Eden Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 5 residents (Residents #1) reviewed for infection prevention measures. CNA A provided care for Resident #1 who had a need for an indwelling urinary catheter and was under Enhanced Barrier Precautions (EBP, an infection control measure in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at risk of spreading multidrug-resistant organisms) and did not wear any Personal Protection Equipment (PPE). This failure could place residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #91 and Resident #117) and in 1 of 1 oxygen storage rooms reviewed for respiratory care. 1. Resident #91's nasal cannulas for oxygen and BiPAP (bilevel positive airway pressure) mask were not covered in a plastic bag when they were not used on 03/17/2026. 2. The facility failed to ensure Resident #117's oxygen concentrator was set to 2 to 3 liters per minute as ordered by the physician on 03/17/2026 and 03/18/2026. 3. Stored oxygen was not separated -1 oxygen cylinder that was empty was in the full area. 1 oxygen cylinder that was empty was in the full side. This failure could place residents at risk of illness, respiratory complications and accidents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 2 medication rooms (500-hall medication room), 2 out of 5 medication carts (500-hall B nursing cart and 500-hall A nursing cart), and 2 of 7 residents (Residents #52 and #155) reviewed for pharmacy services. 1. There was one box of refresh plus eye drop lubricant 50 vials that expired 01/2026 found inside the 500-hall medication room on 03/18/2026. 2. There was one bottle of Mucinex 600 mg guaifenesin extended-release that expired 12/09/2025 found inside the 500-hall B nursing cart on 03/18/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete for 1 of 6 residents (Resident #105) and the facility failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 4 halls (hall#8000), reviewed for Administration. 1. The facility failed to ensure Resident #105's wound care physician visits and notes were documented in the resident's EHR prior to or after the resident's discharge on [DATE]. 2. The facility failed to ensure the Medical Records room/Staff break room was closed and kept private and secure. These failures could place residents at risk of not receiving appropriate follow up care, decreased continuity of care, and loss or unauthorized use of their medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #117) who were observed for call light placement. The facility failed to ensure the call light which had been placed on Resident #117's oxygen concentrator was within reach for Resident #117. This deficient practice could place residents at risk of not being able to call for help as needed.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the resident had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, including the right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 8 (Resident #136) residents in that:Resident #136 was not able to eat in her room, which was her preference. This failure could affects the residents' ability to live a dignified life at facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #156) out of 26 residents reviewed for environmental concerns. Resident #156's toilet seat was dirty with feces, and staff did not flush feces inside the toilet. This failure could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the assessment accurately reflected the residents' status for 1 of 8 (Resident #94) residents in that:Resident #94's MDS was not accurate and did not reflect her indwelling catheter. This failure could affect all residents and staff could not know how to provide care to residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #64) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent and indwelling urinary catheter care to Resident #64 on 03/19/2026, the CNA did not clean the resident's left buttock area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed store food in accordance with professional standards for food service safety. for 1 of 3 (Bluebonnet Hall unit pantry) unit pantries in that:The unit pantry refrigerator was out of range temperature; and the apple juice container was not labeled or dated. This could affect residents that used the unit pantry and place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly, for 1 of 1 dumpster in that:The garbage container did not have a plug at the bottom. This could affect all residents and could cause debris, foul odors and harborage and feeding of pests.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 of 26 residents (Resident #47 and #153) reviewed for infection control practices. 1. RN-G did not put on gloves and a gown when entering Resident #47's room, and Resident #47 was on contact precautions. 2. When LVN-L changed the dressing of Resident #153's gastrostomy tube site, the LVN-L changed her gloves without sanitizing or washing her hands. The deficient practices could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure abuse, neglect and exploitation training and dementia training for 1 of 5 (CNA-M) employees reviewed for training requirements were completed. The facility failed to ensure abuse, neglect and exploitation training was provided to CNA-M. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on observation, interview and record review, the facility failed within 14 days after a facility completes a resident's assessment to transmit encoded, accurate, and complete MDS data to the CMS System for 5 of 14 residents (Residents #62, # 86, #107, #123, and #132) reviewed for MDS transmission. 1. Residents #62, #107, #123, and #132's, discharge MDS assessments were not transmitted within 14 days of completion. 2. Resident #86's admission MDS assessment on 03/20/2026 was not completed and not transmitted within 14 days since the resident was admitted to the facility on [DATE]. This deficient practice placed residents at risk of not having completed assessments and not having appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult the resident's Physician and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status or an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's Physician and notify the resident's Responsible Party of a worsened wound to sacrum. This failure could place residents at risk of delays in decision making, and poor quality of care and life. Findings Include:Record review of Resident #1's face sheet revealed an [AGE] year old male admitted for respite on 12/01/2025. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure resident environments remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #1) of 3 residents reviewed for 2-person mechanical lift transfers. The facility failed to ensure CNA A transferred Resident #1 on 01/19/2025 with a mechanical lift per her [NAME] (Notes for CNAs to access in PCC to provide a quick overview of the resident's needs) and her comprehensive plan of care plan. CNA A transferred Resident #1 with a gait belt by herself which resulted in a displaced fracture of her right humeral neck (bone at top of arm that connects to ligament (tough fibrous connective tissue) of shoulder). An Immediate Jeopardy was identified as past noncompliance on 5/21/2025. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #146) whose records were reviewed for code status. The facility failed to obtain a DNR order for Resident #146 upon admission, [DATE], based on her Living Will, dated [DATE]. This deficient practice could affect any resident who requested a DNR code status and could result in staff providing CPR for a resident who did not want to be resuscitated.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 5 residents (Residents #38) reviewed for reporting allegations of abuse and neglect. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the assessment must accurately reflect the resident's status for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed for assessments. 1. MDS staff failed to include Resident #48 was diagnosed with Major Depressive Disorder on her most recent quarterly MDS assessment, dated 9/22/24. 2. MDS staff failed to include Resident #73 was diagnosed with Major Depressive Disorder, Post Traumatic Stress Disorder on his most recent quarterly MDS assessment, dated 10/18/24. This deficient practice could affect any resident and could result in Residents not receiving needed care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed. 1. The facility failed to refer Resident #48 to the stated-designated authority after she was diagnosed with Major Depressive Disorder (MDD). 2. The facility failed to refer Resident #73 to the stated-designated authority after he was diagnosed with Major Depressive Disorder (MDD), Post Traumatic Stress Disorder. This deficient practice could affect a resident with a new onset diagnosis of mental disorder, intellectual disability, or a related condition and could result in residents not receiving needed care and services for identified psychiatric problems.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 Residents (Resident #48 and Resident #73) whose records were reviewed. 1. MDS staff failed to include Resident #48 was diagnosed with Major Depressive Disorder (MDD), that she received Sertraline (anti-depressant) and was receiving psychiatric services on her most recent Care Plan, revised 9/23/24. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to assess a resident using the quarterly review instrument specified by the state and approved by CMS not less frequently than once every 3 months for 1 (Residents #1) of 18 residents reviewed for quarterly MDS assessments. The facility failed to complete a quarterly MDS for Resident #1 with the ARD of 10/10/2024. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information for care plans.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident the residents environment remained as free of accident hazards as was for 1 of 14 Residents (#16) reviewed for mechanical soft diet needs and supervision. 1. The facility failed to follow the Speech Language Pathologist's (SLP) recommendations to grind meat for Resident #16's mechanical soft diet, served Resident #16 a ham sandwich, with 2 slices of ham lunch meat, each doubled in half; Resident was found shortly after unresponsive, received Cardio Pulmonary Resuscitation (CPR), was sent to the hospital via Emergency Medical Services (EMS) where she died due to a Difficult airway with lots of debris as quoted by the physician. An Immediate Jeopardy (IJ) was identified on 06/23/2024. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals, in accordance with State and Federal laws, were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 3 residents (Resident #2) reviewed for storage of drugs. The facility failed to ensure Resident #2's medications were secured. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for meal service. Dietary staff stacked 12 trays on a food cart filled with multiple individual servings of lemon cake which were exposed to the elements in the kitchen. This deficient practice could contribute to the spread of foodborne illnesses and make the residents sick.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 3 of 4 Residents (#35, #51 and #75) reviewed for accident hazards. The water temperature at the bathroom sink exceeded the safe water temperature of 110 degrees for Resident's #35, #51 and #75. 1. The water temperature in Resident #35's bathroom was 119 degrees. 2. The water temperature in Resident #51's bathroom was 115 degrees. 3. The water temperature in Resident #75's bathroom was 118 degrees. This deficient practice could place residents at risk for avoidable skin burns.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to ensure a comprehensive care plan was revised by the interdisciplinary team after the quarterly review assessments were completed for 2 of 8 Residents (#51 and #66) whose care plans were reviewed. 1. Resident #51's revised Care Plan did not address her ADL deficits and the level of assistance she required for all ADL's. 2. Resident #66's revised Care Plan did not reflect Resident #66's used corrective lenses for adequate vision. These deficient practice could contribute to residents not receiving required care identified in their MDS assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 1 of 2 staff (LVN B) reviewed for infection control, in that: LVN B took a stack of PPE gowns enclosed with a plastic wrap on the outside and handed them to another person on the outside the door of Unit 6 ([NAME]) without following infection control procedures when removing items from a isolation/quarantine area. These failure could place residents at risk for cross contamination.