Eastview Healthcare & Senior Living

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision for a resident in a resident's room to prevent falls for one resident (R2) and failed to implement fall prevention interventions to for one resident (R3). These failures affect two of four residents (R2, R3) reviewed for falls in the sample list of 19. These failures resulted in R2 sustaining a subarachnoid hemorrhage and a compression fracture of the T12 vertebral body from falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform adequate sanitation of residents' eating utensils, cutlery, and dishware. This failure has the potential to affect all 20 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to provide and maintain a safe, functional, and sanitary environment for three of five residents (R2, R5 and R6) reviewed for unsealed windows/environment in the sample list of 19. Findings Include:On 6/16/26 at 11:35 AM R5's window was observed with a window air conditioning unit sitting on the left side of the window opening and a piece of cardboard on the side right side which was taped loosely in place with white tape. There were openings around the cardboard where the tape was not sealed and outside light was observed through the gaps. There were dead gnats and other bugs and dirt on the sill of the window. R5 used her grabber to poke the cardboard, and it moved easily and the tape came apart. R5 stated the staff are aware her window is like this and she does not like it because she cannot see out of her window. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for three residents (R2, R3, R6) reviewed for abuse, in a sample list of nine residents. Findings Include: 1. R3's Incident report dated 4/5/2026, documents the incident occurred in the lounge on 4/5/2026 at 6:15pm. It also documents that R3 came out of the dining room when R4 hit R3 on the left forearm. The incident reports that R3 had no redness, bruising, or swelling noted. R3 was interviewed and was documented as stating that R4 came toward R3 and hit R3's arm. The immediate action documented is that R3 and R4 were separated and assessed for injury. R3's Physician's Order Sheet documents diagnosis of: Dementia with Anxiety, Schizoaffective Disorder, Bipolar Disorder, and Repeated Falls. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent a fall for one resident (R1) who has a history of seizures and takes an anticoagulant of three residents reviewed for falls in a sample list of eight residents. This failure resulted in R1 falling from R1's bed while having a seizure and R1 sustaining a six centimeter scalp laceration requiring evacuation of a hematoma and sutures, and a subdural hematoma. R1's Care Plan updated 10/20/25 includes the following diagnoses: Epileptic Seizures, Peripheral Vascular Disease. Recent Femoral/Popliteal Bypass with Wound Dehiscence, Chronic Kidney Disease Stage III, Muscle Weakness, Difficulty Walking, Osteoarthritis, Major Depression, History of Subarachnoid Hemorrhage with Residual Hemiplegia and Hemiparesis of the Left Side. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely call light response for one of four residents (R6) reviewed for staffing in the sample list of eight residents.

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled for one of four residents (R6) reviewed for staffing in the sample list of eight residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one of four residents (R2) reviewed for incontinence in the sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention measures for two of two residents (R2, R7) reviewed for falls on the sample list of 13. These failures resulted in R2 experiencing a displaced fracture of the right hand, and R7 a fractured nasal bone. Findings Include:Falls and Fall Risk Management policy dated March 2018 documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.1. Facility Reported Incident Final Investigation dated August 19, 2025, documents on August 11th, 2025, the Certified Nursing Assistant (CNA) reported that while giving R7 a shower, R7 lunged forward out of the chair and onto the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate and maintain a full-time Director of Nursing (DON). This deficiency has the potential to affect all 50 residents in the facility by compromising the oversight and coordination of nursing services. Findings Include:Review of staffing schedules from 7/25/25 thru 8/25/25 confirmed that no licensed nurse was designated as Director of Nursing (DON) and no interim appointment was made. On 8/25/25 at 1:20pm, V12 Licensed Practical Nurse (LPN), confirmed there is no DON at this time and stated we haven't had a DON for a few weeks now. On 8/26/25 at 12:20pm, V1 Administrator stated, We've been trying to hire a Director of Nursing (DON), but we haven't been able to find anyone. We do have an interim DON starting soon. [...]

Inspectors wroteBased upon interview and record review, the facility failed to employee a certified dietary manager for food services. This failure has the potential to affect all 50 residents currently residing in facility.

Inspectors wroteBased upon observation, interview and record review, the facility failed to ensure meals were palatable and at a safe and appetizing temperature. This failure has the potential to affect all 50 residents currently residing at facility. Facility Resident Census dated 8/21/25 documents that there are 50 residents currently residing in the facility. The Food Temperature Chart for August reviewed. Chart dated 8/10/25-8/16/25 documents food temperatures at meal service. Breakfast meal for dates 8/11 and 8/12 are missing documentation. Lunch meal for dates 8/10, 8/11, 8/12, and 8/13 are missing, and dinner meal for dates 8/15 and 8/16 are missing documentation. Vegetable temperatures are being documented at 200 degrees Fahrenheit (F) at time of service. Chart dated 8/17/25-8/23/25 missing documentation for the 8/17/25 dinner meal. [...]

Inspectors wroteBased on interview and record review the facility failed to protect residents rights to be free from resident to resident physical abuse. This failure affects four of four residents (R3, R4, R5, R6) reviewed for abuse in the sample list of 13. Findings Include:Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 documents: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility reported incident final investigation dated July 25th, 2025, documents on July 18th, 2025, at 4:50pm was reported by R4 that R3 made contact with R4's right forearm. The same document documents: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the right to be free from physical abuse for two (R1, R2) of three residents reviewed for physical abuse from a total sample list of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one (R3) of three residents reviewed for injuries of unknown origin from a total sample list of four residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a full time Director of Nurses and failed to provide eight consecutive hours of Registered Nurse coverage for four of fourteen days reviewed. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/24 through 11/14/24 document four days (11/5/24, 11/8/24, 11/9/24, 11/10/24) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility currently has no Director of Nurses (DON) employed by the facility and the previous DON's last day was 9/18/24. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 42 residents in the facility. Findings Include: The January 2024 QAA meeting attendance signature sheet does not document the facility Director of Nursing or Infection Preventionist was present for the meeting. The April 2024, July 2024, and November 2024 QAA meeting attendance signature sheets do not document the facility Director of Nursing was present for any of these meetings. [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to don appropriate Personal Protective Equipment (PPE) while providing resident care and failed to prevent cross contamination during medication administration for three of three residents (R11, R26, R5) reviewed for Infection Control in a sample list of 22 residents. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: 1.) R11's undated Face Sheet documents medical diagnoses as Dementia, Alzheimer's Disease and active COVID-19. R11's Physician Order Sheet (POS) dated November 2024 documents a physician order dated 11/10/24 for R11 to be placed on Droplet and Contact Isolation for positive COVID-19 test to end on 11/20/24. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify specific medical conditions or symptoms necessitating the use of physical restraints, failed to assess safe use of restraints, and failed to release a physical restraint every two hours per plan of care. This failure affects two residents (R24, R28) of two reviewed for restraints in the sample list of 22. Findings Include: The facility policy titled Physical Restraint/Enabler Policy revised 7/24/18 documents physical restraints are any manual method or physical or mechanical device, equipment or material attached, or adjacent to the resident's body which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include, but is not limited to: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care and incontinence care in accordance with facility standards for two of two residents (R22 and R10) reviewed for incontinence care in a sample list of 22 residents. Findings Include: The facility policy titled Perineal Cleansing reviewed 12/17 documents staff should wash pubic area including upper inner aspect of both thighs and frontal portion of perineum prior to washing resident buttocks and to dry areas thoroughly after cleansing. The basic infection control concept for perineal care is to wash from the cleanest to the dirtiest and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly store and date nebulizer tubing for one of one resident (R5) reviewed for oxygen in a sample list of 22 residents. Findings Include: The facility policy titled Nebulizer Therapy dated 10/07 documents staff should store Nebulizer tubing in a plastic bag and change mouthpiece tubing and nebulizer weekly. R5's undated Face Sheet documents medical diagnoses as Dementia, Intellectual Disabilities, Chronic Obstructive Pulmonary Disorder (COPD), Glaucoma, Chronic Systolic Heart Failure, Dependence on Wheelchair and Need for Assistance with Personal Care. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's Physician Order Sheet (POS) dated November 2024 documents a physician order for Oxygen at 3 Liters (L)/minute via nasal cannula continuously. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure therapy services were provided for five (R1, R2, R3, R4 and R5) of five residents reviewed for therapy services from a sample list of five residents.

Inspectors wroteBased on record review and interview, the facility failed to provide treatment and services to prevent the development and worsening of a residents pressure ulcer. These failures affect one (R1) of three residents reviewed for pressure ulcers in the sample list of five. These failures resulted in R1's facility acquired pressure ulcer worsening.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses. This failure has the potential to affect all 45 residents who reside in the facility. Findings Include: On 12/6/2023 at 12:50 PM, V1 Administrator confirmed the facility does not currently employ a Registered Nurse to serve as full time Director of Nurses. Upon survey entrance and throughout the survey (12/6/23- 12/14/23) there was no Director of Nurses present and/or employed by the facility. The facility's Facility assessment dated [DATE], documents a full time Director of Nurses is required in order to meet the resident's needs and provide support and care for the facility's resident population. The facility's Room Roster/Census given on 12/6/2023 documents 45 residents currently reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to properly transfer one resident (R1) of three residents reviewed for falls on the sample list of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control during incontinent care. The facility also failed to properly clean a wound for one resident (R2), of three residents reviewed for infection control in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident for two residents (R23, R46) of 16 residents reviewed for abuse on the sample list of 29. This failure resulted in R23 requiring emergency services for lacerations to the bridge and left side of the nose. This past noncompliance occurred from 9/12/23 to 9/19/23.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a full time Director of Nursing and staff a Registered Nurse for eight consecutive hours a day. This failure has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 44 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to complete Psychotropic medication assessments and care plan targeted behaviors and interventions for five of five residents (R35, R9, R24, R46, R13) reviewed for Unnecessary medications in the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to obtain a new PASARR (Pre-admission screening and resident review) screening when a change in behaviors occurred for one (R46) of four residents reviewed for PASARR on the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R1) of four residents reviewed for PASARR level II screenings, from a total sample list of 29. Findings Include: R1's level I PASARR dated 8/24/04, documents that a level II PASARR is required due to R1's history of depression with electric shock therapy treatments and inpatient psychiatric hospitalizations. R1's undated diagnosis sheet documents diagnoses of Schizophrenia, Anxiety and Major Depression. R1's October 2023 physician order sheet documents the following psychotropic medications: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop a comprehensive care plan for contractures for one of 15 residents (R35) reviewed for care plans on the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to provide discharge planning to one (R47) of one residents reviewed for discharge planning from a total sample list of 29 residents.

Inspectors wroteBased on interview and record review the facility failed to develop a discharge summary for one (R47) of one residents reviewed for discharge planning from a total sample list of 29 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to address and implement interventions for a decline in the ability to communicate for one (R23) of 16 residents reviewed for communication on the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adaptive equipment to prevent further reduction in Range of Motion for one of one resident (R35) reviewed for Range of Motion in the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to elevate the head of bed during enteral feeding and failed to completely transcribe a dietician's enteral feed orders. This failure affects one resident (R13) of one reviewed for enteral feeding in the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oxygen therapy as ordered for one (R1) of one residents reviewed for oxygen therapy on the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to address a pharmacy recommendation for one (R46) of five residents reviewed for unnecessary medications on the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent potential cross contamination by failing to perform hand hygiene and change gloves during incontinence care and failing to maintain clean linens for two of two residents (R31, R35) reviewed for incontinence care in the sample list of 29.

Inspectors wroteBased on interview and record review the facility failed to provide education for and offer Pneumococcal vaccines for two of five residents (R23, R24) reviewed for vaccinations on the sample list of 29. Findings Include: 1.) R23's Care Plan with a revised date of 9/6/23 documents diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia, Parkinson's Disease, Generalized Epilepsy, Morbid Obesity and Cochlear Implant Status. There is no documentation in R23's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. 2.) R24's Order Summary Report dated 10/24/23 documents diagnoses including Dementia, Disorder of Thyroid, Cardiomegaly and Chronic Kidney Disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident bed side rails in a safe condition. This failure affects two residents (R4, R40) of two reviewed for bed side rails in the sample list of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for four of four residents (R3, R4, R1 and R2) reviewed for abuse on the sample list of 9.

Inspectors wroteBased on record review and interview the facility failed to maintain complete medical records by failing to document resident physically abusive behaviors toward another resident for one of four residents (R2) reviewed for behavioral tracking on the sample list of nine.

Inspectors wroteBased on interview and record review, the facility failed to provide the required eight hours of Registered Nurse staffing coverage per 24-hour period for three of thirteen days reviewed for staffing and failed to employ a qualified Director of Nursing. These failures have the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview and record, the facility Quality Assessment and Assurance (QAA) committee failed to document the identification of quality deficiencies and the facility's efforts to correct those issues in the facility. This failure has the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete required quarterly Quality Assessment and Assurance (QAA) committee meetings and failed to ensure required personnel attended the QAA committee meetings. This failure has the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to respond to a resident council complaint concerning a wandering resident (R6) for four of four residents (R24, R2, R17, R14) reviewed for grievances on the sample list of 29 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure that one resident (R16) was not subjected to physical abuse by another resident (R18). R16 and R18 are two of two residents reviewed for abuse in a sample list of 29

Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician's orders and assess for the use of physical restraints for three of three residents (R100, R8, R20) reviewed for restraints in the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a Physician's Order for an indwelling urinary catheter, failed to obtain an order to change and maintain an indwelling catheter and failed to prevent possible cross contamination by failing to keep the indwelling urinary catheter drainage tubing off the floor for one of one resident (R100) reviewed for catheters in the sample list of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to assess a resident for risk of entrapment prior to installing half side rails for one of two residents (R42) reviewed for side rails in the sample list of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement resident specific behavioral interventions for one resident (R6) who wanders into other residents' rooms and walks in public areas disrobed. R6 is one of one residents reviewed for unsafe wandering in a sample list of 29 residents. Findings Include: R6's Physician's Orders Sheet (POS) for September 1, 2022 through September 30, 2022 includes the following diagnoses: Bipolar Disorder, Dementia with aggressive behavior, Parkinson's Disease, Anxiety, and major depression. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is severely cognitively impaired and has Hallucinations, Delusions, wanders, and has other behavioral symptoms. R6's Care Plan updated 9/7/22 does not include interventions for wandering. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent, assess and care plan for the use of psychotropic medications for one resident (R8) of five residents reviewed for psychotropic medications in a sample list of 29 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to appropriately install, inspect for areas of entrapment and maintain side rails for two of two residents (R42, R15) reviewed for side rails in the sample list of 29.

Inspectors wroteBased on interview and record review, the facility failed to develop a water management plan that included a detailed assessment of the facility's water system, identification of specific control measures and limits, system monitoring, and interventions including testing protocols when control limits are not met to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 49 residents in the facility.