Deficiency Records for Eden Springs Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Eden Springs Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-19 | 2024-02-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-19 | 2024-02-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-19 | 2024-02-08 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-03 | 2023-12-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-05 | 2023-10-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-05 | 2023-10-03 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-13 | 2023-05-10 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-02-13 | 2023-05-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-13 | 2023-05-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-13 | 2023-03-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-16 | 2023-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-14 | 2022-10-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-14 | 2022-10-14 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-09-14 | 2022-10-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-17 | 2022-06-17 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-05-17 | 2022-06-17 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-05-17 | 2022-06-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-17 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-23 | 2021-11-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-23 | 2021-11-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-18 | 2021-07-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-20 | 2020-03-20 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-20 | 2020-03-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-20 | 2020-03-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-20 | 2020-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-19 | 2020-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-19 | 2020-03-20 | N |
