Town East Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1, (Resident # 2) of 7 residents reviewed for abuse. The facility failed to prevent MA T from verbally abusing Resident #2 on 07/01/26. As a result of the incident, the resident stated he was upset and shaken. This failure could affect the residents and put them at risk for verbal abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #1) of seven residents reviewed for medication storage. The facility failed to ensure that there were no medications inside Resident #1's room on 07/09/26. This failure could place residents at risk of misuse of medications that could lead to overdosing and other adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary services to residents who were unable to carry out activities of daily to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Resident #1 and Resident #2) reviewed for ADL activities. The facility failed to change Resident #1's brief within a timely manner on either Monday or Tuesday of the week 05/03/26. The facility failed to provide Resident #2 assistance with brief change within a timely manner. These failures could place residents who required assistance with ADL's at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 7 residents reviewed for comprehensive care plans (Resident #1). The facility failed to ensure Resident #1 had a fall mat at his bedside while he was observed in bed on 02/03/2026 at 11:58 AM and 12:25 PM. This failure could place residents requiring supervision at risk for serious injury and death.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care on the bed by herself on 11/13/2025 which led to Resident #1 falling off the bed and sustaining a left forehead injury. An IJ was identified on 12/05/25 at 09:50 a.m. The IJ template was provided to the facility on [DATE] at 12:33 p.m. While the IJ was removed on 12/06/25 at 5:17 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received adequate supervision and assistance to prevent accidents and hazards for 1 of 6 ( Resident #1) reviewed for accidents and hazards. CNA A failed to have another staff member help her with care, and as a result, the resident rolled out of bed and sustained a laceration on the forehead. This failure could place resident at risks for accidents and injuries. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for 6 medication carts (MC#1, MC#2, MC#3, MC#4, MC#5, and MC#6) of 6 medication carts observed for medication storage. -The facility failed to lock medication carts #1, # 2, 3, #4, #5, and #6 at the nurses' station on 10/15/25 at 6:10 AM. These failures could place residents at risk of a drug diversion, or ingesting medications not prescribed for them.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure residents who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding for 1 (Resident#1) of 5 residents reviewed. The facility failed to ensure unlicensed/untrained nursing staff did not adjust G-Tube pumps. This failure could place residents at risk of malnutrition. Record review of Resident#1's face sheet, dated 10/24/25 reflected, he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE], diagnosed with but not limited to: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of thirteen (Resident #97) residents reviewed for accidents and supervision. The facility failed to prevent Resident #97's elopement from the facility on 6/12/25 without staff being aware that she had eloped. An Immediate Jeopardy (IJ) situation was identified on 8/13/25. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need of corrective systems. This failure could place residents at risk for serious injuries, serious harm and death. Record review of Resident #97's face sheet, dated 8/12/25, reflected an [AGE] year-old female who was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #24, Resident #5 and Resident # 75 and Resident #88) of 18 residents reviewed for ADLs. The facility failed on 08/12/2025 to ensure the following:1. Resident #24 had her fingernails trimmed.2. Resident #5 had her fingernails trimmed.3. Resident #75 had her fingernails cleaned and trimmed.4. Resident #88 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items were properly stored in the facility freezer on 08/12/25. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident bedside, toilet, and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relays the call directly to a staff member or a centralized staff work area for 13 of 24 residents (Resident #56, Resident #6, Resident #57, Resident #5, Resident #8, Resident #79, Resident #36, Resident #78, Resident #65, Resident #50, Resident #38, Resident #53, and Resident #27) reviewed for residents' call system.1-The facility failed on 08/12/2025 to ensure the call light system was accessible to a resident lying on the floor in the shared residents' toilets located inside the residents' rooms . Resident#6. Resident#57. Resident #5. Resident #8. Resident #79. Resident #36. Resident #78. Resident #65. Resident #50. Resident #38. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for three (Resident #34, Resident #96, Resident #97) of thirteen residents reviewed for care plans. The facility failed to develop a care plan for elopement for Resident #97 after the resident eloped on 06/12/25 and remained in the facility until discharge on [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Record review of Resident #97's face sheet, dated 8/12/25, reflected an [AGE] year-old female who was admitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #44) reviewed for feeding tubes. The facility failed to ensure Resident #44's hydration bag for the tube feeding pump was labeled and dated. This failure could result in complications of enteral feedings such as receiving incorrect hydration or elevated risk of infection with using the same hydration bag over multiple days.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 6 Residents (Resident #56, Resident #61) reviewed for respiratory care. 1-The facility failed to ensure Oxygen (O2) in use signage was on Resident #56's, and Resident#61 doorway. This failure could place residents at risk of not receiving appropriate respiratory care. 1-Record review of Resident #56's MDS assessment, dated 08/12/25, reflected Resident #56 was an [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident#11, and Resident#70) reviewed for infection control. [...]

Inspectors wrote[Based on observations, interviews, and record review the facility failed to ensure the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #3) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light in resident room used by Resident #3 was always within reach. This failure could place resident at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of 9 residents reviewed for comprehensive care plans. The facility failed to care plan Resident #2 for ADLs. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, Resident#2) of 9 residents reviewed for ADL's. The facility failed to ensure. 1-Resident#1 had his fingernails trimmed and cleaned. 2-Resident #2 had her fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for 1 (Resident #2) of 9 residents observed for physician orders for ADLS. The facility failed to have a physician order for a soft hand roll for the contracted left hand for Resident #2. These failures could place the residents at risk of not receiving necessary care and services that could result in the worsen condition.

Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that, The facility failed to distribute mail to residents on Saturdays. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in resident's psychosocial well-being and quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 6 residents reviewed for quality of care. 1. The facility failed to promptly test Resident #2 for COVID 19 when nurse practitioner ordered the test on [DATE] until [DATE]. 2. The facility failed to follow nurse practitioner order for nasal spray for Resident #2 on [DATE], [DATE], and [DATE]. These failures could place residents at risk for not receiving or experiencing a delay in treatment or not having health conditions identified promptly.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility failed to ensure potato rolls in the walk-in refrigerator had expiration date. The facility failed to ensure Dietary Aide F and Assistant Dietary Manager used appropriate hair restraints in the kitchen. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for the residents in the facility. 1) The facility failed to implement the measure stated in their Water Management Program policy to prevent the Legionella bacteria growth in their water system. 2) The facility failed to ensure CNA H put on appropriate PPE before entering and exiting Resident #48's room, who was on isolation precautions for COVID-19. These failures placed residents at risk for contacting Legionella bacterial infection through the water system, and could place residents at risk for illness and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #66, Resident #80) of 8 residents reviewed for quality of life. The facility failed to ensure: 1- Resident #66 had his fingernails cleaned and trimmed. 2- Resident #80 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall 400) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure LVN B, responsible for Nurses Cart Hall 400, removed medications in unsecure containers from the Nurses Cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments for 1(Resident #1) of 1 resident reviewed for storage of medication. The facility failed to ensure Resident #1's Fluticasone Propionate (Nasal spray) and Trelegy Ellipta Inhalation Aerosol Powder (Inhaler) were not stored at the resident's bedside table and not secured in the medication cart or medication room. This failure could place residents at risk of overdosing.

Inspectors wroteBased on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for two (03/28/23 and 04/25/23) of three Resident Council meetings reviewed for resident group response. The facility failed to ensure prompt efforts were made by the facility to resolve grievances of the confidential Resident Council reviewed for grievances. This failure could place facility residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #48, Resident #56) of 8 residents reviewed for ADLs. The facility failed to ensure: 1-Resident #48 had her fingernails trimmed. 2-Resident #56 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items in dry storage were labeled and dated. 2. The facility failed to ensure 4 individual packets of yogurt in refrigerator was not expired. These failures could residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' patient care equipment was in safe operating condition for two (Residents #39 and #19) of 24 residents reviewed for wheelchairs. 1. The facility failed to ensure Resident #39's wheelchair was properly maintained. Resident #29's side arm cushions on both sides of her wheelchair were missing for a couple of months. 2. The facility failed to ensure Resident #19's wheelchair was properly maintained. Resident #19's right brake handle on his wheelchair was loose. These failures could place residents at risk for skin tears, falls, and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality for one (Resident #39) of 17 residents reviewed for resident rights. The facility failed to ensure MA C respected Resident # 39's wishes for him to wait before entering resident's room. This failure placed residents at risk of feeling disrespected and having their request unheard.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be fully informed of his or her total health status, including but not limited to, his or her medical condition for 1 (Resident #50) of 24 residents reviewed for residents' rights. The facility failed to ensure Resident #50 was informed of his x-ray results on 05/01/23 and 05/03/23. The failure could place the residents at risk of not being to make informed decisions regarding their care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #5) of two residents reviewed for incontinence care. The facility failed to ensure CNA B provided appropriate perineal care for Resident #5 after an incontinent episode when she failed to wipe from the base of the labia towards and extending over the resident's buttocks. This failure placed residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #42) of one resident reviewed for tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. The facility failed to ensure LVN G followed the procedure for tracheostomy care for Resident #42 on 05/10/23 by: 1. Maintaining a sterile/clean field for supplies necessary for care 2. Changing his gloves and performing hand hygiene before applying a clean trach drainage sponge 3. Using sterile technique when inserting the inner cannula into the resident's trach. These failures could place residents at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 medication carts (300 hall medication aide cart) of 4 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecured containers were immediately removed from stock. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 05/09/2023 at 2:50 PM of the Medication Aide Cart Hall 300 revealed the blister pack for Resident #118's trauma 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of three residents (Resident #42) observed for infection control. The facility failed to ensure LVN G perform hand hygiene while administering medication to Resident # 42. This failure could place the residents at risk for infection.