Eastland Subacute and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse and follow its policy and procedure (P&P) titled Abuse & Mistreatment of Resident, for one of three sampled residents (Resident 1) when on 6/8/2026, Resident 1 reported Certified Nursing Assistant 1 (CNA 1) sexually abused Resident 1. This failure resulted in Resident 1 subjected to sexual abuse by CNA 1 while under the care of the facility. Resident 1 refused to eat breakfast and lunch on 6/8/2026 and Resident 1 cried and did not want CNA 1 to be assigned to Resident 1. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for a sexual assault response team (SART, a group of trained professionals who comes together to support people after a report of sexual harm) assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with dignity and respect for three out of three sampled residents (Resident 1, 2, and 3) when: 1. Resident 1 was not notified about not attending adult day care center (a community-based facility providing supervised, structured, and non-residential care for adults with physical or cognitive impairments) and was not given a reason why she did not attend. 2. Resident 2 and Resident 3's bed were temporarily relocated to the hallway and were not provided any privacy. These deficient practices had the potential to cause psychosocial harm, loss of dignity and respect, and feelings of frustration for Resident 1, 2, and 3.

Inspectors wroteBased on interview, and record review, the facility failed to develop a care plan (a document that outlines a person's health needs and the care they require) for one of two sampled residents (Resident 1) when: 1. Facility did not ensure Resident 1 had a care plan for attending activities outside the facility. This deficient practice had the potential to negatively affect Resident 1's mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) and Social Services Director (SSD), properly wore N95 (a highly protective tight-fitting mask that filters harmful germs and requires a fit test to work properly) respirator/mask in accordance with infection control standards. This deficient practice had the potential to result in residents and staff being at increased risk of infection due to inadequate adherence to infection control procedures. On March 3, 2026, at 2:15 p.m., an unannounced complaint visit was conducted at the facility regarding an infection control. During an interview with LVN 1 on 3/3/2026 at 3:38 p.m., LVN 1 was observed wearing an N95 respirator that did not have a tight seal to the face due to facial hair. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the medical records upon written request for one of three sampled residents (Resident 1). This deficient practice violated Resident 1's right to obtain a copy and Resident 1's representative to obtain a copy of Resident 1's medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights/pad sensors (a communication device used by residents in healthcare facilities to signal for assistance from nursing staff) were within reach for two of two sampled residents (Residents 46 and 32). These failures had the potential for Residents 46 and 32 not to receive necessary care or receive delayed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 2, Resident 38 and Resident 83) medications were properly labeled and stored in accordance with the current accepted professional standards of practice.a. Resident 2's bottle of Gabapentin (an anticonvulsant medication used for nerve pain and seizures) stored in the refrigerator was not labeled with the residents' identifying information, drug information, or drug instructions. b. Resident 38's package of Sinemet (Carbidopa- Levodopa, used to treat tremors, stiffness and slow movement) medication was not removed from the medication cart once it had expired; andc. Resident 83's package of carvedilol (Coreg, used to manage heart conditions) medication was not removed from the medication cart once it had expired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure proper sanitation and safe handling practices in the kitchen in accordance with professional standards for food service safety. The site glass tube (transparent area that allows you to check the level of a liquid) on the coffee maker and the ice machine were both observed with brown substances. This deficient practice caused an increased risk in mold and bacteria, leading to contamination and residents having foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 40's) right to a clean homelike environment. Resident 40's room had peeling paint on the walls and closet. This deficient practice caused an increased risk for Resident 40's psychosocial environment and comfort in accordance with resident preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of six sampled residents (Resident 28) was free from physical abuse when Resident 78 had become anxious (experiencing worry, unease, or nervousness) and failed to monitor Resident 78's whereabouts. This deficient practice of not monitoring Resident 78's whereabouts after he felt anxious caused Resident 28 to be physically abused by Resident 78.

Inspectors wroteBased on interview and record review, the facility failed to transmit the Minimum Data Set (MDS - a resident assessment tool) to the Centers for Medicare and Medicaid Services (CMS) system for two of four sampled residents (Resident 39, and Resident 85). This deficient practice resulted in CMS not having accurate information for Resident 39 and Resident 85.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 44) received necessary care and services to ensure resident's abilities to perform activities of daily living (ADL -routine tasks to perform daily care for themselves) do not diminish. Resident 44 was observed in bed for three days during the day shift and was not out of bed per physician's order. This deficient practice caused an increased risk in Resident 44's mental and physical abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 32), who had a shoulder injury, received care and equipment assistance. Resident 32's splints (a medical device used to stabilize and support a body part), were not applied per physician's order. This deficient practice caused an increased risk in contractures (a stiffening/shortening at any joint, that reduces the join's range of motion) for Resident 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 101), who had history of falls, had a fall mat at the bedside per the physician's order to prevent injury. This deficient practice caused an increased risk in Resident 101 being injured. During a review of Resident 101's admission Record, the admission Record indicated Resident 101 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including lack of coordination, history of falling, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of the Physician's Order Summary, dated 6/9/2025, the summary indicated Resident 101 was ordered for the bed at lowest position and a floor mat to prevent injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the nasal cannula (NC, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing of a resident on oxygen therapy (treatment that provides supplemental oxygen, or extra oxygen) consistent with the facility's policy and procedure (P&P) for one of two sampled residents (Resident 75). This failure caused an increased risk for infection to Resident 75.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 25 had a Total T3 level (a lab test that measures the amount of thyroid hormone in the blood) completed every two weeks per physician's order for 4/2025. This deficient practice resulted in a lack of monitoring of Resident 25's thyroid function (crucial for regulating metabolism, growth and development in the body). During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including thyrotoxicosis (excess of thyroid hormones in the blood) and hypertension (HTN - high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 63) had a bottle of opened prune juice refrigerated as indicated on the product label. This deficient practice had the potential for Resident 63 to experience foodborne illness (diseases caused by contamination of food and occur at any stage in food production, delivery and consumption).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the shift nurse staffing information was completed and posted in accordance with the facility's policy and procedures (P&P) for three of three recertification days inspected (7/22, 7/23, and 7/24/2025) by failing to:-Ensure to post the actual nurse staffing information for the skilled nursing and sub-acute stations at the beginning of each shift in a prominent location readily accessible to residents, visitors, and staff for viewing.-Ensure the nurse staffing information for the three to eleven post meridiem (PM, indicate hours from 12 noon to 11:59 pm at night) shifts indicated the number of licensed and unlicensed staff working for the skilled nursing (SNF, referred as nursing home) and sub-acute (level of medical care less intensive but more specialized than typical skilled nursing care) stations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven of 63 resident rooms (Rooms 114, 115, 116, 117, 119, 121, and 123) met the square footage requirement of 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident rooms. This deficient practice had the potential for the residents not have enough space for activities of daily living (ADL- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) and hinder staff from providing nursing care to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dignity for two of two sampled residents (Residents 13 and 55) by failing to: a. Completely close the privacy curtain when Resident 55's back and buttocks were exposed while Certified Nursing Assistant 3 (CNA 3) changed Resident 55's gown and linen. b. Close the privacy curtain when Resident 13's abdominal area was exposed while Registered Nurse 1 (RN 1) checked the resident's gastrostomy tube (GT, surgically placed devised used to deliver supplemental feeding to the stomach) site. This failure had the potential to cause psychosocial (mental and emotional well-being) decline for Residents 13 and 55.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need for four of four sampled residents (Resident 5, 21, 24 and 99) by failing to ensure the residents' call light was within reach. These failures had the potential for the residents not to receive or received delayed care that could result in a fall or accident.

Inspectors wroteBased on interview and record review, the facility failed to provide information regarding Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) to two of five sampled residents (Residents 23 and 65) in accordance to the facility's policy and procedure (P&P) titled, Advance Directives. This deficient practice had the potential for facility staff to provide treatment and services against Residents 23 and 65's will.

Inspectors wrotec. During a review of Resident 7's AR, the AR indicated the facility readmitted the resident on 2/25/2022, with diagnoses that included COPD and diabetes mellitus (a condition that happens when the blood sugar [glucose] is too high). During a review of Resident 7's OSR dated 2/25/2022, the OSR indicated an order for licensed staff to provide Resident 7 up to two liters (unit of measurement) per minute of oxygen continuously through nasal cannula for oxygen saturation (amount of oxygen circulating in the blood) less than 92 percent (%) every shift for diagnosis of COPD. During a review of Resident 7's CP for oxygen therapy dated 2/15/2024, the CP indicated Resident 7 will be free of adverse effects (undesirable or harmful result) related to use of oxygen by providing oxygen at two liters per minute through nasal cannula as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use appropriate alternative interventions before installation of bilateral (both sides) bedrails for five of five sampled residents (Residents 14, 24 78, 101, and 373). These failures placed Residents 14, 24, 78, 101, and 373 at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe food handling practices by failing to: 1. Discard one bowl of leftover egg salad in one of one facility walk-in refrigerator, stored for more than three days which exceeded food storage time limit in accordance with the facility's policy on Left Over Food. 2. Store one of one ice scoop in a sanitary condition. The ice scoop was stored in the ice scoop container that had some brown stains at the bottom. These deficient practices placed the residents at risk for food borne illnesses (illness caused by consuming contaminated food or beverages)

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's order to apply heel protector (a device designed to minimize the risk of pressure injuries [pressure ulcer, lesion/wound caused by unrelieved pressure that results in damage of underlying tissue]) for one of two sampled residents (Resident 33). This failure had the potential risk for Resident 33 to develop pressure injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services for the resident's Foley catheter (a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on Indwelling Catheter Urinary Drainage Bag Maintenance for one of one sampled resident (Resident 88). This deficient practice had the potential to result in catheter-related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed was elevated at 30 to 45 degrees for a resident with G-tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the facility's Policy and Procedure (P&P) titled Enteral Feedings for one of two sampled residents (Resident 36). This failure had the potential risk for aspiration (food, drink, or foreign objects accidentally entered the lungs), resulting to a decline in Resident 36's health.

Inspectors wroteBased on interview and record review, the facility failed to perform post (after) hemodialysis (HD, a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) assessment on 7/4/2024, 7/30/2024 and 8/10/2024 for one of one sampled resident (Resident 24). This failure had the potential risk for complications caused by unexpected and excessive bleeding from the hemodialysis site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its binding arbitration agreement included selection of a venue convenient to both facility and resident/resident responsible party (RP) for one of three sampled residents (Residents 13). This deficient practice placed Resident 13 at risk for an unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on observation, interview and record review, the facility failed to post nurse staffing information of the total number and actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily for two of two recertification survey days inspected. This deficient practice misleads the residents and visitors and had the potential to affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure seven of 63 resident rooms (Rooms 114, 115, 116, 117, 119, 121 and 123) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in multiple resident rooms. This deficient practice had the potential for the residents not to have enough space for activities of daily living and hinder staff from providing nursing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the voice messaging system (voicemail) for one of one Director of Social Service (DSS 1) staff was functioning in the facility's social services department (SSD - the staff in this department perform several duties beginning with assisting residents and families by providing information and helping them find placement). This deficient practice had the potential to result in missed information regarding residents or inability for family members to address important resident concerns between DSS 1 and the Case Manager (CM) due to the messaging system's malfunction.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to:Ensure Licensed Vocational Nurse (LVN) 1 reported the alleged abuse to the Administrator (ADM), State Survey Agency, Law Enforcement, and Ombudsman when Resident 1's Family Member (FM 2) reported to LVN 1 that Resident 1 told FM 2 that a male staff member (Registered Nurse [RN] 1) slapped Resident 1 on the face on 1/20/2024 at around 1:30 PM. This deficient practice violated the Federal mandated reporting timeframe. This had the potential to result in psychological (mental or emotional) and physical harm or injury, and placed Resident 1 at risk for further abuse from RN 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating and protect one of three sampled residents (Resident 1) from physical abuse by failing to:1. Ensure Registered Nurse (RN) 1, who was the alleged perpetrator (the person identified in the initial report or during the investigation as the person suspected of committing an act of abuse), was placed on leave of absence (authorized absence from work for a certain period of time) and did not have contact with Resident 1 and other residents in the facility from 1/20/2024 to 2/17/2024.2. [...]

Inspectors wroteBased on observation, interview, and record, review, the facility failed to provide care and services for one of three sampled residents (Resident 1), to prevent the development of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence as a result of pressure) and promote healing by failing to: 1. Ensure facility staff applied bilateral heel protectors (padding to protect the back of heels and feet from pressure injuries) on Resident 1's heels as ordered by the physician. 2. Ensure the Wound Care Nurse (WCN, treatment nurse) accurately set Resident 1's low air loss mattress (LAL, mattress designed to distribute resident's body weight and help prevent skin breakdown) according to Resident 1's current weight. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility's policy and procedures (P&P) titled, Policy Respiratory Protection Program and the Department of Public Health (DPH) guidelines by failing to: Conduct an N95 mask or respirator (a respiratory protective device designed to achieve a very close facial fit and efficient filtration of airborne particles) fit testing (a test to evaluate the fit and determine how effectively a mask or respirator will protect the wearer) upon hire for one of three sampled staff (Certified Nursing Assistant 1) during a COVID-19 outbreak. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide immediate and continuous cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to one of three sampled residents (Resident 1) who had a full code status (resident ' s heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Registered Nurse Supervisor 1 (RNS 1), Licensed Vocational Nurse 1 (LVN 1), Certified Nursing Assistant 1 (CNA 1), and CNA 2 had the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) and to recognize when to provide CPR when: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record for one of three sampled residents (Resident 1) was complete and accurate when Resident 1 ' s clinical record did not indicate there was blood on the back of Resident 1 ' s head after a fall on [DATE]. This failure had the potential for Resident 1 to not get the appropriate care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure competency evaluation for one of one Certified Nursing Assistants (CNA) was obtained from the Nurse Aide Registry before working in the facility on 10/2/23. This deficient practice placed Resident 1 at risk of not receiving needed care and possible injury of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change of condition to one of four sampled residents (Resident 1) in accordance with the facility ' s policy and procedure. This deficient practice had the potential to negatively affect the delivery of care and services necessary for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an environment free of accident and hazard for two of three sampled residents (Resident 8 and Resident 64). 1. For Resident 8, call light was not within reach while Resident 8 was sitting in wheelchair at foot of the bed. 2. For Resident 64, padded side rails for seizure (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) precaution was torn off leaving metal side rails to the resident. These deficiencies had the potential risk for injury to Residents 8 and 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care services for two of four sampled residents (Resident 14 and Resident 47). 1. For Resident 14, the facility failed to change the oxygen tubing and the oxygen humidifier (a device used to make supplemental oxygen moist) in accordance with the facility's policy and procedure. This deficient practice had the potential for the resident to develop respiratory infection. 2. For Resident 47, the facility failed to ensure that resident received continuous oxygen as ordered by the physician. This deficient practice had the potential to result in respiratory distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards of food service safety by failing to: a. Label and date food in the freezer b. Discard freezer-burnt (discoloration or damage to frozen food due to inadequate packaging or storage condition in the freezer) food c. Store food 12 inches off the floor in accordance with the facility's policy and procedure. These deficient food practices had the potential to result in food borne illnesses (disease caused by ingesting contaminated food) for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to practice infection control measures for three of 26 total sampled residents (Resident 14, 85, and 368) by failing to: 1. Ensure staff wore required personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and perform hand hygiene when entering a Yellow Zone Room (designated area for residents in isolation for exposure or suspected of COVID-19 [Coronavirus disease, a mild to severe respiratory illness that spread from person to person]) for Residents 14 and 368. 2. Ensure Resident 85's oxygen humidifier (used to prevent airways from getting too dry while breathing air directly from the concentrator of supplemental oxygen) was changed weekly as ordered by the physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assist resident formulate an advance directive and/or obtain copies of the existing advance directive from the responsible party for two of 12 sampled residents (Residents 68 and 80). This deficient practice had the potential for the staff to violate the resident's right to refuse treatment and implement the preferred medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 97) received treatment and care in accordance with professional standards of practice by failing to verify the physician's order of metoprolol succinate extended release (ER) 25 milligram (mg) tab when the actual medication administered to Resident 97 was metoprolol tartrate, immediate release 25 mg tab for hypertension (high blood pressure) and atrial fibrillation (irregular heartbeat). This deficient practice had the potential to result in medication error from not checking the physician order with the actual medication on hand.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt the use of appropriate alternatives to bed rails before its installation for one of one sampled resident (Resident 112). This deficient practice placed Resident 112 at risk for entrapment and injury from the use of bed rails.

Inspectors wroteBased on interview and record review, the facility failed to ensure narcotic (a kind of controlled drugs that produces pain relief, state of sleep and physical dependence on the drug) and hypnotic (sleeping pills) count sheet was signed in/out by licensed nurse during shift change for 2 of 14 days (1/2/2022 and 1/3/2022). This deficient practice had the potential risk for controlled medications get lost, diverted or accidental exposed.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of the pharmacist's recommendation for one of three sampled residents (Resident 57). Resident 57's physician was not notified of the pharmacist's recommendation for TSH (thyroid stimulating hormone) blood test since 12/19/2021. This deficient practice placed Resident 57 at risk for delayed care and appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of five percent or greater, as evidenced by the identification of two medication errors out of 26 opportunities for error. This yielded a medication error rate of 7.69 percent. These deficient practices had the potential to cause harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 42) was free from significant medication errors (causes the resident discomfort or jeopardizes his or her health and safety) by failing to follow physician's order to check the resident's heart rate before administering metoprolol tartrate (medicine used to treat high blood pressure). This deficient practice had the potential to result in serious harm to Resident 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure seven of 63 resident rooms (Rooms 114, 115, 116, 117, 119, 121, 123) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential for the residents not to have enough space for activities of daily living and hinder staff from providing nursing care to the residents.