Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eden Healthcare Center during CMS and state inspections, most recent first.
Resident personal and medical information was shared through a nursing WhatsApp group chat on staff personal smart phones. The DON and nursing staff confirmed the chat was used to communicate resident issues and significant changes, but observed messages included full resident names and details such as hospice status, conserved status, and return from the ACH. The DON stated there was no policy for WhatsApp use and no staff monitoring compliance with privacy and confidentiality.
A resident using a Purewick external catheter system reported that the urine collection canister was only rinsed with soap and water and never disinfected. A CNA confirmed the canister was cleaned once or twice daily with soap and water only, with no documentation of cleaning. An undated posted procedure directed staff to scrub the canister with soap and water and dry it, but did not include the manufacturer-required steps of fully submerging the canister in a soapy solution and then in 70% IPA for at least ten minutes each. The IP and facility policies stated that the urine collection system should be cleaned and disinfected per manufacturer instructions and that alcohol is an appropriate disinfectant for non‑critical items, but actual practice did not meet these requirements.
A resident with intact cognition and significant comorbidities was left in a Hoyer sling for an extended period during a bed change, developed increasing and eventually excruciating L hip pain, and repeatedly requested to be returned to bed. Instead of honoring these requests, staff and an outside vendor proceeded in attempting a wheelchair/power chair fitting while the resident remained in pain and became increasingly agitated, screaming and using profanity. The resident was only returned to bed after the chair was removed, despite a facility policy requiring that residents be treated with dignity and respect and allowed to make choices about daily life.
Two moderately cognitively impaired roommates, both ambulatory and with significant medical conditions including metabolic encephalopathy, pneumonia due to COVID-19, spinal stenosis, and dementia, were involved in an altercation after one resident asked the other to take a cell phone call into the hallway so he could rest. A CNA alerted an LVN, who found a resident in the bathroom washing blood from his face and noted facial injuries, while the roommate sat on his bed talking to himself and was later observed with a small drop of blood on his hand. Progress notes and ED documentation described lacerations to the right eyebrow and lower eyelid, swelling and bloodshot appearance of the right eye, facial contusions, and resident reports of being struck in the face and chest by the roommate. This occurred despite a facility abuse prevention policy stating residents have the right to be free from all forms of abuse, including physical abuse.
Two residents with cognitive impairments were involved in a physical altercation, resulting in multiple skin tears and a bite injury. Staff responded after hearing a commotion and found one resident swinging her arms at the other, who was defending herself. The incident led to pain and injuries, demonstrating a failure to protect residents from abuse as required by facility policy.
A licensed nurse (ADON) increased a resident's Seroquel dose to 50 mg twice daily without a physician's order, as shown in the MAR and confirmed by record review and staff interviews. The DON verified that the nurse acted beyond her scope of practice by making this medication change without proper authorization.
A resident with schizoaffective disorder and severe cognitive impairment received an increased dose of Seroquel without a documented physician order, clinical indication, or timely informed consent. The medication change was implemented based on a verbal instruction, but records did not support the need for the increase, and the required written consent from the responsible party and physician was not obtained until months later.
A resident with quadriplegia was left unsupervised on a hoyer lift for 30 minutes and assisted by only one staff member during a transfer, contrary to the care plan requiring a two-person assist. This resulted in the resident's discomfort and potential risk of injury, as confirmed by the ADON and facility policy.
The facility failed to ensure appetizing and nutritious meals, affecting all residents, including those on pureed diets. Residents reported unpalatable food, confirmed by test trays showing flavorless and greasy meals. Staff did not follow recipes for pureed bread, using water instead of broth, milk, or juice, affecting nutritional value. The Dietary Supervisor and RD were responsible for food quality, but deficiencies in taste and nutrition were evident.
The facility failed to maintain sanitary conditions for resident food storage, as observed in a refrigerator with brown stains and undated food items. Staff interviews revealed inconsistencies in policy implementation, with some family members placing food in the refrigerator themselves. The Dietary Supervisor, IP LVN, DON, and Administrator all highlighted the need for food to be labeled and dated, but the refrigerator was found dirty and with undated items.
The facility failed to ensure proper disposal of garbage and refuse, as the dumpster lid was observed open on multiple occasions, contrary to facility policy. Interviews with staff confirmed the expectation for the dumpster to be closed, with janitorial staff responsible for its maintenance. This deficiency potentially affected all 116 residents.
The facility did not consistently complete infection surveillance checklists as part of its antibiotic stewardship program. The IP LVN admitted to performing McGeer criteria assessments mentally without documentation, citing a lack of guidance. The DON and Administrator expected the IP LVN to review antibiotic use against the McGeer criteria and consult with physicians if criteria were not met, potentially affecting all residents prescribed antibiotics.
The facility failed to conduct smoking assessments for a resident, provide supervision for another, and implement safety measures for a third, leading to unsafe smoking practices. Additionally, medications were left at the bedside for two residents without proper assessments, violating facility policy.
The facility failed to properly label and store medications on two units, with loose pills and improper storage of topical and oral medications on the South 2 Unit, and an illegible expiration date on a medication bottle on the North 1 Unit. Staff interviews revealed inconsistencies in responsibilities for maintaining medication cart cleanliness and checking for expired medications.
A facility failed to notify a physician when a resident's blood sugar levels exceeded 350 mg/dL, contrary to its policy. The resident, with a history of diabetes and on insulin therapy, had multiple instances of elevated blood sugar levels documented without physician notification. Staff interviews revealed inconsistent understanding of the notification policy, with some nurses indicating they would only notify if levels exceeded 400 mg/dL, while others suggested a lower threshold.
The facility failed to maintain a safe and homelike environment for two residents, one with a hole in their bathroom door and another with an exposed electrical box. Despite policies requiring prompt maintenance, no requests were documented, and staff interviews revealed a lack of communication and oversight, with the acting administrator unaware of these issues.
A facility failed to accurately code the MDS assessment for a resident with schizophrenia, despite a PASRR Level II determination indicating the need for specialized mental health services. The MDS was incorrectly marked as not having a serious mental illness, contrary to the resident's documented condition. Interviews with staff revealed a lapse in ensuring the accuracy of assessments, as required by facility policy.
A resident with a serious mental disorder was not referred for a Level II PASARR evaluation after a positive Level I screening, contrary to facility policy. The deficiency was discovered during a survey, revealing that the necessary referral was delayed until prompted by the surveyor. Interviews with staff indicated a lapse in following the established process for PASARR evaluations.
A resident's medication orders lacked specified dosages, leading to improper administration of supplements by an LVN. Despite the facility's policy requiring clarification of incomplete orders, the LVN did not contact the physician for the correct dosages. Interviews with staff confirmed the expectation to verify and clarify medication orders, highlighting a deficiency in following established procedures.
A facility failed to ensure a resident's physician order matched their POLST form, which indicated a DNR status. Despite the resident's advance directive and POLST form indicating DNR, the Order Summary Report listed a Full Code order. Interviews with staff, including LVNs and the DON, highlighted the expectation for matching documentation, which was not met, resulting in a failure to adhere to the resident's advance directive.
A facility failed to maintain accurate medical records for a resident with a history of dementia and other conditions, by incorrectly documenting skin assessments. Despite having a Stage 4 pressure ulcer, nursing staff mistakenly recorded the resident as having clear skin. The DON and Administrator acknowledged the records should have been accurate but were unsure why errors occurred.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure injury, as required by their policy. During an observation, an LVN performed wound care without using a gown or following EBP, and there was no signage or PPE available outside the resident's room. The resident's family had requested that EBP not be used, feeling it demeaned the resident, but this refusal was not documented. The IP LVN and DON acknowledged the necessity of EBP for residents with wounds to prevent infections.
A resident with severe cognitive impairment was offered a pneumococcal vaccine without the facility contacting the conservator for consent, as required by policy. The resident, unable to make healthcare decisions, declined the vaccine. Staff interviews revealed a misunderstanding of the protocol, with no documented evidence of conservator contact.
A resident with osteoporosis did not receive their prescribed Fosamax medication despite it being documented as administered in the MAR. The resident reported not receiving the medication, indicating a failure in the facility's medication management process. Interviews revealed that the facility did not follow its policy for handling unavailable medications, leading to a significant lapse in care.
The facility failed to provide a safe and clean environment for two residents when another resident with severe cognitive impairment repeatedly entered their rooms and urinated on their belongings and the floor, causing emotional distress. Staff interviews confirmed the behavior and the need for more supervision.
Resident information shared in staff WhatsApp group chat
Penalty
Summary
The facility failed to ensure resident personal and medical information was communicated in a way that protected privacy and confidentiality for four sampled residents. During interviews and observations, nursing staff and the DON confirmed that a WhatsApp group chat on personal smart phones was being used by nurses to communicate resident issues and significant changes. The DON stated the group chat was used by nurses to communicate with each other regarding what was happening with residents, and that the intended process was to avoid using full names by using room numbers and partial initials instead. Despite that stated process, messages observed in the Nursing group chat included Resident 1’s first and last name along with hospice status, Resident 2’s first and last name along with conserved status, and the first and last names of Resident 3 and Resident 4 with a note that they had returned from the acute care hospital. The DON stated the facility had no policy and procedure on the use of WhatsApp, and that there was no staff member monitoring compliance with privacy and confidentiality during use of the group chat. The DON also stated the official and more secure communication option in the facility was Point Click Care, while the Administrator stated WhatsApp was not an official communication tool mandated by the facility.
Failure to Clean and Disinfect Urine Collection Canister per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to clean and disinfect a urine collection canister according to the manufacturer’s instructions and the facility’s own policies. A cognitively intact resident, admitted with chronic systolic heart failure, acute myocardial infarction, and type 2 diabetes mellitus, used a Purewick external female catheter urine collection system every shift for urinary incontinence management. During an observation and interview in the resident’s room, the resident reported that the urine canister had never been disinfected and had only been rinsed with soap and water. A CNA stated that the resident’s urine canister was cleaned with soap and water once or twice a day and that there was no documentation of canister cleaning. An undated procedure titled “Cleaning Procedure for Purewick Cannister, Tubing, and External Catheter” posted in the resident’s bathroom directed staff to empty urine into the toilet, scrub the canister with soap and water using a brush, and dry it with a paper towel, with no disinfection step or required contact time. The Infection Preventionist confirmed that staff were educated to clean and disinfect the canister with soap and water and to wipe off sediments with a brush, and also confirmed there was no documentation for canister cleaning. Review of the facility’s policy “External Catheter for Female Urinary Incontinence Management” stated that the urine collection system and accessories should be cleaned and disinfected at each use or at least daily per manufacturer’s instructions. The manufacturer’s instructions for “Cleaning the Collection Canister” required an initial rinse, then full submersion of the canister and lid in a dish soap solution for a minimum of ten minutes with brushing while submerged, followed by rinsing, visual inspection, and then full submersion in 70% isopropyl alcohol for a minimum of ten minutes, with a final rinse and drying. The Infection Preventionist acknowledged that following these instructions could prevent growth of bacteria and fungus and that the canister is a non‑critical care item. The facility’s policy on cleaning and disinfection of resident-care items identified alcohol as an appropriate disinfectant for non‑critical items, but the implemented procedure and staff practice did not follow the required cleaning and disinfection steps or contact times for the resident’s urine collection canister.
Failure to Honor Resident’s Choice and Dignity During Painful Hoyer Transfer
Penalty
Summary
The deficiency involves a failure to honor a cognitively intact resident’s right to dignity, respect, and choice during a transfer and equipment change. The resident, who had chronic systolic CHF and morbid obesity, was admitted on an earlier date and had a BIMS score of 15, indicating intact cognition. During an episode in which his malfunctioning bariatric bed was being changed, he was lifted from bed in a Hoyer sling operated by a restorative nursing assistant, with rehab staff and outside Kaiser staff present. The process took longer than the resident anticipated, and while he remained suspended in the sling, he began experiencing increasing left hip pain. Staff adjusted the existing bariatric bed so it could be removed from the room, leaving the resident in the sling for an extended period. Once the old bed was removed, instead of immediately returning the resident to bed as he requested due to escalating, “excruciating” left hip pain, Kaiser staff brought in a wheelchair/power chair and attempted to proceed with a wheelchair fitting. The resident repeatedly requested to be returned to bed and expressed that he did not want to continue with the fitting because of his pain. Staff attempted to support his left hip but continued with efforts to fit him to the chair while he remained in the sling and became increasingly agitated, screaming, cussing, and demanding to go back to bed. Only after the wheelchair/power chair was removed from the room was the new bariatric bed brought in and the resident returned to bed, at which point he verbalized displeasure with vulgar comments about the pain he experienced while in the sling. The facility’s own resident rights policy states that residents are to be treated with dignity and respect and allowed to make choices about daily life, which was not followed in this incident.
Failure to Protect Resident From Physical Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. One resident with metabolic encephalopathy and pneumonia due to COVID-19, who had a BIMS score of 12 indicating moderate cognitive impairment, shared a room with another resident diagnosed with spinal stenosis and unspecified dementia, also with a BIMS score of 12. On the evening of the incident, a CNA alerted an LVN that the first resident was in the bathroom with visible facial bleeding. The resident reported that his roommate had hit him in the face after he asked the roommate, who was pacing and talking on a cell phone, to take the call into the hallway so he could rest. When the LVN entered the room, the injured resident had an injury on his forehead and was washing blood from his face, while the roommate was sitting on his bed talking to himself; during the subsequent police investigation, a small drop of blood was noted on the roommate’s hand. Progress notes documented that the resident had lacerations to the right eyebrow and right lower eyelid, with the right eye swollen, red, and bloodshot. The lacerations measured approximately 4 cm by 0.5 cm on the right eyebrow and 2 cm by 0.5 cm on the right lower eyelid. The resident stated that when he tried to talk to his roommate about pacing and phone use, the roommate suddenly raised his arms and made contact with his right eye, causing the injury. An emergency department note recorded that the resident complained of pain in his head, face, and chest, and that he reported being hit in both the face and chest by his roommate. The ED documented contusions to the right maxillary soft tissues and the soft tissue surrounding the right eye and supraorbital ridge, with a discharge diagnosis of injury due to physical assault, contusion of face, and safeguarding concerning adult. These events occurred despite the facility’s written Abuse Prevention Policy, which states that residents have the right to be free from all forms of abuse, including physical abuse, and that the facility prohibits and prevents such abuse.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injuries
Penalty
Summary
The facility failed to protect two residents from abuse when a physical altercation occurred between them. Resident 2, who had dementia with behavioral disturbances and severe cognitive impairment (BIMS score of 5), and Resident 4, who had moderate cognitive impairment (BIMS score of 10) and a diagnosis of osteomyelitis, were involved in the incident. Resident 2 sustained multiple skin tears with bleeding, while Resident 4 suffered a skin tear on her right index finger after being bitten. The altercation began when Resident 4 became upset that Resident 2 was using her wheelchair, leading Resident 4 to scratch Resident 2, and Resident 2 to bite Resident 4's finger. A registered nurse responded to a commotion in the shared room and observed Resident 4 swinging her arms at Resident 2, who was attempting to defend herself. Staff intervened and separated the residents, but not before Resident 2 had sustained significant injuries. The facility's abuse prevention policy prohibits all forms of abuse and neglect, but the incident resulted in pain and injuries to both residents, indicating a failure to ensure their safety from abuse.
Nurse Increased Medication Dose Without Physician Order
Penalty
Summary
A licensed nurse, specifically the Assistant Director of Nursing (ADON), increased the dose of Seroquel (Quetiapine) for a resident without obtaining a physician's order. The resident's medication was changed to 50 mg twice daily, as reflected in the Medication Administration Record (MAR) from December 2024 through April 2025. Review of the resident's electronic health record and order summary did not show any physician authorization for this dosage increase. During interviews and record reviews, the ADON acknowledged entering a verbal order for the increased dose but could not provide evidence of a physician's directive for this change. The Director of Nursing (DON) confirmed that the ADON acted beyond the scope of her license by increasing the medication dose without a physician's order. This action was not supported by any documented indication or authorization from a physician.
Unnecessary Psychotropic Drug Increase Without Proper Orders or Consent
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and severe cognitive impairment had their Seroquel (Quetiapine) dosage increased from 25 mg twice daily to 50 mg twice daily without a documented physician order, clinical indication, or timely informed consent. The resident's records showed no increase in hallucination episodes to justify the dosage change, and the new order for Seroquel did not match the previously documented indication or monitoring for schizoaffective disorder. The Assistant Director of Nursing (ADON) stated she entered the new order based on a verbal instruction during an interdisciplinary team meeting, but could not find documentation of a physician's order or indication for the increase in the resident's electronic health record. Additionally, the required written informed consent for the psychotropic medication increase was not obtained from the resident's responsible party (RP) until over two months after the medication change was implemented. The consent form remained unsigned by both the RP and the physician during this period, and facility records indicated the RP was available for part of the time when the consent could have been obtained. Facility policy requires that psychotropic medications be clinically indicated, necessary, and supported by documented evaluation and consent, which was not followed in this case.
Resident Left Unsupervised on Hoyer Lift
Penalty
Summary
The facility failed to ensure safe patient handling for a resident who was left unsupervised on a hoyer lift for 30 minutes and was assisted by only one staff member during a transfer. The resident, who was admitted with diagnoses of polymyositis and quadriplegia, required assistance for personal care and was totally dependent on staff for transfers. The resident's care plan specified the need for a two-person assist during transfers and emphasized the importance of staff supervision while the resident was on the hoyer lift. On the day of the incident, a Certified Nursing Assistant (CNA) left the resident suspended on the hoyer lift without supervision, assuming the next CNA would lower the resident. However, the resident remained unsupervised for an extended period, and when another CNA eventually attended to the resident, they attempted to transfer the resident alone, causing discomfort. The Assistant Director of Nursing confirmed that two staff members should be present during hoyer lift transfers to prevent falls and ensure resident comfort, as per the facility's policy on safe resident handling and transfers.
Deficiencies in Food Preparation and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was appetizing and prepared according to the facility's guidelines, affecting all 116 residents receiving meals, including 18 on pureed diets. During a Resident Council Meeting, several residents with intact cognition reported that the food lacked variety, flavor, and was unpalatable. Observations during meal service confirmed these complaints, with test trays revealing flavorless, overcooked vegetables, greasy chicken, and dessert with an artificial taste. The Dietary Supervisor acknowledged the issues, describing the meals as bland and the chicken as tough. Additionally, the facility did not adhere to its own recipe for pureed bread, which called for broth, milk, or juice, and instead used water and margarine, potentially affecting the nutritive value. Staff were observed preparing pureed bread incorrectly, and interviews revealed a lack of awareness about the recipe requirements. The Dietary Supervisor and Registered Dietitian confirmed that the use of water instead of the specified ingredients could dilute the nutritional content, as water lacks calories and protein. Interviews with the Director of Nursing and the Administrator indicated a reliance on the Dietary Supervisor and Registered Dietitian to ensure food quality and adherence to recipes. However, the failure to follow recipes and ensure palatable meals was evident, as staff did not review or follow the recipes correctly, leading to deficiencies in both taste and nutritional value of the meals served to residents.
Failure to Maintain Sanitary Conditions for Resident Food Storage
Penalty
Summary
The facility failed to ensure that foods brought in by visitors were stored in a sanitary manner, specifically in the resident refrigerator. During an observation, the refrigerator was found to have brown stains and liquid at the bottom, along with undated food items such as half a cake, a bag of Chinese takeaway, and a fast-food bag. Licensed Vocational Nurse (LVN) #6 confirmed that the food items were not dated and mentioned that some residents' family members placed food into the refrigerator themselves, contrary to the facility's policy. Interviews with various staff members, including the Dietary Supervisor (DS), Infection Prevention Licensed Vocational Nurse (IP LVN), Director of Nursing (DON), and the Administrator, revealed inconsistencies in the implementation of the facility's policy. The DS stated that only staff were permitted to place food in the refrigerator, and it was supposed to be cleaned every three days. However, the IP LVN admitted that the refrigerator was not routinely checked or cleaned, and the DON and Administrator both emphasized that food should be labeled and dated by whoever received it. Despite these expectations, the refrigerator was observed to be dirty with undated food items, indicating a lapse in adherence to the facility's procedures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the proper disposal of garbage and refuse, as observed during a survey. The facility's policy required that refuse containers and dumpsters outside the facility have tightly fitting lids and be kept covered when not being loaded to minimize debris accumulation and prevent insect or rodent attraction. However, during observations on two separate occasions, the dumpster lid was found open, with trash visible. Interviews with the Dietary Supervisor, Director of Nursing, and the Administrator confirmed that the dumpster was supposed to be closed, with the janitorial staff responsible for maintaining it. This deficiency had the potential to affect all 116 residents residing in the facility at the time of the survey.
Failure to Complete Infection Surveillance Checklists
Penalty
Summary
The facility failed to consistently complete infection surveillance checklists as part of its antibiotic stewardship program for residents who received prescribed antibiotic therapy. The facility's policy, implemented in July 2023, required an infection prevention and control program that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. However, the facility's Infection Control Data Logs from January 2024 through September 2024 did not indicate if infections met the McGeer criteria, except for one instance in February 2024. The Infection Prevention (IP) Licensed Vocational Nurse (LVN) admitted to performing the McGeer criteria assessments mentally without documenting them, citing a lack of guidance as a new IP. Interviews with the IP LVN, Director of Nursing (DON), and the Administrator revealed a lack of adherence to the expected procedures. The IP LVN acknowledged her inexperience and the absence of proper guidance, while the DON and Administrator expressed their expectations for the IP LVN to review antibiotic use against the McGeer criteria and consult with physicians if the criteria were not met. This deficiency had the potential to affect all residents in the facility who were prescribed antibiotics.
Deficiencies in Smoking Safety and Medication Administration
Penalty
Summary
The facility failed to complete a smoking assessment for Resident #79, who was admitted with a medical history including schizophrenia and cognitive impairment. Despite the facility's policy requiring smoking assessments, there was no evidence that Resident #79 was assessed for their ability to smoke safely. Observations revealed burn holes in the resident's pants, indicating unsafe smoking practices. Interviews with staff, including the Director of Nursing and a Certified Nurse Assistant, confirmed a lack of awareness and assessment regarding the resident's smoking habits. Resident #91, who was assessed to require supervision while smoking, was observed smoking without supervision in the facility's courtyard. The resident had a history of schizoaffective disorder and intact cognition, as indicated by their BIMS score. Despite the assessment indicating the need for supervision, staff interviews revealed that the resident was provided with a nicotine patch but was not consistently supervised while smoking. The facility also failed to implement a safety intervention for Resident #10, who required a smoking apron due to safety concerns such as dropping ashes and impaired motor skills. Observations showed the resident smoking without the apron, and staff interviews indicated a lack of communication and awareness about the need for this safety measure. Additionally, the facility did not adhere to its medication policies, as medications were left at the bedside for Residents #58 and #82 without proper assessments for self-administration, contrary to facility policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in the medication carts on two units, South 2 and North 1. On the South 2 Unit, loose pills were found in the medication cart, and a topical medication and nebulizer solution were not stored separately from oral medications, contrary to the facility's policy. On the North 1 Unit, a bottle of guaifenesin oral solution had an illegible expiration date, which was confirmed by the LVN responsible for the cart. Interviews with various staff members, including RNs, LVNs, the Infection Prevention LVN, the Director of Nursing, and the Administrator, revealed inconsistencies in the understanding and execution of responsibilities regarding medication cart cleanliness, organization, and checking for expired medications. While charge nurses were generally held responsible for maintaining the carts, there was uncertainty about the frequency of checks for expired medications and the protocol for handling medications with illegible expiration dates. The facility's policies clearly outlined the need for separate storage of different types of medications and the importance of identifying expiration dates, but these were not consistently followed.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar levels reached 350 mg/dL or higher, as required by the facility's Hypoglycemia/Hyperglycemia Management policy. This deficiency was identified for one resident who had a history of type two diabetes mellitus and was on long-term insulin therapy. The resident's blood sugar levels were documented to be 350 mg/dL or higher on multiple occasions in July 2024, yet there was no documentation in the resident's progress notes indicating that the physician was notified of these elevated levels. Interviews with facility staff revealed a lack of consistent understanding and adherence to the policy regarding when to notify a physician about high blood sugar levels. Licensed Vocational Nurse #3 and Registered Nurse #17 indicated they would contact a physician only if blood sugar levels exceeded 400 mg/dL, while Registered Nurse #18 stated that most physicians wanted to be notified if levels were above 300 mg/dL. The Director of Nursing was unsure of the specific threshold for notification, and the Administrator acknowledged the need for an established level for physician notification.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe and homelike environment for its residents, as evidenced by the presence of a tennis ball-sized hole in the bathroom door of a resident's room. The resident, who had a history of depression and moderate cognitive impairment, reported that the hole had been there since their admission. Despite the facility's policy requiring maintenance issues to be documented and addressed promptly, no maintenance request was made for this issue. Interviews with staff revealed a lack of communication and documentation regarding the damage, with the CNA admitting to noticing the hole months prior but failing to report it. Another deficiency was identified in a different resident's room, where the cover for the call light electrical box was not fully attached, exposing wires. This resident also had moderate cognitive impairment and reported that while the call light issue had been resolved, the electrical box remained unrepaired. The facility's maintenance records showed no documented requests for this repair, and interviews with staff indicated that the maintenance director position was vacant, leading to a lack of oversight and follow-up on maintenance issues. The facility's policies on maintaining a safe and homelike environment and electrical safety were not adhered to, resulting in unresolved maintenance issues that compromised the residents' living conditions. The acting administrator, who had taken on the role of maintenance director, was unaware of these specific issues, highlighting a gap in the facility's maintenance request and repair process.
Inaccurate MDS Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the Preadmission Screening and Resident Review (PASRR) requirements for a resident with a serious mental illness. Specifically, the MDS assessment for a resident with a diagnosis of schizophrenia was incorrectly coded as not having a serious mental illness, despite a PASRR Level II determination report indicating the need for specialized services to address mental health needs. This discrepancy was identified during a review of the resident's annual MDS, which was not aligned with the PASRR Level II determination. Interviews with facility staff, including an MDS Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the MDS assessments were expected to be accurate and reflective of the resident's condition. The LVN acknowledged the error in coding and was unsure why it was missed, while the DON emphasized the responsibility of MDS staff to ensure accuracy. The facility's policy on conducting accurate resident assessments requires that each assessor certifies the accuracy of their portion of the assessment, highlighting a lapse in adherence to this policy.
Failure to Conduct Timely Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with a serious mental disorder, was referred for a Level II PASARR evaluation following a positive Level I PASARR screening. The facility's policy requires that all applicants be screened for serious mental disorders or intellectual disabilities, and if a Level I screening is positive, a Level II evaluation must be conducted by the state-designated authority. However, the facility did not adhere to this policy for one resident who was admitted with a diagnosis of bipolar type schizoaffective disorder and schizophrenia, as indicated by their medical records and admission MDS. The deficiency was identified during a survey when it was discovered that the resident's Level I PASARR screening, which was positive for a suspected mental illness, did not lead to a timely Level II evaluation. Interviews with facility staff, including the MDS LVN and the Director of Nursing, revealed that the necessary referral to the PASARR office was not made until prompted by the surveyor. The facility's policy assigns the responsibility of tracking PASARR screening status and making referrals to the Social Services Director and/or MDS Coordinator, but this process was not followed in this instance.
Failure to Specify Medication Dosages
Penalty
Summary
The facility failed to ensure medication orders specified the intended dosages for a resident, leading to a deficiency in medication administration. The resident, who was admitted with a medical history of essential hypertension, chronic systolic heart failure, and alcohol-induced acute pancreatitis, had active orders for supplements such as folic acid, vitamin A, vitamin B6, and vitamin D3. However, these orders did not specify the dosages to be administered. During a medication pass, an LVN administered these supplements using the facility's stock bottles without confirming the correct dosages, as the orders were incomplete. Interviews with various staff members, including the LVN involved, the Infection Prevention LVN, another LVN, the DON, and the Administrator, revealed a consistent understanding that medication orders should include specific dosages and that nurses should contact the physician for clarification if orders are incomplete. Despite this understanding, the LVN did not seek clarification from the physician before administering the medications, resulting in a failure to adhere to the facility's medication administration policy, which requires correcting discrepancies and reporting them to the nurse manager, MD, or DON.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's physician order was consistent with their Physician Orders for Life-Sustaining Treatment (POLST) form, which indicated a Do Not Resuscitate (DNR) status. The resident, who had a history of neuropathy, type 2 diabetes, epilepsy, bipolar type schizoaffective disorder, dysphagia, and cognitive communication deficit, was admitted with an advance directive indicating DNR. However, the resident's Order Summary Report contained an order for Full Code, which was inconsistent with the POLST form signed by both the resident and the physician. Interviews with facility staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that there was an expectation for the POLST form and physician orders to match. Staff were responsible for ensuring the correct code status was documented and communicated. The discrepancy between the POLST form and the physician's order was not identified or corrected, leading to a failure in adhering to the resident's advance directive and the facility's policy on communication of code status.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, identified as Resident #22, by not documenting accurate skin assessment information. The facility's policy on documentation required that each resident's medical record accurately represent their experiences and include sufficient details about their care. However, the records for Resident #22, who had a medical history of unspecified dementia, major depressive disorder, muscle wasting and atrophy, dysphagia, protein-calorie malnutrition, and adult failure to thrive, were found to be inaccurate. Specifically, the resident's care plan indicated a focus on impaired skin integrity related to peripheral vascular disease, with interventions requiring weekly skin assessments. Despite this, a surgical and wound care progress note reported a Stage 4 pressure ulcer on the resident's right lateral foot, which was not accurately reflected in the nursing weekly summaries. Both a Registered Nurse and a Licensed Vocational Nurse documented that the resident had clear skin, which was incorrect. Interviews with the nursing staff revealed that these entries were mistakes, and the Director of Nursing and the Administrator acknowledged that the medical records should have been complete and accurate, but they did not know why the assessments were filled out incorrectly.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a pressure injury, as required by their policy. The policy specified that EBP should be considered for residents with wounds or indwelling medical devices, and included making gowns and gloves available near the resident's room. However, during an observation, a Licensed Vocational Nurse (LVN) performed wound care for the resident without using a gown or following EBP, and there was no signage or personal protective equipment (PPE) available outside the resident's room. Interviews revealed that the resident's family had requested that EBP not be used, feeling it demeaned the resident. The Infection Preventionist (IP) LVN and the Director of Nursing (DON) both stated that EBP was necessary for residents with wounds to prevent infections, and the IP LVN was surprised that the precautions were not in place. The IP LVN also noted that the refusal by the resident's family was not documented, and the LVN should have communicated this refusal when it occurred. The facility staff acknowledged the mistake in not implementing EBP during the resident's wound treatment.
Failure to Obtain Conservator Consent for Vaccination
Penalty
Summary
The facility failed to ensure that the responsible party for a resident with severe cognitive impairment was educated and provided the opportunity to consent for a pneumococcal vaccination. The facility's policy required that residents or their representatives receive education about the benefits and potential side effects of the vaccine, and that a consent form be signed prior to administration. However, in the case of the resident in question, who had a conservator due to severe cognitive impairment, the facility did not contact the conservator for consent. Instead, the resident, who was unable to make healthcare decisions, was approached directly and refused the vaccine. The resident's medical records indicated a history of schizophrenia and severe cognitive impairment, with a BIMS score of 6. Despite the resident's inability to consent, the facility's staff offered the vaccine directly to the resident, who declined and refused to sign the declination form. Interviews with facility staff, including the Infection Prevention LVN and the Director of Nursing, revealed a misunderstanding of the protocol, as the staff believed they had contacted the conservator but had no documented evidence of such contact. The Director of Nursing and the Administrator both acknowledged that the conservator should have been contacted for consent before approaching the resident.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for a resident diagnosed with quadriplegia and osteoporosis, as they did not ensure the availability and administration of Fosamax, a medication prescribed to treat osteoporosis. Despite the medication being ordered and documented in the Medication Administration Record (MAR) as administered on specific dates in May and June 2024, the resident reported not receiving the medication. The discrepancy between the MAR entries and the resident's account suggests a failure in the medication administration process. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the facility did not follow its policy for handling unavailable medications. The policy requires notifying the pharmacy, physician, and resident if a medication is unavailable, which was not adhered to in this case. The facility's failure to ensure the medication was available and administered as ordered by the physician highlights a significant lapse in the medication management process, potentially affecting the resident's treatment and well-being.
Failure to Provide a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe and clean environment for two residents when another resident, who had severe cognitive impairment and a history of psychotic disorder, repeatedly entered their rooms and urinated on their belongings and the floor. Resident 4, who had a BIMS score of 2 out of 15 indicating severely impaired cognition, was reported to have gone into Resident 1's room and urinated on the curtain next to the bed, causing Resident 1 emotional distress. Resident 1, who had a BIMS score of 13 out of 15 indicating intact cognition, expressed feeling mad and upset about the incident. Staff interviews confirmed that Resident 4 had a behavior of entering other residents' rooms and urinating in undesignated areas, which was a known issue documented in Resident 4's progress notes. Additionally, Resident 4 was observed entering Resident 6's room without permission and had previously urinated on the floor in Resident 6's room. Resident 6, who had a BIMS score of 10 out of 15 indicating moderately impaired cognition, also expressed feeling mad about the incident. Staff interviews corroborated that Resident 4's behavior was a concern and that more supervision was needed for Resident 4 to ensure the safety of other residents. The facility's policy on residents' rights to a safe and clean environment was not upheld, as confirmed by the administrator during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,076 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hayward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emmanuel Post Acute Care - Hayward | 0.4 mi | ★★★★★ | 18 | 0 |
| Hayward Post Acute | 0.9 mi | ★★★★★ | 10 | 0 |
| Serenethos Care Center, Llc | 2.2 mi | ★★★★★ | 0 | 0 |
| Hayward Healthcare & Wellness Center | 2.3 mi | ★★★★★ | 1 | 0 |
| St Anthony Care Center | 2.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Eden Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.