Eden Rehab Suites and Green House Homes

Inspectors wroteBased on staff interview and resident representative interview and record review, the facility did not provide timely access to a medical record for 1 resident (R) (R1) of 3 sampled residents. R1 requested a copy of R1's medical record in writing on 1/20/26. As of 2/5/26, R1 had not received the requested records.

Inspectors wroteBased on staff interview and record review, the facility did not notify Hospice in a timely manner of uncontrolled pain for 1 resident (R) (R2) of 5 sampled residents. R2 received Hospice services and complained of uncontrolled pain. The facility did not notify R2's Hospice agency so adequate pain relief could be provided.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure written bed-hold and transfer/discharge notices were provided to 2 residents (R) (R2 and R13) of 3 sampled residents. In addition, the facility did not ensure notices that were provided contained required information on appeal rights. R2 was transferred to the hospital on 1/23/26. Neither R2 or R2's activated Power of Attorney (POA) were provided with a written bed-hold or transfer/discharge notice. R13 was transferred to hospital on 2/1/26. R13's written bed-hold and transfer/discharge notice did not include information pertaining to appeal rights.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R3) of 5 sampled residents. Staff did not assess R3's lungs prior to set-up or after R3's self-administered nebulizer treatments.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide adequate pain relief for 1 resident (R) (R2) of 5 sampled residents. R2 received Hospice services and was admitted to the facility on [DATE]. R2 complained of pain at a level 10 out of 10 on 1/23/26 and had aggressive behavior. Without consulting Hospice, the facility notified an on-call provider, indicated they had administered all of R2's ordered pain medication, and wanted to send R2 to the emergency room (ER). Hospice indicated they could have assessed R2 prior to the transfer to see if R2's pain medications could have been increased or changed which might have prevented the transfer. In addition, R2 had an order for morphine sulfate which could have been administered on the morning of 1/23/26 prior to the transfer.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 35 residents residing in the facility. The kitchen microwave was not kept in a clean and sanitary condition to prevent cross-contamination. The refrigerator in the main kitchen contained food that was past the discard date and/or open to air. The facility's dishwasher did not reach minimum temperature requirements to prevent the spread of foodborne illness.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the right to make healthcare decisions was extended only to those delegated by the resident and in accordance with applicable law for 2 residents (R) (R3 and R28) of 16 sampled residents. R3 was declared incapacitated and had an activated Power of Attorney for Healthcare (POAHC). The facility did not ensure the individual making healthcare decisions on behalf of R3 was the representative delegated by R3. R28 was admitted to the facility on [DATE] and had an activated POAHC. The facility had R28 sign medical consents and did not ensure healthcare decisions were delegated to R28's representative as R28 was deemed incapacitated.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a call light was accessible for 1 resident (R) (R13) of 16 sampled residents. On 5/12/25, R13's call light was not within reach or accessible for R13 to use.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 3 residents (R) (R3, R6 and R28) of 15 sampled residents. R3's medical record indicated R3 had a mental illness (MI) diagnosis and was prescribed psychotropic medication. The facility did not update R3's PASRR Level I Screen with medication changes and did not submit for a PASRR Level II Screen timely when R3 remained in the facility past 30-days. In addition, the facility did not obtain a county exemption (Department of Health Services (DHS) form F-20822) when R3 was admitted to the facility. R6's medical record indicated R6 had MI diagnoses and was prescribed psychotropic medication. The facility did not submit for a PASRR Level II Screen timely when R6 remained in the facility past 30-days. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R31 and R10) of 2 sampled residents received assistance with activities of daily living (ADLs) in order to maintain their highest practicable physical well being. R31 had a perirectal abscess that extended to the left gluteal region following surgery. Staff did not provide timely care which caused R31 to be incontinent and posed a risk for wound infection. R10's Physical Therapy Discharge Summary contained an ambulation program that indicated to ambulate R10 in the hallway once per shift with caregiver stand-by assist (SBA)/contact guard assist (CGA) and wheelchair follow for 30-35 foot intervals. The ambulation program was not consistently implemented. In addition, R10's care plan did not include ambulation or a restorative program.

Inspectors wrote3. From 5/12/25 to 5/14/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, encephalopathy, osteoarthritis, and weakness. R7's MDS assessment, dated 3/20/25, had a BIMS score of 9 out of 15 which indicated R7 was moderately cognitively impaired. The MDS assessment also indicated R7 required substantial/maximal assistance for transfers. R7's medical record indicated R7 had unwitnessed falls on 2/1/25 and 3/24/25. R7 was found on the floor following both falls. Surveyor reviewed the investigations for both falls and noted the facility did not identify a root cause for the falls or update R7's care plan with new interventions. R7's falls care plan (revised 3/11/25) did not contain any new interventions following the falls on 2/1/25 and 3/24/25. Surveyor reviewed R7's neuro checks for the unwitnessed falls. [...]

Inspectors wrote2. From 5/12/25 to 5/14/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, mononeuropathy of bilateral lower limbs, adult failure to thrive, and urinary retention due to neurologic bladder. R27's MDS assessment, dated 4/7/25, had a BIMS score of 13 out of 15 which indicated R27 had intact cognition. R27 had a Foley catheter and was on EBP. On 5/13/25 at 1:27 PM, Surveyor observed CNA-J and CNA-M complete pericare for R27 and transfer R27 to a recliner via Hoyer lift. CNA-J and CNA-M completed hand hygiene and donned gloves and a gown prior to care. CNA-M provided peri-rectal care after R27 was incontinent of a large amount of stool. Without completing hand hygiene, CNA-M changed gloves and assisted R27 onto the left side. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure wound care was completed as ordered and in accordance with the resident's care plan for 2 residents (R) (R1 and R4) of 4 sampled residents. R1 was admitted to the facility on [DATE] for rehab following surgery for Charcot's foot (a foot/ankle structural and nerve damage due to diabetes) and had an order for a daily dressing change. R1's daily dressing change was not completed from 5/22/24 until 5/27/24. During a dressing change on 5/27/24 at approximately 1:00 AM, Registered Nurse (RN)-C observed maggots in R1's pin site surgical wound. RN-C also noted areas of redness, warmth, tenderness, and swelling. R1 was transferred to the hospital on 5/27/24 where the wound was debrided (mechanical removal of dead tissue) and flushed twice with sterile saline. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 24 residents residing in the facility. Staff did not ensure proper methods were used to rapidly cool time/temperature control for safety food. In addition, staff did not document cooling temperatures for time/temperature control for safety food not held hot or not for consumption within 4 hours. Staff did not clean the kitchenettes daily which resulted in unclean and unsanitary conditions.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment for 1 Resident (R) (R8) of 2 residents was as free of accident hazards as possible. The facility did not implement fall interventions contained in R8's person-centered comprehensive care plan and medical record.

Inspectors wroteBased on observation and resident and staff interview, the facility did not ensure a continuous positive airway pressure (CPAP) machine (a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders) was cleaned for 2 Residents (R) (R89 and R95) of 2 residents reviewed with CPAP machines. R89 and R95 used a CPAP machine for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Staff did not clean R89 and R95's CPAP machines per the facility's policy. In addition, R89 and R95 did not have physician orders or care plans for CPAP use.