Eastgate Village Care & Rehab Center

Inspectors wroteOn 07/01/25, a past non-compliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the safety of residents at risk for elopement. On 06/19/25, Resident #1 eloped from the property through the front entrance at approximately 6:30 p.m. by following out a food delivery person. Resident #1 had a history of threatening to elope and wandering. The police found and returned Resident #1 to the facility at approximately 7:30 p.m. and reported Resident #1 was located in a field near the facility. Based on record review and interview, the facility failed to provide supervision to ensure the safety of a resident for 1 (#1) of 2 sampled residents reviewed with exit seeking behaviors. The DON identified one resident wandered.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident assessments were accurate for 3 (#1, 52, and #60) of 18 sampled residents whose assessments were reviewed. The administrator identified 75 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a care plan was updated/revised for 1 (#1) of 18 sampled residents whose care plans were reviewed. The administrator identified 73 residents resided in the facility with 2 in the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper infection control practices were utilized during transportation of linen to the soiled closet for 1 observation during review of infection control practices. The administrator identified the census of 73 in house with 2 in the hospital.

Inspectors wroteBased on record review and interview, the facility failed to notify a resident's representative/legal representative for treatment of a UTI for 1 (#1) of 1 sampled resident reviewed for notification of change. The administrator identified 73 residents resided in the facility with two in the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure advance beneficiary notices were provided for 2 (#10 and #18) of 3 sampled residents who were reviewed for beneficiary notices. The Beneficiary Notice - Residents discharged Within the Last Six Months form documented four residents who were discharged to home with skilled days remaining in the last six months.

Inspectors wroteBased on record review and interview, the facility failed to provide a notice of bed hold to 2 (#1 and #80) of 2 sampled residents who were transferred to the hospital. The administrator identified 75 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan intervention for the creation and implementation of a behavioral flow sheet had been implemented for 1 (#60) 5 sampled residents who were reviewed for unnecessary medications. The DON identified 75 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were weighed weekly for four weeks upon admit for 1 (#78) of 3 sampled residents who were reviewed for nutrition. The DON identified 75 residents who resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were secured for 2 (E hall medication cart, and B/C hall treatment cart) of 6 medication/treatment carts observed. The DON identified six medication/treatment carts were utilized in the facility. A Medication Storage in the Facility policy, dated 2021, read in part, Medication rooms, carts, and medication supplies are locked. On 02/04/25 at 3:40 p.m., an observation was made of an unlocked and unattended cart on E hall across from room E1. Inside the cart were resident medications. There was no staff near the cart nor on E hall at the time of observation. On 02/04/25 at 3:44 p.m., CMA #1 came from around the corner by the dining room to the cart and locked it. They stated the policy for medication storage was to lock the cart. They stated they went to get a laptop and forgot to lock it. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods were dated when opened for 2 of 2 observations in the kitchen. The DON identified 72 residents who received nourishment from the kitchen.

Inspectors wroteBased on record review, observation, and interview, the facility failed to prepare and serve food for the residents in a sanitary manner. The administrator identified 82 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to treat residents with dignity during meal service in the dining room. The administrator identified 50 residents who ate meals and were served in the dining room.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessments were accurate for two (#35 and #75) of 19 sampled residents whose assessments were reviewed. The DON identified 82 residents who currently resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to conduct a significant change assessment for one (#37) of 18 sampled residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 80 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to correctly complete a PASRR level l form and make a referral to the state mental health authority or state intellectual disability authority for one (#26) of three residents reviewed for PASRR. The administrator identified 82 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the necessary ADL assistance to residents who were unable to carry out their own for one (#37) of four residents sampled for ADL assistance. The DON identified 82 residents who currently resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' nutritional issues were supervised by a physician for one (#39) of one resident sampled for weight loss. The Resident Census and Conditions of Residents form documented 80 residents resided in the facility.

Inspectors wrote2. Res #38 had diagnoses which included major depressive disorder, diabetes mellitus, chronic obstructive pulmonary disease, and abnormal weight loss. An annual assessment, dated 09/28/23, documented Res #38 was moderately impaired with cognition and required minimal assistance with ADLs. On 10/31/23 at 12:19 p.m., Res #38 stated the pancakes and eggs were always cold when they received them. 3. Res #70 was admitted to the facility with diagnoses of diabetes mellitus type II, depression, anxiety, and metabolic encephalopathy. An admission assessment, dated 10/10/23, documented Res #70 was cognitively intact and required minimal assistance with ADLs. On 10/31/23 at 12:33 p.m., Res #70 stated the food was always cold. Based on observation and interview, the facility failed to serve food at an appetizing temperature for the residents. [...]

Inspectors wroteBased on record review, observations, and interview, the facility failed to ensure a comprehensive care plan was developed for three (#45, 46, and #63) of 21 residents whose care plans were reviewed. The Resident Census and Condition of Residents form documented 70 residents resided at the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure certifications were not expired for one (CMA #1) of four Certified Medication Aides who were reviewed for current certifications. The DON identified 70 residents who received medications in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a major decline in the residents status was assessed for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure alternatives were attempted, an assessment was conducted, an informed consent and a physician's order was obtained, prior to installing side rails for one (#46) of one resident reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to conduct regular inspections of beds, side rails, and mattresses, to identify any areas of potential entrapment for one (#46) of one residents reviewed for accident hazards. The Resident Census and Conditions of Residents form documented 70 residents resided in the facility.