Above 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 Center At Eden Hill, Llc during CMS and state inspections, most recent first.
Failure to care plan TLSO brace use. A resident admitted with a lumbar fracture had care plans initiated, but the record lacked an individualized plan for the TLSO brace. Notes documented the brace was to be worn to support the lumbar spine, that it was very wide and went up to the chest, and that the resident was not strong enough to apply it tightly. POC documentation stated the brace was to be applied at all times, and the DON confirmed there was no care plan addressing brace application, positioning, or tightness.
A resident hospitalized for depression returned with discharge instructions to continue fluoxetine 20 mg daily, but the facility transcribed the order as 10 mg daily. The resident received multiple doses at the lower dose before psychiatry later documented depression/anxiety and the dose was increased to 20 mg; the DON confirmed the initial transcription error resulted in 17 undermedicated doses.
Two residents missed ordered doses after admission because pharmacy services were delayed. One resident with anxiety did not receive clonazepam on multiple scheduled doses because staff were waiting for pharmacy clearance, a valid prescription, and medication availability. Another resident with major depressive disorder and mood disorder missed quetiapine doses because the medication had not yet been delivered. Staff confirmed that newly admitted residents sometimes do not have all medications available and that pharmacy delivery can take 24 to 48 hours.
Three cognitively intact residents were not offered the opportunity to formulate advance directives upon admission. Social history assessments documented code status and power of attorney but did not address advance directives, and staff interviews confirmed that the required offer was not made or documented.
A resident who was cognitively intact reported to nursing staff that she was touched inappropriately by a nurse during vital sign assessment. The RN and DON were notified the same day, and an internal investigation began, but the required report to the State Agency was not submitted until two days later, exceeding the mandated two-hour reporting window.
A resident was given metoprolol despite physician orders to hold the medication if systolic blood pressure or heart rate fell below specific parameters. Nursing staff confirmed the medication was administered when the heart rate was below the ordered threshold, contrary to expectations to hold the dose and notify the provider.
A facility failed to create a care plan for a resident's earwax build-up despite physician orders for Debrox Otic Solution. The absence of a person-centered care plan was confirmed by an RN and discussed during an exit conference with facility leadership and Ombudsman representatives.
A resident with moderate cognitive impairment did not receive proper nail care, resulting in long fingernails with dark debris. Despite requests from the resident's family and observations by staff, the facility failed to provide timely assistance with grooming, as required by the resident's care plan and facility policy.
A resident with ear wax build-up did not receive prescribed Debrox ear drops due to a failure in medication administration documentation. Despite the medication being delivered, staff were unfamiliar with a chart code on the MAR, leading to the resident experiencing ongoing ear pain and discomfort.
A resident with respiratory failure and hypoxia was on oxygen therapy without a physician's order, despite fluctuating oxygen levels and documented respiratory concerns. Facility staff, including an LPN and the DON, confirmed the absence of a physician's order until it was highlighted by a surveyor.
A resident admitted with dementia and psychotic disturbance was not adequately monitored for side effects of antipsychotic medication. Despite a physician's order and facility policy requiring AIMS testing and daily side effect monitoring, the facility failed to conduct these assessments in a timely manner. The deficiency was confirmed by the RN and unit manager, and an AIMS assessment was only completed after a surveyor's request.
Failure to Care Plan TLSO Brace Use
Penalty
Summary
The facility failed to create an individualized care plan for R108’s use of a TLSO brace. R108 was admitted on 7/18/25 with multiple diagnoses including a lumbar back fracture, and care plans were initiated on 7/21/25, but the care plans lacked evidence of any plan addressing the TLSO brace. The admission MDS on 7/22/25 documented fractures as active diagnoses and partial moderate assistance with upper body dressing. Clinical notes later documented that R108 was to continue wearing the brace to support the lumbar spine, and a physician note on 8/25/25 stated that the TLSO brace appeared very wide, went up to the chest, and that R108 was not strong enough to apply it very tightly, which may have been impeding healing of the fracture. POC documentation in July and August 2025 stated that the TLSO brace was to be applied at all times, and the DON confirmed the facility failed to develop a care plan related to the brace, including interventions for application, positioning, and tightness for the desired outcome.
Incorrect Transcription of Antidepressant Order
Penalty
Summary
The facility failed to ensure that a resident’s discharge medication orders were correctly transcribed after hospitalization. The resident was hospitalized from 7/14/25 to 7/18/25, and discharge instructions dated 7/18/25 directed continuation of fluoxetine 20 mg daily for depression. When the resident was admitted to the facility on 7/18/25 with multiple diagnoses including depression, a physician’s order was written on 7/19/25 for fluoxetine 10 mg daily instead of the 20 mg dose listed on the discharge documentation, and the record was unclear why the dose was reduced. The resident’s record showed a diagnosis of depression on the admission MDS, an initial psychology visit note documenting mild depression, and a depression care plan with an intervention to administer medication according to physician’s order. Review of the MAR showed thirteen doses of fluoxetine 10 mg given in July 2025 and four doses in August 2025. A psychiatry progress note on 8/4/25 documented depression/anxiety and stated to change fluoxetine to 20 mg to target mood, and a physician’s order was written that day to increase the dose from 10 mg to 20 mg. The DON later confirmed that the facility failed to correctly transcribe the initial antidepressant order, resulting in seventeen undermedicated doses.
Missed doses of newly admitted residents’ medications due to delayed pharmacy delivery
Penalty
Summary
The facility failed to provide prompt pharmacy services for newly admitted residents, resulting in missed doses of ordered medications for two residents reviewed for unnecessary medications. R77 was admitted with diagnoses including anxiety and had a physician’s order for clonazepam twice daily, but progress notes documented that doses were not given because staff were waiting for pharmacy clearance, awaiting a signature, and later because the medication was not available. The MAR showed missed doses on multiple occasions before the clonazepam was delivered by pharmacy. During interview, R77 stated the medication had been stopped for no reason when they came to the facility. R2 was admitted with diagnoses including major depressive disorder and mood disorder and had a physician’s order for quetiapine daily at 9:00 PM. Progress notes documented that the medication was not administered because it had not yet been delivered from the pharmacy, and the MAR lacked evidence that the ordered quetiapine was given on the first two scheduled doses. Pharmacy delivery documentation showed the medication was delivered later. Staff interviews confirmed that newly admitted residents sometimes do not have all medications available, that pharmacy delivery may take until the next day or 24 to 48 hours, and that the emergency medication box did not contain quetiapine.
Failure to Offer Opportunity to Formulate Advance Directives
Penalty
Summary
Three residents who were cognitively intact upon admission were not offered the opportunity to formulate an advance directive. Clinical record reviews showed that, although social history assessments documented code status and the presence of a general power of attorney, there was no documentation indicating that the residents were asked about existing advance directives or given the chance to create one. The assessments failed to address whether the residents had or wished to establish an advance directive. Interviews with facility staff, including the clinical liaison and an LPN, confirmed that the admitting nurse is responsible for reviewing admission documents and completing resident assessments. The NHA and DON stated that the physician would discuss advanced care options with residents during an exam, but there was no evidence in the records that this discussion or offer occurred. The lack of documentation and confirmation from staff interviews indicated that the facility did not provide the required opportunity for these residents to formulate advance directives.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe. According to the facility's policy, any allegation involving abuse must be reported to the State Survey Agency no later than two hours after management becomes aware of the allegation. In this case, a resident who was cognitively intact reported to nursing staff that she had been touched inappropriately by a nurse while vital signs were being taken. The incident was communicated to the RN and then to the DON on the same day it was reported by the resident. An internal investigation was initiated at that time. Despite the prompt internal communication and initiation of an investigation, the facility did not submit the required report to the State Agency until two days after the allegation was made. This delay in external reporting was confirmed through interviews with staff and review of the clinical record. The deficiency centers on the failure to adhere to the mandated reporting timeline for suspected abuse, as outlined in both facility policy and federal and state regulations.
Failure to Follow Physician's Order for Medication Parameters
Penalty
Summary
A deficiency was identified when a resident was administered metoprolol tartrate 25 mg despite physician orders specifying the medication should be held if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. The medication administration record (MAR) showed that the resident received the medication on multiple occasions when the HR was below the ordered parameter, including instances where the HR was 55 and 58. Interviews with nursing staff confirmed that the medication was given outside of the prescribed parameters and that the expectation was to hold the medication and notify the provider if parameters were not met. There were no adverse effects documented as a result of these administrations.
Failure to Develop Care Plan for Earwax Management
Penalty
Summary
The facility failed to develop a care plan for a resident to address wax build-up in the ears. The resident was admitted to the facility and subsequently received a physician's order for Debrox Otic Solution to be administered in both ears to manage earwax. Despite the physician's orders, a review of the resident's clinical record revealed that no person-centered care plan was created to address this issue. This deficiency was confirmed during an interview with a registered nurse and unit manager, who acknowledged the absence of a care plan for the wax build-up. The findings were discussed during an exit conference with the nursing home administrator, director of nursing, and representatives from the Ombudsman office.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R3, who was moderately cognitively impaired and required assistance with activities of daily living (ADLs). R3 was admitted to the facility and had a care plan that included assistance with grooming and personal hygiene. Despite this, observations revealed that R3's fingernails were long and had dark encrusted debris underneath them, indicating a lack of proper nail care. Interviews with R3's family member and staff confirmed that requests for nail care had been made but not fulfilled in a timely manner. The deficiency was further highlighted by multiple observations over several days, where R3's fingernails remained untrimmed and dirty. Staff interviews revealed a lack of consistent assessment and action regarding R3's nail care needs, despite the facility's policy requiring assistance with ADLs every shift. The failure to provide nail care was acknowledged during an exit conference with facility administrators and representatives from the Ombudsman.
Failure to Administer Ear Drops as Ordered
Penalty
Summary
The facility failed to administer ear drops as ordered by the physician for a resident, identified as R46, who was admitted with a condition of ear wax build-up. Despite a physician's order on 5/31/24 for Debrox Otic Solution to be administered twice daily for five days, the resident did not receive the medication as prescribed. Interviews with the resident and staff revealed that the resident continued to experience ear pain and discomfort, which was not addressed by the facility. The resident reported an inability to sleep due to the pain, and staff interviews confirmed that the medication was not administered from 5/31/24 through 6/5/24. Further investigation revealed that the medication was delivered to the facility and signed for on 5/31/24, but there was no documentation on the Medication Administration Record (MAR) to confirm its administration. Staff, including the Director of Nursing (DON) and a Registered Nurse (RN), were unfamiliar with a chart code used on the MAR, which contributed to the oversight. The facility's failure to provide the necessary care and services for the resident's ear condition was confirmed during an exit conference with facility representatives and the Ombudsman office.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident admitted with multiple diagnoses, including sudden onset respiratory failure with hypoxia. The resident was care planned for respiratory issues, including the provision of oxygen as ordered. However, there was a lack of a physician's order for the resident's oxygen therapy, despite the resident being on varying levels of oxygen therapy over several days. Observations and nurse progress notes documented the resident's fluctuating oxygen levels and the use of oxygen therapy, but no physician's order was in place until it was brought to the facility's attention by the surveyor. The deficiency was confirmed during interviews with facility staff, including an LPN and the Director of Nursing (DON), who acknowledged the absence of a physician's order for the resident's oxygen therapy. The issue was discussed during the exit conference with the Nursing Home Administrator (NHA), DON, and representatives from the Ombudsman office. The deficiency highlights a lapse in ensuring that physician orders are in place for necessary medical interventions, such as oxygen therapy, for residents with respiratory concerns.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring of antipsychotic medication for a resident, identified as R40, who was admitted with multiple diagnoses including unspecified dementia, psychotic disturbance, and mood disturbance. Upon admission, a physician's order was made for R40 to receive an AIMS (Abnormal Involuntary Movement Scale) test every 180 days. However, the facility's policy required an AIMS evaluation within 14 days of admission and every six months thereafter. An MRR (Medication Regimen Review) completed shortly after admission recommended an AIMS test at baseline and every six months, which was acknowledged by the facility. Despite this, the resident's medical records, including the MAR (Medication Administration Record) and progress notes, lacked evidence of daily side effect monitoring related to the use of antipsychotic medications. The deficiency was confirmed during an interview with the RN and unit manager responsible for R40's care, who acknowledged the absence of daily monitoring for side effects. An AIMS assessment was eventually completed and submitted to the surveyor on the day of the request, but this was not in accordance with the facility's policy or the physician's order. The findings were discussed during an exit conference with the Nursing Home Administrator, Director of Nursing, and representatives from the Ombudsman office.
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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.
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Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cadia Rehabilitation Capitol | 1.5 mi | ★★★★★ | 6 | 1 |
| Bay Terrace Rehabilitation And Health Center | 1.7 mi | ★★★★★ | 6 | 1 |
| Complete Care At Silver Lake Llc | 1.7 mi | ★★★★★ | 13 | 0 |
| Westminster Village Health | 1.8 mi | ★★★★★ | 13 | 1 |
| Evergreen Post Acute | 8 mi | ★★★★★ | 5 | 0 |
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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.