Eastport Memorial Nursing Home

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair in 2 of 2 environmental tours.

Inspectors wroteBased on record reviews and interviews, the facility failed incorporate recommendations from the Preadmission Screening Resident Review (PASRR) level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care, and ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) was notified after a resident was newly diagnosed and/or experienced symptoms related to a mental disorder to determine if a change in services was required for 2 of 3 sampled resident (Resident #12 and Resident #2 [R12, and R2]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure baseline care plans was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 2 of 4 sampled residents reviewed for baseline care plans (Resident #12 [R12], R15).

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 2 of 3 days of survey (2/9/26 and 2/10/26).

Inspectors wroteBased on record reviews and interview, the facility failed to implement its Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 2 months reviewed (December 2025 and January 2026). This has the potential to affect all residents receiving an antibiotic.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents were offered influenza and pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 4 of 5 residents reviewed for immunizations (Resident #2 [R2], R3, R5 and R10).

Inspectors wroteBased on interview and employee personnel record reviews, the facility failed to implement and maintain an effective training program by failing to ensure that 5 of 5 Certified Nursing Assistant's (CNA) employed, completed training (CNA1, CNA2, CNA3, CNA4 and CNA5).

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were treated with respect and dignity while providing care for 2 of 2 residents reviewed for Dignity [Resident #10 (R10) and R3].

Inspectors wroteBased on interviews and clinical record reviews, the facility failed to follow a Physicians order for in-house Physical Therapy for 1 of 2 sampled residents reviewed for position, mobility (Resident #24).

Inspectors wroteBased on record review, facility policy review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Coronavirus (COVID-19) vaccine for 1 of 5 residents reviewed (Resident #3 [R3]).

Inspectors wroteBased on observation and interview, the facility failed to ensure that the environment was free from potential risk of accidents by allowing 2 of 3 egresses on the resident's ground floor to be blocked by snow and not easily passable.

Inspectors wroteBased on interview, the facility failed to conduct regular inspections of all bed frames and mattresses as part of a regular maintenance program to ensure that the mattress and bed frame are compatible and identify areas of entrapment for 1 of 5 beds reviewed. (Resident #1)

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the current resident representative was notified of a change in the resident's representative status and a change in the resident's medical plan of care for 1 of 1 resident representative not notified of resident changes. (Resident #1 [R1])

Inspectors wroteBased on record review, facility reported incident and investigation reviews, and interviews, the facility failed to implement a comprehensive care plan for Resident #1 (R1) for 2 of 2 facility reported incidents of elopement reviewed (5/13/25 and 5/17/25).

Inspectors wroteBased on the facility's incident report forms and investigations, facility policy review, and interviews, the facility failed to provide adequate supervision to a resident who was actively exit seeking and was able to leave the facility unwitnessed and/or failed to follow it's own Elopement and Wandering Policy by ensuring secured exits were in working order for 2 of 2 facility reported incidents of elopement reviewed (5/13/25 and 5/17/25) for Resident #1 (R1).

Inspectors wroteBased on interviews, the facility failed to employ a qualified Activity Director (AD) to manage resident centered activities for all residents (24 residents).

Inspectors wroteBased on observations, record review, and interviews, the facility's quality assurance committee failed to ensure that the Plan of Correction (PoC) for identified deficiencies from the Recertification Survey, dated 1/29/25, were implemented / effective. The facility lacked evidence that the PoC for deficiencies F636 (Comprehensive Assessments & Timing), F637 (Comprehensive Assessments After Significant Change), F656 (Develop/Implement Comprehensive Care Plan), F684 (Quality of Care), and F689 (Free of Accident Hazards/Supervision/Devices) was implemented in order to prevent repeat deficient practice. The deficiencies F695 (Respiratory Care), and F761 (Label/Store Drugs and Biologicals) were again identified during the re-visit survey on 3/18/25.

Inspectors wroteBased on record review and interview, the facility failed to complete an annual Comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment timely for 1 of 1 residents reviewed for hospice (Resident #23 [R23])

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's admission to hospice services, for 1 of 1 sampled residents (Resident #23 [R23]).

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan to address the physical needs of a resident for 1 of 5 residents reviewed for unnecessary medication (Resident #9 [R9]).

Inspectors wroteBased on record review and interview the facility failed to follow a doctors order for daily weights for a resident with heart failure for 1 of 5 residents reviewed for unnecessary medications [Resident #9 (R9]. and the facility failed to have a provider appropriately addresss a pharmacist reocmmendation regarding a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications (R1).

Inspectors wroteBased on record review, review of the facility incident report, and interviews, the facility failed to monitor an unlocked and/or non-alarmed door to prevent a resident identified as an elopement risk from leaving the building unnoticed. A staff member, who was on the third floor, looked out the window and saw a resident outside, unattended. The failure to have monitoring of unlocked, and/or non-alarmed doors, resulted in an avoidable elopement for 1 of 1 resident reviewed for elopement risk (Resident # 15 [R15]).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain a physician ordered oxygen setting on an air concentrator, and failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care (Resident #20 [R20], and R8).

Inspectors wroteBased on observations and interviews, the facility failed to remove an expired medication from the supply available for use in 1 of 2 locations where medications are stored (medication storage room).

Inspectors wroteBased on review of the facility's Water Management Program/Legionella and interview, the facility failed to fully develop/implement a water management program to prevent the growth and spread of legionella and other water-borne pathogens in the area of testing protocols.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident was provided a hearing aid device daily for 1 of 1 resident that required a hearing aid (Resident #1 [R1]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included problems, interventions, and initial goals needed to provide minimum healthcare information necessary to properly care 2 of 3 newly admitted sampled residents (Resident [R] 176 and R8).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that care plans were developed to reflect a resident's current needs for 4 of 14 residents reviewed (Resident [R6], [R23], [R2], [R8], and [R12]).

Inspectors wroteBased on facility policy reviews, record reviews, and interviews, the facility failed to ensure that physician's orders were obtained for treatment of pressure ulcers for 2 of 5 residents reviewed for pressure ulcer care (Resident #11 [R11], Resident#18 [R18]). and failed to ensure that weekly pressure ulcer assessment documentation, used to monitor the healing progress of the wounds, included all of the required documentation for 3 of 5 residents reviewed with a pressure ulcer (R18, R8, R12).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that wooden doors were maintained in a manner to prevent possible injury to residents on 3 of 3 days of survey (1/8, 1/9, and 1/11/24) and failed to ensure that electrical outlet adapter was used in accordance with current fire prevention codes for 1 of 3 days of survey (1/8/24).

Inspectors wrote6. On 1/8/24 at 2:20 p.m., a surveyor observed R6's oxygen concentrator was covered in a white substance and the vent on the back of the concentrator was covered with dust. On 1/9/24 at 3:27 p.m., a second surveyor observed that the oxygen concentrator was covered in a white substance and that the vent on the back of the concentrator was still covered with dust. On 1/9/24 at 3:27 p.m. a surveyor confirmed the above finding with the Assistant Director of Nursing (ADON). Based on observations, record reviews, and interviews, the facility failed to provide physician ordered respiratory services for 1 of 1 residents (Resident [R] 20} reviewed with a bilevel positive airway pressure (BiPap) machine when the facility failed to obtain services in the form a of rental BiPap machine while R20's machine was broken and needing repair. [...]

Inspectors wroteBased on facility policy review, record reviews and interviews, the facility failed to ensure that a resident's pressure ulcer care was supervised by a physician when the physician did not document the evaluation or assessment of the pressure ulcers for 3 of 4 residents reviewed (Resident [R] 11, R18, and R12).

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident's physician was notified immediately of a significant change in the resident's medical condition for 1 of 2 residents (Resident #25(R25)) chosen for closed record review.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 1 of 1 environmental tours (1/11/24).

Inspectors wroteBased on interviews, and record reviews the facility failed to report suspected abuse to the State Agency in a timely manner after it was brought to their attention that it was suspected that a resident was abused physically (Resident #16 [R16]).

Inspectors wroteBased in interviews, record review and facility policy review, the facility failed to thoroughly investigate an allegation of suspected abuse for 1 of 1 abuse allegations investigated.

Inspectors wroteBased on record review and interviews, the facility failed to complete an admission Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessment (CAA) in a timely manner for 1 of 1 closed records reviewed for hospitalization (Resident [R] 26).

Inspectors wroteBased on record review and interview, the facility failed to transmit an entry, comprehensive, and discharge Minimum Data Set 3.0 (MDS) electronically to the State MDS database for 1 of 1 closed records reviewed for hospitalization (Resident [R] 26).

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 1 resident reviewed for PASRR (Resident #5).

Inspectors wroteBased on record review and interviews, the facility failed to update a care plan to reflect a resident's current needs for the use of oxygen and a gastrointestinal (GI) bleed for 2 of 14 sampled residents (Resident [R] 8 and R20).

Inspectors wroteBased on record reviews and interviews, the facility failed to a physician order to send a urine specimen to the hospital for a urinalysis/culture for 1 of 1 residents reviewed (Resident [R] 21) and the facility failed to assess and monitor a resident for a potential allergic reaction after the administration of a medication listed as an allergy for 1 of 1 closed records reviewed for death (R25).

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #23 [R23]).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 3 of 14 residents reviewed (Resident [R] #21, R8, and R20}.

Inspectors wroteBased on observation, interviews, and facility policy reviews, the facility failed to ensure that gloves were changed, and hands washed/sanitized during a dressing change observation for 1 of 1 dressing change observations. (1/11/24)

Inspectors wroteBased on record review, facility policy review, and interviews, the facility failed to ensure that the Medical Provider (MP) was notified timely of a negative result of a urinalysis for a resident that was already started on an antibiotic for 1 of 1 residents reviewed for antibitoic use (Resident [R] 21).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the resident and/or resident representative in writing for the reason of a transfer/discharge from the facility, for 2 of 3 sampled residents reviewed for hospitalization (Resident [R8], [R26]).

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written bed hold notice to the resident and /or resident representative for 2 of 3 sampled residents reviewed for hospitalization (Resident [R8], [R26]).