East End Health & Rehab Center

Inspectors wroteBased on review of facility policy and documents, and interviews with staff, it was determined that the facility staff failed to implement policies and procedures to notify the local law enforcement in a timely manner after a visitor verbalized threats of harm, physical intimation, and/or allegedly threatened to use a weapon on facility property against an employee, on one of three resident care units (Fourth Floor Nursing Unit).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen.

Inspectors wroteBased on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for eleven of eleven months (September 2024 thru August 2025).

Inspectors wroteBased on a review of facility policy and staff interview, it was determined the facility failed to ensure that the Infection Prevention and Control Program (IPCP) was overseen by an individual who adequately assesses, develops, implements, monitors, manages and has appropriate knowledge, skills and time to perform the IPCP for eleven of twelve months.

Inspectors wroteBased on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for four of eight residents (Residents R25, R81, R88 and R104).

Inspectors wroteBased on review of clinical records, facility policy and staff and interviews it was determined the facility failed to make certain consistent dialysis communication was maintained for two of two residents (Residents R14 and R81), and failed to ensure resident's receiving dialysis received care and treatment as ordered and ensured fluid restrictions were maintained for one of two residents (Resident R81)

Inspectors wroteBased on review of facility documents, resident clinical records and staff interviews it was determined that the facility failed to ensure resident's had the capacity to understand the terms of a binding arbitration agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) for two of three residents (Resident R82, CR315).

Inspectors wroteBased on facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to implement COVID monitoring, isolation, tracking, and testing in accordance with state and federal guidance for one of two residents (Resident R31), failed to prevent cross contamination during a dressing change for one of three residents (Resident R86), and failed to ensure enhanced barrier precautions were implemented for one of three residents (Resident R131). The facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for eleven of twelve months (September 2024, thru August 2025).

Inspectors wroteBased on clinical records, an observation and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for one of six residents (Resident R19).

Inspectors wroteBased on review of clinical records, staff and interviews, it was determined that the facility failed to develop and implement a baseline care plan for one out of three residents (Resident R131).

Inspectors wroteBased on review of clinical records, staff, and resident interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one out of two residents (Resident R19).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of three residents (Resident R84).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store medications and biologicals properly andsecurely in one of five medications carts (fourth floor medication cart) and one of three medication rooms (fourth floor medication room).

Inspectors wroteBased on review of clinical records, observations, staff, and resident interviews, it was determined that the facility failed to provide residents food products based on their preferences for one out of four residents (Resident R19).

Inspectors wroteBased on review of facility policy, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of two medication carts (3 South medication cart).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels as per physician's order and failed to document appropriate interventions for a resident with hypoglycemia (low blood glucose), for two of four sampled residents (Residents R30 and R63).

Inspectors wroteBased on review of facility policy, resident clinical records, and staff interviews, it was determined that the facility failed to properly assess pressure ulcers and update wound treatments for one of three sampled residents (Residents R30).

Inspectors wroteBased on review of facility policy, resident clinical records, resident and staff interview, it was determined that the facility failed to provide adequate and timely podiatry care treatment for one of two residents (Resident R85).

Inspectors wroteBased on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a urinary catheter as required for one of two residents (Resident R84).

Inspectors wroteBased on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for two of four residents (Resident R16 and R46).

Inspectors wroteBased on review of facility policy, observations and staff interview it was determined that the facility failed to label/date opened medications on one of two medication carts (3 South medication cart) and failed to properly store medical supplies and biologicals in one of two medication carts (3 South medication cart) and failed to secure treatment medications and supplies in one of two treatment carts. (3rd floor treatment cart).

Inspectors wroteBased on review of facility policy, observation, clinical record review, and staff interviews, it was determined that the facility failed to provide a safe and sanitary environment to help prevent the potential for cross contamination for two of two laundry room observations, failed to provide PPE (Personal Protective Equipment) signage which created the potential for cross-contamination and the spread of diseases and infections for one of two residents (Resident R51), failed to prevent cross contamination during a dressing change for one of three residents (Resident R16) and failed to prevent cross contamination during a medication pass for one of two residents (Residents R52).

Inspectors wroteBased on a review of facility policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen (Main kitchen).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to complete a Legionella assessment and plan, implement infection control practices to prevent cross contamination during a dressing change for one of three residents (Resident R279) and the facility failed to maintain a clean dryer filter to ensure linens and laundry are processed in accordance with accepted national standards for one of two dryers (Laundry room).

Inspectors wroteBased on facility policy, documents and observations and staff interviews it was determined the facility failed to maintain an effective pest control program related to fruit flies in the kitchen (Main Kitchen).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual (RAI), clinical record review and staff interview, it was determined that the facility failed to complete Minimum Data Set (MDS) assessments in a timely manner for one of six residents (Residents R71).

Inspectors wroteBased on staff interview, record review, and state scope of practice, it was determined that the facility failed to follow professional standards of practice for to one of six residents reviewed (Resident R57).

Inspectors wroteBased on review of facility policy, personnel files and staff interview it was determined that the facility failed to complete annual nurse aid employee evaluations for one of four sampled records (Nurse aide (NA) Employee E8).

Inspectors wroteBased upon clinical record review, and staff interview, it was determined that the facility failed to ensure that any irregularities submitted in the medication regiment reviews (MRR) by pharmacy were acted upon for one out of two residents (Resident R10).

Inspectors wroteBased on a review of facility policy, resident clinical record review, medication review, and staff interview it was determined the facility failed to label open medications with a date on one of three medication carts (Third floor Medication B-Cart).

Inspectors wroteBased on review of facility documents and staff inteviews, it was determined that the facility failed to employ staff with the required skills and competencies to carry out the daily functions of the Dietary Department for three out of 12 months (August, September and October 2023).

Inspectors wroteBased on review of facility documents, resident clinical record and staff interview it was determined that the facility failed to ensure a representative signed a binding arbitration agreement on the behalf of residents lacking capacity to understand the agreement terms for two out of four sampled resident records (Resident R38 and Resident R60).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interview, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R13).