Eastland Rehabilitation and Nursing Center

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure that vital signs were monitored as ordered prior to the administration of medication. This affected one (Resident #70) of eight residents reviewed for medications. The facility census was 92 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were stored appropriately. This affected one (Resident #13) of eight residents reviewed for medications. The facility census was 92 residents.

Inspectors wroteBased on review of the medical record, review of hospital records, staff interviews, and review of facility policies, the facility failed to ensure accuracy of the medical record related to residents neurological assessments. This affected two Residents (#54 and #78) of three reviewed for falls. The facility census was 76.

Inspectors wroteBased on closed medical record review and interview, the facility failed to timely report a change in condition to Resident #20's physician. This affected one resident (#20) of three residents reviewed for change in condition. The facility census was 83.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to prevent the development and/or worsening of pressure ulcers and to ensure adequate and appropriate interventions/treatments were in place as ordered and to promote healing. This affected two residents (#40 and #49) of two residents reviewed for pressure ulcers. The facility census was 76. Actual harm occurred beginning on 04/10/25 when Resident #49, who was cognitively impaired, rarely/never understood and dependent on staff for activities of daily living was assessed by Wound Certified Nurse Practitioner (CNP) #1200 to have a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. [...]

Inspectors wroteBased on observation, interview, and facility policy review. The facility failed to store Insulin in a safe manner on the 100 and 300 hall medication carts. This had the potential to affect six residents (Residents #2, #14, #16, #36, #41 and #47) who received insulin on those halls. The facility census was 76.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to store food in a sanitary manner. This had the potential to affect 73 of 76 residents who ate food from the kitchen (Residents # 20, #42, and #55 were identified by the facility as not eating or drinking from the kitchen.) The facility census was 76 residents.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure enhanced barrier precautions were in place for Resident #49 who had pressure ulcer wounds while at the facility. This affected only Resident #49 who was reviewed for enhanced barrier precautions. This had the potential to affect 10 residents on the same hall. The total facility census was 76.

Inspectors wroteBased on medical records review, observations and staff interviews, the facility failed to provide dignity with dining for two residents who needed assistance with their meals (Resident # 4 and #31) out of fourteen residents reviewed for dining observation. This had the potential to affect five residents (#4, #12, #21, #31, and #33) that needed assistance with dining. The facility census was 76 residents.

Inspectors wroteBased on resident record review, observations and staff interviews, the facility failed to provide supervision in the dining room for a resident who was at risk for choking. This affected one resident (Resident #33) and had the potential to affect 23 residents that the facility identified as having dysphagia, difficulty swallowing (Resident #2, #9, #12, #16, #22, #25, #28, #29, #33, #34, #38, #44, #46, #49, #59, #67, #71, #73, #74, #75, #78, #133, and #233.) The facility census was 76 residents.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to communicate with dialysis center and failed to perform pre and post dialysis assessments for one, Resident #29. This had the potential to affect four residents (Residents #6, #29, #31 and #36) who received dialysis. The facility census was 76.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure proper parameters were identified for as needed (PRN) pain medications. The deficient practice affected one resident (#26) of five residents reviewed for unnecessary medications. The facility census was 76.

Inspectors wroteBased on medical review, observation, staff interview and review of facility policy and procedure, the facility failed to follow infection control practices when changing a dressing. This affected one resident (#78) of three sampled residents. The census was 89.

Inspectors wroteBased on record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported immediately to the state agency as required. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents.

Inspectors wroteBased on record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure residents were protected from further potential abuse during abuse investigations. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to complete a comprehensive assessment of continence for a resident. This affected one of three residents reviewed for incontinence (Resident #27). The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure laboratory testing was completed as ordered, the physician was notified timely of the results after completed, and physician's orders were followed related to medication administration for one of five sampled residents (Resident #2). The facility census was 88.

Inspectors wroteBased on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status including body weight. This affected one of three residents reviewed for meal assistance (Resident #2). The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to report allegations of misappropriation to the state agency. This affected one resident (#86) of five residents reviewed for misappropriation. The facility census was 84. Findings Include: Review of the closed record for Resident #86 revealed an admission date of 10/09/22 and discharge date [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 (no impairment). [...]

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to investigate an allegation of misappropriation. This affected one resident (#86) of five residents reviewed for misappropriation. The facility census was 84. Findings Include: Review of the closed record for Resident #86 revealed an admission date of 10/09/22 and discharge date [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 (no impairment). [...]

Inspectors wroteBased on closed record review, policy review, and interview, the facility failed to provide and document sufficient preparation, coordination and orientation for Resident #86 to ensure the resident had a safe and orderly transfer/discharge from the facility to an appropriate location that could meet his total care needs. This affected one resident (#86) of three residents reviewed for discharge. The facility census was 84. Findings Include: Review of the closed medical record for Resident #86 revealed an admission date of 10/09/22 and a discharge date [DATE]. Resident #86 had diagnoses including paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. [...]

Inspectors wroteBased on medical record review, interviews with facility staff, review of laboratory test results, review of hospital records, and review of facility policies, the facility failed to provide timely, adequate, and necessary care and treatment to Resident #74 following laboratory notification of a critically low potassium level. This resulted in Immediate Jeopardy and Actual Harm on 09/08/23 when a Basic Metabolic Panel (BMP) laboratory blood test showed a critically low potassium level of 2.7 milliequivalents (meq)/hour (hr) (normal 3.5 to 5.3 meq/hr), and the facility failed to notify the physician or provide treatment until 09/15/23. On 09/15/23 Resident #74 was assessed to be dehydrated and had increased confusion which had worsened over the previous week. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected ten residents (#59, #28, #68, #37, #14, #19, #56, #75, #42, and #55) of 13 residents reviewed for PASRR documents. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and facility policy review the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected ten residents (#59, #28, #68, #37, #14, #19, #56, #75, #42, and #55) of 13 residents reviewed for Pre-admission Screening and Resident Review (PASRR) documents. The facility census was 84.

Inspectors wroteBased on medical record review, financial record review, and staff interview, the facility failed to provide spend down notices to all residents who received Medicaid benefits. This affected three residents (#2, #3, and #19) of four resident financial records reviewed. The facility census was 84.

Inspectors wroteBased on medical record review, facility staff interviews, and facility policy review, the facility failed to ensure resident code status was accurate and consistent throughout medical records for two residents (#8 and #74). The deficient practice affected two residents (#8 and #74) of two residents reviewed for advanced directives. The facility census was 84.

Inspectors wroteBased on medical record review, financial record review, and staff interview, the facility failed to notify residents/representatives in a timely manner when there was a change in Medicaid benefits. This affected one resident (#3) of four residents reviewed for Medicaid benefits. The facility census was 84.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to complete thorough neurological checks for Resident #8 after a fall. This affected one resident (#8) of two residents reviewed for accidents. The facility census was 84.

Inspectors wroteBased on medical record review, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when it was above the Medicaid allowable limit. This affected three residents (#2, #3, and #19) of four resident's financial records reviewed. Also, the facility failed to provide adequate social services to ensure residents didn't lose their Medicaid benefits. This affected one resident (#3) of four resident's financial records reviewed. The facility census was 84. Findings Include: 1. Resident #2 was admitted to the facility on [DATE]. His diagnoses were chronic respiratory failure, type II diabetes, morbid obesity. [...]

Inspectors wroteBased on interview and record review the facility failed to adequately address the pharmacy recommendations and have proper diagnosis for medications for Resident #28 and did not write contraindication for recommendations to decrease a medication for Resident #20. This affected two residents (#28 and #20) of five residents reviewed for unnecessary medications. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to obtain proper parameters for as needed pain medications. This affected one Residents (#11) of five residents reviewed for unnecessary medications. The facility census was 84.

Inspectors wroteBased on observation, resident medical records, staff interview, and facility policy review, the facility failed to ensure pureed food was maintained in a manner that met the resident's health and safety needs. This affected two residents (#8 and #235) of two residents who had orders for puree diets. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain accurate medical records. This affected one resident (#37) of 27 residents medical records reviewed. The facility census was 84.

Inspectors wroteBased on observation, interview, review of the manufacturers guidelines, and facility policy review the facility failed to follow proper infection control procedures regarding cleaning a glucometer. This had the potential to affect two residents (#2 and #235) on the 300-memory care hall that received fingerstick blood sugars using the glucometer. The facility census was 84.

Inspectors wroteBased on observation, record review, review of the facility Perineal Care policy and procedure and family and staff interview, the facility failed to implement adequate skin risk interventions, including timely incontinence care and treatment for Resident #34, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's coccyx. Actual harm occurred on 08/13/23 at 7:04 A.M. when a reddened area was noted to Resident #34's coccyx area without evidence of effective preventative measures being in place or additional interventions implemented at that time. On 08/14/23 at 10:13 P.M. the Wound Certified Nurse Practitioner (CNP) assessed Resident #34 to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide bathing as scheduled and per resident preference. This affected three residents (#5, #6, and #86) out of eight residents reviewed for bathing. The facility census was 86.

Inspectors wroteBased on observation, record review, interviews, and policy review the facility failed to provide appropriate incontinence care for Resident #50. This affected one resident (#50) out of three residents reviewed for incontinence. The facility census was 86.

Inspectors wrote2. Review of the medical record for Resident #63 revealed an admission date of 01/02/20 with diagnoses including sepsis, depression, and dementia. Review of the nurse's note for Resident #63 dated 01/12/20 at 2:43 P.M. revealed Resident #63 was admitted to the hospital with a diagnosis of sepsis, possible pneumonia, and hypotension. Review of the nurse's note dated Discharge Minimum Data Set assessment dated [DATE] revealed Resident #63 was expected to return to the facility from the hospital. Review of the bed hold notice provided to Resident #63 and his representative dated 01/12/20 revealed Resident #63 was private pay and there was no per diem bed hold rate included on the bed hold notice. Interview with the Regional Director on 02/05/20 at 2:46 P.M. verified the per diem bed hold rate was not included on Resident #63's bed hold notice dated 01/12/20. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were invited to and included in care conference meetings. This affected one (Resident #50) of one resident reviewed for care conferences. The census was 75. Findings Include: Review of the medical record for Resident #50 revealed an admission date of 03/24/17 with diagnoses including multiple sclerosis, bipolar disorder, and schizophrenia. Review of the annual Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the care conference note dated 01/17/20 revealed a care conference was held on 01/17/20 and social services, nursing, and Resident #50's brother attended the care conference. The note did not include evidence Resident #50 was invited to or attended the care conference on 01/17/20 nor did it include any input from Resident #50. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to monitor for significant weight change in an appropriate manner. This affected two (Resident #2 and #24) of five residents reviewed for nutrition. The census was 75. Findings Include: 1. Record review revealed Resident #2 was admitted on [DATE]. Her diagnoses were dementia, acute kidney failure, polyosteoarthritis, history of falling, pain in left knee, urinary tract infection, unspecified protein calorie malnutrition (01/29/20), peripheral vascular disease, pain in right knee, hypertension, and hyperlipidemia. Her Brief Interview for Mental Status (BIMS) score was five, which indicated she was severely cognitively impaired. The assessment was completed on 01/24/20. Review of Resident #2 medical records revealed significant changes in her weights. [...]

Inspectors wroteBased on medical record review, staff interview, and facility contract review, the facility failed to complete on-going monitoring and assessments of residents who attend dialysis appointments. This affected one (Resident #24) of one resident reviewed for dialysis. The census was 75. Findings Include: Record review revealed Resident #24 was admitted to the facility on [DATE]. Her diagnoses were acute kidney failure, cognitive communication deficit, difficulty walking, muscle weakness, need for assistance with personal care, anemia, type II diabetes, hyperlipidemia, hypertension, vitamin D deficiency, abdominal pain, arthropathy, hypothyroidism, mitral valve insufficiency, end stage renal disease, dependence on renal dialysis, personal history of transient ischemic attacks, and thrombocytopenia. [...]

Inspectors wroteBased on observation, record review, interview, review of dietary spread sheet, the facility failed to provide diet textures as ordered by a physician. This affected one (Resident #63) of five residents reviewed for nutrition. Findings Include: Review of the medical record for Resident #63 revealed an admission date of 01/02/20 with diagnoses including dysphagia, dementia, and protein-calorie malnutrition. Review of the active physician orders for Resident #63 revealed an order dated 01/30/20 for a regular diet with mechanical soft, ground textures and regular consistency liquids. Observation of Resident #63's lunch tray on 02/05/20 at 12:49 P.M. revealed he received a pulled pork sandwich, mixed vegetables, and baked beans. The pulled pork sandwich was not ground and was partially eaten. Interview with Registered Dietitian #301 on 02/05/20 at 12:52 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional supplements and honey thickened water were dated as to when they were opened. This had the potential to affect two (Resident #10 and #128) out of 17 Residents who have orders for Med Pass supplements and honey thickened liquids. The census was 75. Findings Include: 1. Observation of the 400 hall unit refrigerator on 02/05/20 at 12:03 P.M. revealed two opened containers of vanilla Med Pass supplements both undated as to when they were opened. Interview with Director of Nursing (DON) on 02/05/20 at 12:03 P.M. verified the two opened partially empty containers of vanilla Med Pass supplements were undated as to when they were opened. Interview with DON on 02/05/20 at 4:46 P.M. [...]