing all night long for two days in a week. This deficient practice can lead to residents' unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility did not provide written notice to the resident nor resident's responsible party of a room change for one of 32 sampled residents (Resident 84) before Resident 84's room was changed. This deficient practice was a violation of Resident 84's rights, and had the potential to lead to increased agitation and confusion for Resident 84.

Inspectors wroteBased on interview and record review, facility did not follow its policy and procedures for change in residents' condition for one (Resident 60) of 32 sampled residents, when Resident 60 had acute changes in behavior with episodes of crying and racial slurs throughout the night. This failure had the potential for Resident 60 to not receive appropriate treatment needed for his well- being

Inspectors wroteBased on interview and record review, the facility failed to inform and give reasonable notice for two (Resident 3 and 313) of three sampled residents (or the responsible party) that their Medicare services were ending and their right to appeal. This failure resulted in Resident 3 and the responsible party (RP) and Resident 313 not being able to appeal for an extension of Medicare coverage.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (Resident 78 and 106) of 32 sampled residents received a summary of the baseline care plan which was developed within 48 hours of the residents' admission. This failure had the potential for Resident 78 and Resident 106 to stay unaware of their updated plan of care.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for one of thirty-two sampled residents (Resident 40) following an altercation in the smoking area with another resident. This deficient practice had the potential for placing residents at risk for injury.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy and procedure on medication storage and labeling, when unlabeled medications and medications without physician orders were stored in Treatment cart 1 and 2. This failure had the potential for facility's residents' to not receive accurate administration of medications and treatments.