Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Nursing Center during CMS and state inspections, most recent first.
Failure to Report Injury of Unknown Source: A resident with dementia, depression, and COPD developed a large purple area on the left forearm that was observed by surveyors and later staff, but the injury was not reported to admin as required. Records showed no incident report or progress note documenting the finding, and staff interviews indicated caregivers, an LPN, the ADON, and the DON were not aware of the new skin issue when it was seen.
A resident with recent Influenza A was readmitted from the hospital with paperwork stating Tamiflu should be continued, but the facility did not enter an active Tamiflu order on readmission. Staff later confirmed the MAR had no Tamiflu order and acknowledged the discharge documents should have been reviewed and clarified. The facility also had expired flu swabs and then a delay in receiving replacement swabs after a flu test order was placed, while the resident continued to have cough, poor intake, lethargy, and decreased mentation.
The facility failed to ensure that a resident's advanced directives identifier was consistent with their wishes and provider's orders. The resident's wheelchair had a red band indicating DNR status, despite the resident's wish to be a full code. This inconsistency was confirmed through multiple interviews and observations, highlighting a failure in the facility's system for managing advanced directives.
A resident with mobility deficits and edema was not provided with planned positioning devices, leading to pain and potential skin breakdown. Staff failed to consistently implement the care plan intervention of placing a positioning wedge beneath the resident's feet while in bed.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility did not ensure that an alleged injury of unknown source was reported immediately to the administrator as required. Resident #12, who had diagnoses including dementia without behavioral disturbances, depression, and COPD, was moderately cognitively impaired and dependent on staff for much of their care, including transfers with a mechanical lift and substantial assistance with personal hygiene. During observation, a large purple area was seen on the resident’s left forearm, and when asked, the resident stated they did not know where it came from. The purple discoloration remained visible on the resident’s left forearm during a later observation. Review of accident and incident reports and nursing progress notes showed no documented report of the injury to administration. The resident’s shower and skin care were provided by staff, and a weekly skin check documented no skin impairment on the evening of the shower day. The facility’s internal investigation report stated a surveyor had notified staff that the discoloration had been observed previously, and the nurse who completed the skin assessment said the area was likely obscured by the resident’s wrist band. Staff interviews showed that multiple caregivers and nursing staff were not aware of the new skin issue when they observed or cared for the resident. An LPN stated they were not aware of any new injury and would have reported it if they had been aware. The ADON stated they were not aware of any new skin issues and expected whoever found the area to report it. The DON and Medical Director both stated that any new bruise or injury of unknown origin should be reported to administration, but the record showed no evidence that this occurred for the resident’s left forearm discoloration.
Missed antiviral continuation and delayed flu testing supplies
Penalty
Summary
Services provided by the facility did not meet professional standards of quality for one resident who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, anxiety, and dementia without behavioral disturbances. The resident’s care plan documented altered respiratory status related to a recent hospitalization for Influenza A and the need for oxygen as needed. Upon readmission from the hospital, the discharge paperwork and after-visit summary documented that Tamiflu was to be continued, but the facility did not enter an active Tamiflu order into the resident’s medication record. Staff later reviewed the resident’s medication administration record and confirmed there was no order for Tamiflu, active or discontinued, even though the hospital documents indicated the antiviral should continue. The resident had been hospitalized with shortness of breath and productive cough and was found to be positive for Influenza A. The hospital discharge summary stated the resident completed Tamiflu in the hospital course, but also listed follow-up issues to continue Tamiflu. The after-visit summary listed Tamiflu among the medications to start, and the medication list showed a change to Tamiflu dosing. Despite these documents, the admitting process did not result in a continued facility order for the antiviral. The facility’s own staff, including the Infection Preventionist, Assistant DON, Pharmacy Consultant, NP, Medical Director, and DON, acknowledged that the discharge paperwork should have been reviewed for medication discrepancies and clarified with the provider, but that did not occur at the time of readmission. The report also identified a delay in obtaining influenza swab supplies after a physician order was placed to test the resident for flu. Staff documented that the facility did not have usable swabs available because the supplies were expired, and when new swabs were ordered they were not immediately available. Nursing notes and interviews showed the NP was informed that swabs were unavailable and later instructed staff not to swab the resident and to treat symptoms conservatively. The resident continued to have cold symptoms, poor intake, lethargy, and decreased mentation, and later the NP documented the resident had recently had an upper respiratory infection suspected to be influenza due to exposure in the facility and had declined, with family requesting transfer to the emergency room.
Inconsistent Advanced Directives Implementation
Penalty
Summary
The facility did not ensure that the system developed for advanced directives was implemented in a manner consistent with the residents' wishes for one resident reviewed. Specifically, the facility failed to ensure that Resident #8's advanced directives identifier was consistent with the resident's wishes and the provider's orders. The resident had a diagnosis including a fracture of the sixth cervical vertebra, dementia, and intracerebral hemorrhage. The Minimum Data Set documented that Resident #8 was severely cognitively impaired and had a do-not-resuscitate (DNR) order. However, the comprehensive care plan and the Medication Review Report indicated that Resident #8 wished to be a full code, meaning they wanted CPR if needed. Despite this, the resident's wheelchair had a red band indicating DNR status, and there was no MOLST form in the advanced directives binder for Resident #8. This inconsistency was confirmed through multiple interviews with staff and the resident's family member, who stated that the resident wished to be a full code. During observations and interviews, it was found that the staff relied on various identifiers to determine a resident's code status, including arm bands, electronic medical records, and the MOLST form. However, in the case of Resident #8, these identifiers were not consistent. Certified Nurse Aide #3 and Licensed Practical Nurse #2 both confirmed that a red bracelet indicated DNR and a blue bracelet indicated full code. The Social Worker and the Director of Nursing also confirmed that the code status bands should match the orders and the MOLST form. The inconsistency in Resident #8's code status band could have led to a delay in receiving CPR if needed, as staff would have wasted time looking for the correct documentation. The Director of Nursing stated that the Registered Nurse Resident Care Coordinator and the Social Worker were responsible for checking the code bands weekly and documenting it on an audit sheet. However, in this case, the system failed to ensure that Resident #8's code status band matched the resident's wishes and the provider's orders. This failure to implement the advanced directives system correctly could have resulted in the resident not receiving the life-saving measures they wanted or receiving measures they did not want.
Failure to Implement Care Plan for Resident Positioning
Penalty
Summary
The facility did not ensure that a resident's person-centered care plan was implemented to meet their medical and nursing needs. Specifically, a resident who required extensive assistance for bed mobility was not provided with their planned positioning devices. The resident, who had diagnoses including unspecified fracture of the right lower leg, periprosthetic fracture around the internal prosthetic left knee joint, and congestive heart failure, was observed multiple times with their left foot pressed firmly against the footboard, causing pain and potential risk for skin breakdown. The care plan had documented the need for a positioning wedge beneath the resident's feet while in bed, but this intervention was not consistently implemented by the staff. During observations and interviews, it was noted that the resident's left leg had pitting edema, and the resident expressed pain due to their foot being pressed against the footboard. The resident was unable to reposition themselves independently and stated that staff had not placed the wedges under their feet as required. Certified Nursing Assistant #1 and Registered Nurse #1 acknowledged the care plan intervention but failed to implement it consistently. The Director of Physical Therapy and the Director of Nursing also confirmed the importance of the intervention to prevent pain and skin breakdown. The facility's policies and procedures for quality of care, turning and positioning, and edema management were not followed. There was no documented evidence that the resident refused or did not tolerate the use of the positioning wedges. The failure to implement the care plan interventions as documented led to the resident experiencing pain and potential risk for skin issues due to improper positioning in bed.
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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) |
|---|---|---|---|---|
| Autumn View Health Care Facility L L C | 6 mi | ★★★★★ | 3 | 0 |
| Elderwood At Hamburg | 6.4 mi | ★★★★★ | 3 | 0 |
| Father Baker Manor | 8.9 mi | ★★★★★ | 1 | 1 |
| Fox Run At Orchard Park | 10.6 mi | ★★★★★ | 0 | 0 |
| Mercy Hospital Skilled Nursing Facility | 12.2 mi | ★★★★★ | 0 | 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.