Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, recent stroke, diabetes requiring insulin, and dependence in ADLs was discharged home after rehab despite documented need for 24‑hour care, home health, and DME. Facility staff relied on two friends as contacts, even though they repeatedly stated they could not provide 24‑hour care or assume legal/financial responsibility, and a family member listed as a contact was not included in discharge planning. The care plan lacked a person‑centered discharge component identifying responsible caregivers and coordinated services. When insurance coverage ended, the SW obtained a NOMNC by verbal consent from a friend who later reported feeling pressured and unclear about appeal options. The resident was discharged to an apartment alone, on a holiday, without confirmed 24‑hour support, with home health not yet in place and only a wheelchair delivered. In the days following discharge, home health and APS staff found the resident bedbound, soiled with incontinence, unable to answer the door or evacuate, and not consistently receiving prescribed medications, leading to hospital admission with a UTI. Surveyors determined this constituted immediate jeopardy beginning at the time of discharge.
A resident with severe cognitive impairment, anxiety, depression, communication deficit, and dementia was admitted without an identified legal decision maker or responsible party and with only limited Medicare Part A managed care coverage. The care plan did not address the absence of a legal representative or the need for assistance with a Medicaid application, and when the resident’s Medicare skilled days were exhausted, no additional payor source was identified. Facility staff, including the Admission Director and SW, acknowledged they knew the resident lacked a legal representative and financial coverage beyond Medicare and had discussed the need for guardianship and Medicaid application assistance, but no guardianship referral was made and no Medicaid application was initiated before the resident was discharged home/community with severe cognitive impairment still documented.
Surveyors found that food stored in two nourishment refrigerators was not consistently labeled or dated according to facility policy. Multiple items, including sandwiches, homemade food, beverages, and takeout containers, lacked resident names and dates, and some items were marked only with unclear date ranges. The Dietary Manager, DON, and Administrator all reported that nursing staff are responsible for labeling and dating food brought in by families, that food should be discarded within seven days, and that dietary staff are responsible for checking the refrigerators and discarding expired items, but these practices were not followed as observed.
Surveyors found that a medication cart contained two open, undated Lantus insulin pen injectors and several opened insulin pens (Lispro, Aspart Flex, and Glargine) that were marked as expired but had not been removed. A nurse reported that nurses assigned to the carts are responsible for dating multi-dose medications upon opening and discarding undated or expired vials, but acknowledged she had not checked the opening or expiration dates at the start of her shift. The DON stated that nurses are expected to verify opening and expiration dates on cart medications at the beginning of each shift and ensure no expired items remain.
A resident with a court-appointed Legal Guardian experienced abdominal pain and initially agreed, then refused, to go to the hospital. Nursing staff, believing the resident was alert and oriented, did not notify the Legal Guardian of the refusal or the change in condition, instead proceeding with in-house labs and x-rays. The Legal Guardian was only informed after the resident's condition worsened and a hospital transfer was required, preventing the representative from exercising the resident's rights.
A resident with neuromuscular dysfunction of the bladder had an unsecured indwelling urinary catheter, contrary to physician orders and care plan instructions. Observations showed the catheter was not attached to the leg, and the urine appeared dark with sediment. Staff interviews revealed a lack of knowledge and consistency in securing the catheter, with the DON confirming the need for securement devices to be checked every shift.
The facility failed to manage medications properly, with expired drugs and loose pills found in multiple medication carts. Nurses were unaware of these issues, and an open vial of lidocaine lacked a documented open date. The ADON stated that both third shift and assigned nurses were responsible for these tasks, but deficiencies persisted.
A resident with multiple sclerosis and muscle weakness did not receive the prescribed lightweight utensils with a rubber grip, as required for her condition. During a meal, she was given heavy weighted utensils, which she could not use, and no staff checked on her to correct the mistake. The Dietary Manager acknowledged the error but did not provide the correct utensils or offer to reheat the meal, leaving the resident unable to eat.
A facility failed to implement Enhanced Barrier Precautions during catheter care for a resident with an indwelling catheter. A nurse aide was observed performing the care without wearing a gown, despite the facility's policy requiring gowns and gloves for such procedures. The resident had a physician order for enhanced barrier precautions due to neuromuscular dysfunction of the bladder. The nurse aide admitted to forgetting the gown, and interviews with the DON and Administrator confirmed the requirement for gowns and gloves.
The facility failed to accurately document RN staffing for 51 out of 103 days, as revealed by a review of daily staffing sheets. Interviews with staff indicated a misunderstanding about including salaried RNs on the sheets, despite their presence in the building. The DON and Administrator confirmed the presence of an RN daily but did not ensure accurate documentation, leading to the deficiency.
Unsafe Discharge of Dependent, Cognitively Impaired Resident Without 24‑Hour Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a cognitively impaired resident with multiple comorbidities and dependence in ADLs. The resident had a history of stroke, dementia, diabetes, hypertension, hypothyroidism, hyperlipidemia, osteoarthritis, anemia, anxiety, and depression, and had been admitted after being found on the floor at home with weeks of medication non‑compliance. On admission, the resident required substantial to maximum assistance with bathing, dressing, toileting, transfers, and bed mobility, was frequently incontinent of bowel and bladder, and received insulin injections. The admission MDS documented severe cognitive impairment, and therapy and care plan documentation showed the resident needed extensive assistance and 24‑hour care and medication monitoring. From admission forward, the facility relied primarily on two friends as contacts, even though they repeatedly stated they could not provide 24‑hour care or assume legal or financial responsibility. The face sheet listed two friends as first and second emergency contacts and a family member as third contact, with no responsible party identified. The admissions Director and SW discussed guardianship and Medicaid with the friends, who declined, and the SW did not reach out to the family member at admission for input on care or discharge planning, despite his being listed as a contact and having been involved with the hospital and PCP. The care plan dated 3/20/26 addressed ADL and diabetes needs but did not include a person‑centered discharge plan with goals and interventions for identifying responsible caregivers, coordinating services for ADLs, psychosocial support, or financial needs. As the resident’s Medicare or insurance coverage neared exhaustion, the SW obtained a NOMNC by verbal consent from one friend, documented that the last covered day would be 4/2/26, and recorded that the representative did not wish to appeal and requested discharge. The friend later reported feeling pressured, not understanding the appeal process, and not knowing she could refuse to take the resident home, and both friends continued to tell staff they could not provide 24‑hour care or stay overnight. Despite therapy and NP documentation that the resident required 24‑hour care, home health, in‑home aide services, and DME such as an elevated toilet seat, 3‑in‑1 commode, grab bars, and assistive devices, the discharge proceeded without confirmation that 24‑hour support, services, or necessary DME were in place. Home health was contacted only shortly before discharge, with an anticipated 24–48 hour delay before a visit, and the only DME present at home at the time of the first home health visit was a wheelchair. The resident was discharged home on a holiday, to an apartment where she lived alone, without verified 24‑hour caregivers and without arrangements for continuous assistance with ADLs, incontinence care, mobility, or medication administration. Friends were only able to intermittently visit, provide meals, change the resident, and put her to bed, and they did not administer medications, including insulin. Over the days immediately following discharge, both a home health nurse and an APS worker found the resident in bed, soiled with urine and feces, unable to get out of bed even with assistance, unable to answer the door or vacate in an emergency, and not consistently receiving prescribed medications. The resident was also unable to use her medical alert necklace or call 911. Based on the APS assessment, an emergency order was obtained for transfer to the hospital, where the resident was admitted with a urinary tract infection. Surveyors determined that immediate jeopardy began when the resident was discharged home without the necessary 24‑hour support and services required to ensure her well‑being and safety.
Failure to Assist Cognitively Impaired Resident With Guardianship and Medicaid Application
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services to assist a severely cognitively impaired resident without a legal decision maker or payor source in obtaining guardianship and Medicaid coverage. The resident was admitted with diagnoses including anxiety, depression, communication deficit, and dementia, and the admission MDS documented severe cognitive impairment with no responsible party, guardian, or power of attorney identified. The care plan initiated on 3/20/26 did not include any interventions addressing the lack of a legal decision maker or assistance with completion of a Medicaid application. The resident’s payor source at admission was a Medicare managed care plan with limited Part A skilled days, which were exhausted on 4/3/26, and there was no additional payor source documented. Record review showed no evidence that the facility assisted the resident with a Medicaid application or made any referral for guardianship or other means of establishing a legal decision maker, despite awareness of the resident’s severe cognitive impairment and lack of a representative. The discharge MDS, coded as a return not anticipated to home/community, continued to show severe cognitive impairment. Interviews with the Admission Director and Social Worker confirmed that both were aware the resident had no legal representative and no additional financial coverage beyond Medicare, and that guardianship and Medicaid needs had been discussed but not acted upon. The Social Worker stated that no guardianship referral or Medicaid application assistance was provided and attributed this to running out of time before the resident’s discharge. The Administrator reported there was a breakdown in communication and that existing policies did not clearly define the roles and responsibilities of the Admission Director and Social Worker regarding initiation of guardianship and financial applications for such residents.
Improper Labeling and Dating of Resident Food in Nourishment Refrigerators
Penalty
Summary
Surveyors identified a deficiency in food storage practices in two nourishment refrigerators on the 400 and 500 hallways. During observation of the 400 hallway nourishment refrigerator, they found multiple food items without resident names or dates, including a gallon-size clear plastic bag containing a sandwich, a 4-ounce juice carton, and a snack bag; a peanut butter and jelly sandwich in a plastic bag; food wrapped in aluminum foil; an opened 16-ounce soda bottle; and a takeout 20-ounce coffee cup. They also observed a takeout box with pinto beans and seasoned rice labeled with a date range written as the 13th–15th, rather than a clear single date. In the 500 hallway nourishment refrigerator, surveyors observed a small plastic container with homemade food with no label for resident name or date, a gallon-size plastic container with homemade food labeled only with a date range of 2/5–2/9 and no resident name, and a grocery bag containing a box of fried chicken with no name or date. In interviews, the Dietary Manager stated that nursing staff were responsible for labeling and dating food brought in by visitors for residents before placing it in the nourishment refrigerators, that food could be stored for seven days before being discarded, and that he or dietary staff checked the nourishment refrigerators daily when restocking to discard expired food. The DON similarly stated that all nursing staff, including nurses and nurse aides, were responsible for labeling and dating any food brought in by family for residents, that food should be discarded within seven days, and that no personal staff food should be stored in the nourishment refrigerators. The DON also stated that dietary staff were responsible for ensuring all food was discarded after seven days. The Administrator confirmed that residents’ food should be labeled and dated before being placed in the nourishment refrigerators and that staff should follow policy for residents’ food brought in by families, with dietary staff ensuring expired food was discarded.
Failure to Date and Remove Expired Multi-Dose Insulin Pens From Medication Cart
Penalty
Summary
Surveyors identified a failure to properly date and remove multi-dose insulin pen injectors from a medication cart on the 500-hall. During an observation of the cart with a nurse, two open and undated Lantus insulin pen injectors were found. Review of the manufacturer's instructions showed that Lantus multi-dose vials are to be discarded 28 days after opening, but there was no way to determine when these pens had been opened due to the lack of dating. Further inspection of the same cart's second drawer revealed additional issues with expired insulin pens. One opened Lispro insulin pen was marked as expired on 2/10/26, one opened Aspart Flex insulin pen was marked as expired on 1/15/26, and one opened Glargine insulin pen was marked as expired on 2/9/26, yet all remained in the cart. In interviews, the nurse stated that nurses assigned to the carts were responsible for discarding open and undated multi-dose vials and that training required dating vials upon opening, but she acknowledged she had not checked opening or expiration dates at the start of her shift. The DON also stated that nurses were responsible for checking opening and expiration dates on medications in the carts at the beginning of each shift and expected that no expired items remain in the carts.
Failure to Notify Legal Guardian of Resident's Refusal for Hospital Transfer
Penalty
Summary
The facility failed to communicate with a resident's Legal Guardian regarding the resident's abdominal pain and the resident's refusal to go to the hospital. The resident, who had a history of hypertensive heart disease with heart failure, diabetes mellitus type 2, dementia, and hypomagnesemia, was admitted with a court-appointed Legal Guardian responsible for making medical decisions. On the day of the incident, the resident complained of mild abdominal pain and was initially agreeable to hospital evaluation but later refused. The nurse, assessing the resident as alert and oriented, did not inform the Legal Guardian of the resident's refusal or the change in condition, instead proceeding with labs and x-rays at the facility as ordered by the Nurse Practitioner. Subsequent staff interviews revealed that the Legal Guardian was not notified of the resident's abdominal pain or refusal to go to the hospital on the day it occurred. The following day, the resident's condition worsened, and the nurse on duty notified the Legal Guardian about the transfer to the emergency room and the events of the previous day. The Legal Guardian expressed that he should have been contacted earlier, as he was responsible for medical decisions and believed the resident would have followed his advice to seek hospital evaluation. Interviews with facility leadership, including the DON and Administrator, confirmed that the resident was not capable of making his own medical decisions and that the Legal Guardian should have been contacted regarding the refusal of hospital transfer. The failure to notify the Legal Guardian prevented the representative from exercising the resident's rights as required.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to properly secure the indwelling urinary catheter for a resident with neuromuscular dysfunction of the bladder, leading to potential complications. The resident was admitted with a physician's order to use an indwelling catheter with a closed drainage system and a catheter securing device to reduce tension and facilitate urine flow. Observations revealed that the catheter was not secured to the resident's leg, and the tape used for securement was loose and not attached. The resident's care plan included instructions to position the catheter bag and tubing below the bladder level and to secure the catheter with tape on the leg. During observations, it was noted that the catheter tube was not secured, and the urine in the tubing appeared dark with sediment. A nurse aide admitted to not knowing how to secure the catheter, and the tape was dated several days prior. Interviews with staff, including a nurse and the wound nurse, indicated a lack of consistent checking and securement of the catheter. The Director of Nursing confirmed that all residents with indwelling catheters should have a securement device attached and checked every shift.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage practices, as observed during a survey. On Hall 3's medication cart, an expired bottle of Bisacodyl was found, and Nurse #3 was unaware of its expiration, attributing the responsibility to night shift nurses. Additionally, loose pills were discovered in the medication carts for Halls 1, 2, and 4. Nurse #4 was unaware of a loose pink pill in the cart for Halls 1 and 2, while Nurse #2 did not notice two loose pills in Hall 4's cart. Furthermore, an open vial of lidocaine without a documented open date was found in Hall 4's cart, with Nurse #2 unaware of its status. The Assistant Director of Nursing (ADON) explained that third shift nurses were tasked with cleaning the medication carts, checking for expired medications, and ensuring open dates were documented. However, the nurses assigned to each cart were also responsible for these tasks. Despite the ADON's assertion that the nurses were aware of their duties, the deficiencies were still present, indicating a lapse in adherence to medication management protocols.
Failure to Provide Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide adaptive eating utensils to a resident who required lightweight utensils with a rubber grip, as per the physician's order and care plan. The resident, who was admitted with multiple sclerosis and muscle weakness, was observed during a lunch meal to have received heavy weighted utensils instead of the prescribed lightweight ones. The resident expressed her inability to eat with the heavy utensils and mentioned that no staff had checked on her since her meal was delivered. The Dietary Manager confirmed the error but did not rectify it, leaving the resident without the proper utensils and unable to eat her meal. Interviews with staff revealed a lack of adherence to procedures for ensuring residents receive the correct meal accommodations. The Nursing Assistant admitted to not reading the meal ticket and was unaware of the resident's need for lightweight utensils. The Dietary Aide, who was still in training, acknowledged mistakenly providing the wrong utensils. The Dietary Manager, upon realizing the mistake, failed to provide the correct utensils or offer to reheat the resident's meal, as the resident had stated she would not eat cold food. The Administrator was informed of the situation but noted that the Dietary Manager did not take corrective action after the resident's complaint.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. The facility's policy required the use of gowns and gloves for high-contact resident care activities, such as catheter care. A nurse aide was observed performing urinary catheter care without wearing a gown, although she wore gloves throughout the procedure. The resident had a physician order for the use of an indwelling catheter due to neuromuscular dysfunction of the bladder, and enhanced barrier precautions were ordered for every shift. The nurse aide admitted to forgetting to wear the gown during the procedure. Interviews with the Director of Nursing and the Administrator confirmed that staff should wear gloves and gowns when performing catheter care under EBP.
Inaccurate RN Staffing Documentation
Penalty
Summary
The facility failed to post accurate Registered Nurse (RN) staffing information for 51 out of 103 days reviewed. The daily posted nurse staffing sheets from August 2024 through November 2024 were examined, revealing that on numerous days, there was no RN documented as working for all three shifts. This discrepancy was confirmed through interviews with the Office Assistant, Scheduler, Director of Nursing (DON), and Administrator. The Office Assistant, responsible for completing the daily staffing sheets, stated that she was trained by the Scheduler and was aware that an RN needed to be present in the building for at least 8 hours a day. However, she was informed that salaried RNs could not be counted on the staffing sheets, even though they were present in the building. The Scheduler confirmed the training provided to the Office Assistant and acknowledged the requirement for an RN to be present for at least 8 hours daily. However, there was a lack of communication regarding the inclusion of salaried RNs on the staffing sheets. The DON admitted there was no process in place to verify the accuracy of the daily posted nurse staffing sheets, although she reviewed assignment sheets daily. The Administrator used the staffing sheets to determine who was providing hands-on care, not who was present in the building, and confirmed that an RN was present every day for at least 8 hours. This oversight in accurately documenting RN presence on the staffing sheets led to the deficiency identified by the surveyors.
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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 Eden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Unc Rockingham Rehab & Nursing Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Martinsville Health And Rehab | 11.7 mi | ★★★★★ | 20 | 0 |
| Jacob's Creek Nursing And Rehabilitation Center | 12.3 mi | ★★★★★ | 2 | 0 |
| Penn Nursing Center | 12.3 mi | ★★★★★ | 0 | 0 |
| Cypress Valley Center For Nursing And Rehabilitati | 12.4 mi | ★★★★★ | 0 | 0 |
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