Eastview Health and Rehabilitation Center

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 51 residents residing in the facility. The cooler, counters, and areas underneath kitchen equipment were not in a clean condition. Drywall near the exterior kitchen doors contained holes.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an effective pest control management program. This practice had the potential to affect all 51 residents residing in the facility. The kitchen contained multiple traps for rodents, including rats. Staff statements were inconsistent regarding knowledge of rats, the number of rats caught, who set the traps, and who managed the traps. The facility did not provide documentation that a pest control company was called when rats were first observed in the kitchen.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure 1 resident (R) (R1) of 4 sampled residents received care and treatment to maintain their highest practicable physical well-being. R1 was at risk for constipation due to reduced mobility and the use of pain medication. R1's medical record contained incomplete bowel and bladder tracking upon admission, incomplete shift monitoring for bowel movements, and a delayed response for signs of constipation. In addition, staff did not consistently complete monitoring for incontinence, food and fluid intake, and repositioning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (R) reviewed (R1.)R1 was repositioned inappropriately by unqualified staff which resulted in right humerus fracture. This is evidenced by:Facility policy titled, Safe Resident Handling/Transfers, with a reviewed date of 05/23/23, states: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident. Policy Explanation: All resident require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety which had the potential to affect all 53 residents.-Cook Q did not have a hair or beard restraint on while preparing food.-Cook P did not have a beard net on while preparing food.-Unlabeled and undated food items observed in the cooler.-Expired food items observed in the cooler and freezer.-Excessive frost/ice build-up observed in the freezer including directly above food items.

Inspectors wroteBased on observation, interviews, and record reviews, the facility did not ensure residents received services by qualified staff with the correct certification and skills for 2 of 15 residents (R) that require mechanical lifts. (R1, R54) Activity Aide H, a non-certified personnel, assisted R54 with a direct care mechanical transferBusiness office manager N, a non-certified personnel, assisted R1 with repositioning in a wheelchair. The facility policy titled, Safe Resident Handling/Transfers, states, .Two staff members must be utilized when transferring residents with a mechanical lift. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure residents were correctly positioned to eat meals in bed to promote the highest practical well-being for 2 of 6 residents (R) reviewed. (R7 and R40)R7 was in bed in a lying position the whole time the breakfast tray was provided. R7 was not checked on or repositioned to effectively see and eat the meal. R40 was in bed in a lying position not eating until a family member arrived and asked staff for assistance. R40's position did not allow him/her to adequately see or eat the meal. Example 1 R7 was admitted to the facility on [DATE] with heart disease and rheumatoid arthritis. R7's care plan with a target date of 04/26/26 indicates R7 requires extensive assist of 1-2 and assist as needed and can feed self meals after set-up and to assist as needed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 5 of 5 residents reviewed (R20, R29, R32, R1, R34).-The facility staff did not routinely complete R20's ambulation, exercise, and Activities of Daily Living (ADL) programs.-The facility staff did not routinely complete R29's ambulation program.-The facility staff did not routinely complete R32's ambulation, exercise, and range of motion (ROM) programs.-The facility staff did not routinely complete R1's ROM programs.-The facility staff did not routinely complete R34's ROM programs.

Inspectors wroteBased on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 1 of 16 residents (R32) reviewed for MDS accuracy. The facility did not correctly code R32's dental status as edentulous. This is evidenced by:R32 was admitted to the facility on [DATE]. R32's admission Minimum Data Set (MDS) assessment, dated 03/18/23, noted R32 had no natural teeth or tooth fragments. R32's most recent MDS, dated [DATE], noted no dental concerns. On 04/13/26 at 1:52 PM, Surveyor interviewed R32. R32 stated he had no teeth and no dentures since admission to the facility in 2023. On 04/15/26 at 9:41 AM, Surveyor interviewed MDS Coordinator S regarding R32's MDS assessments. MDS Coordinator S stated being aware that R32 had no teeth or dentures and had no idea why the MDS assessments completed after admission were marked incorrectly.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 1 of 16 residents reviewed (R20).-Facility staff did not perform post-seizure activity assessments and documentation per care plan.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R49 and R50) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI.R49 admitted to the facility with multiple PIs. The facility failed to provide complete admission comprehensive PI assessments. Facility staff did not conduct hand hygiene after removal of gloves during R50's PI care treatment. This is evidenced byThe standard of practice for staging pressure injuries and skin and tissue assessment is based on the NPIAP (National Pressure Injury Advisory Panel) system, which categorizes injuries from Stage 1 to Stage 4, along with Unstageable and Deep Tissue Pressure Injury (DTPI). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 16 residents (R37) reviewed. R37's olanzapine medication label did not match physician's orders. This is evidenced by:Facility policy titled, Labeling of Medications and Biologicals, with a reviewed date of 11/12/2024, states: Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: .4. Labels for individual drug containers must include: a. the resident's name; b. The prescribing physician's name; c. the medication name; d. the dose, strength, and quantity of the medication; .g. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received routine dental services for 1 of 2 residents (R32) reviewed. R32 has not had routine dental services since admission in 2023. This is evidenced by:Facility policy titled, Dental Services, with a reviewed date of 11/12/24, states: Policy: It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Definitions: 'Routine dental services' means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease.taking impressions for dentures and fitting dentures.8. For residents or resident representatives who do not wish to be referred for dental services: a. The physician shall be notified. b. The dietician shall be consulted to assess for any necessary change in diet. c. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure care and treatment provided were consistent with professional standards of practice and resident preference for 2 residents (R) (R1 and R2) of 7 sampled residents. R1 sustained a wound on the right knee during a fall on 2/26/26. Staff did not monitor the wound since it was identified. R2 had a U shaped scar on the left back. Staff and R1's family indicated the area was bruised and had drainage in the recent past. R2's medical record did not contain documentation regarding the area.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R1 and R6) of 7 sampled residents. R1's care plan contained an intervention for the assistance of 2 staff and a manual stand assist lift for transfers. On 2/15/26, Registered Nurse (RN)-C transferred R1 without a second person which resulted in a fall. R6's care plan contained an intervention to use a pivot disc with transfers. On 3/31/26, Certified Nursing Assistant (CNA)-F transferred R6 with a Lumex (manual stand assist lift). R6 used a Lumex to transfer in the past but was not re-assessed for use of the lift. In addition, R6's care plan was not revised to reflect R6's current transfer status.

Inspectors wroteBased on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R3) of 1 sampled resident. R3 was on enhanced barrier precautions (EBP) due to carbapenem-resistant Pseudomonas aeruginosa (CRPA) colonization. Certified Nursing Assistant (CNA)-D and Nursing Home Administrator (NHA)-A did not wear a gown or gloves while transferring R3 from bed to wheelchair with a mechanical lift.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not notify a Power of Attorney for Healthcare (POAHC) of a change in condition for 1 resident (R) (R1) of 1 sampled resident. R1 had bruising on the legs and buttocks from multiple falls and behaviors. R1's POAHC (POAHC-E) was not notified of the injuries.

Inspectors wroteBased on observation, staff and resident representative interview, and record review, the facility did not ensure fall interventions were implemented for 1 resident (R) (R1) of 3 sampled residents. R1 had a history of falls and sustained multiple falls in the facility. The facility did not implement fall interventions or safety measures to prevent future falls or injury.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R7) of 13 sampled residents. R7 had an admission order to hold clopidogrel (Plavix) prior to an appointment to have a urinary stent removed. The facility missed the appointment and the order to hold medication on R7's discharge instructions and After Visit Summary (AVS) from the hospital.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 52 residents residing in the facility. Staff did not monitor or document cooked food temperatures. Staff did not test or document parts per million (PPM) of the quaternary sanitizing solution per manufacturer's instructions. Food items were not discarded when beyond their expiration or use-by dates and/or not stored in a manner to prevent cross-contamination. Staff did not complete appropriate hand hygiene during meal service. Cold food items were not maintained at a proper temperature during meal service.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure safe and accurate administration of medication for 4 residents (R) (R15, R6, R12 and R7) of 24 sampled residents. On 1/26/25 and 1/27/25, medication was left at R15's bedside. R15 did not have a self-administration of medication assessment or a physician's order to self-administer the medication. In addition, medication and treatments were signed out as administered on 1/27/25 but were not completed. On 1/26/25, medication was left at the bedside of R6, R12, and R7. R6, R12, and R7 did not have self-administration of medication assessments or physician orders to self-administer the medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 4 residents (R) (R207, R42, R12, and R7) of 5 sampled residents. R207 had a open wound but did have an order or care plan for enhanced barrier precautions (EBP). R42 was not noted on the facility's infection control line list for antibiotics, intravenous (IV) therapy, a peripherally inserted central catheter (PICC) line, or infectious wounds. Licensed Practical Nurse (LPN)-M did not complete hand hygiene prior to administering medication to R12 and R7.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written transfer notice was provided for 1 resident (R) (R52) of 1 resident reviewed for hospitalization. R52 was transferred to the hospital on [DATE]. Neither R52 or R52's emergency contact were provided with a written transfer notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R42) of 2 residents received a bed hold notice when leaving the facility for therapeutic leave. R42 left the facility for therapeutic leave approximately every other week from October 2024 to January 2025. R42 did not receive bed hold notices prior to leaving the facility for therpeutic leave.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the appropriate care and treatment for a pressure injury was provided for 1 resident (R) (R207) of 24 sampled residents. R207 was admitted to the facility with a pressure injury on the buttock. The facility did not complete accurate weekly wound assessments or include the pressure injury diagnosis on R207's Minimum Data Set (MDS) assessment and diagnoses list.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services for 1 resident (R) (R19) of 1 sampled resident with an indwelling catheter. On 1/27/25, R19 had dark cherry-colored urine and R19's catheter was flushed without a physician's order. R19's care plan did not include an intervention to flush the catheter. In addition, a description of R19's urine was not documented even though R19's care plan contained an intervention to monitor/record/report blood-tinged urine.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R43) of 4 sampled residents received the necessary care and services to monitor weight loss. R43 had an unplanned weight loss of 15.72% between 9/13/24 and 1/1/25 with a 5.26% weight loss between 12/9/24 and 1/1/25. R43's medical record did not contain a current order for weight monitoring. In addition, staff did not monitor R43's weight per the facility's policy.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R306) of 3 sampled residents received the appropriate respiratory care and services for a nebulizer treatment. On 1/26/25 and 1/27/25, R306 self-administered a nebulizer treatment (aerosolized breathing treatment) incorrectly.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R37) of 1 sampled resident had an accurate and complete medical record. R37's pre and post-dialysis communication forms were not retained in R37's medical record.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their antibiotic stewardship program was consistently followed. On 1/28/25, Surveyor reviewed R207's medication administration record (MAR) which indicated R207 was on an antibiotic since admission on [DATE]. There was no stop date indicated for the antibiotic.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 2 residents (R) (R24 and R34) of 5 sampled residents. Staff did not offer R24 or R34 the PCV20 (Prevnar 20®) vaccine.