Eagle Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure each resident received food that was prepared in a form designed to meet individual needs for two residents (R) (R4 and R20) of six residents who required a pureed diet. Specifically, the facility failed to ensure that the consistency of the pureed diet was appropriate to meet the needs of the residents. Findings included: Review of the IDDSI (International Dysphagia Diet Standardization Initiative) dated 2019 read in part: Level 4 Pureed - Have a smooth with no lumps .not sticky .do not require chewing .Food characteristic to AVOID .tough or fibrous foods .food with skins or outer shell, food with husks, bone or gristle .stringy food .visible lumps. Examples of food to AVOID .steak .peas .corn .meat with gristle .lumps in pureed food. Review of the lunch menu for the week of 4/22/2025 through 4/24/2025 included: 4/22/2025 Beef stew, white rice, green peas, and frosted spice cake. 4/23/2025 BBQ ribs, baked beans, corn, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to provide special eating equipment and utensils and assistance for one of one resident (R) (6) reviewed for the use of adaptive equipment. Specifically, the facility failed to identify the correct position of a plate guard and who was responsible for the correct position of the plate guard on the resident's plate during meals. Findings included; R6 was admitted to the facility on [DATE] with diagnoses that included spastic hemiplegic cerebral palsy, lack of coordination, severe intellectual disabilities, and general weakness. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], which contained a Brief Interview for Mental Status (BIMS) assessment that the staff completed, identified that the resident had long and short-term memory problems and was severely cognitively impaired and never or rarely made decisions. The resident required setup and/or clean-up assistance with meals, in which a helper set up and/or cleaned up; and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, record review, review of the facility's policy titled, Abuse Prohibition, the facility failed to protect the residents' right to be free from sexual abuse by another resident for two of three residents (R) (R1 and R4) reviewed for abuse prohibition. Specifically, the facility failed to develop or implement interventions to address R2's sexual behavior to protect R1 and R4 from sexual abuse. Findings included: Review of the facility's policy titled, Abuse Prohibition, dated 12/27/2024, revealed the Intent section included, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Guideline section included, . Identification of patients whose behavior is abusive to other patients. If a patient is identified in one of the following categories, a thorough assessment will be completed to include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and facility document review, and review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, the facility failed to ensure allegations of sexual abuse for three of three residents (R) (R1, R3, and R4) reviewed for abuse prohibition were reported to the state survey agency (SSA) no later than two hours after the allegations were made. Findings included: Review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, dated 12/27/2024, revealed the Guidelines section included, Any person hearing a complaint of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation must immediately tell the Administrator, the Director of Nursing, the Social Services Director, any specific department leader, or the nurse in charge. Any person identifying any signs and symptoms of abuse as listed in the Abuse Prohibition policy related to a specific patient is responsible to immediately inform the Administrator, the Director of Nursing, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Food Preparation and Distribution and Storage Areas, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure meal temperatures were documented and failed to ensure dented cans were removed from the dry storage area and were not available for use. This failure had the potential to affect 37 of 39 residents who received meals from the kitchen. Findings included: A review of the Food Preparation and Distribution policy, dated 10/11/2022, revealed It is the intent of the center to prepare and distribute food in a manner that minimizes the risk of food borne illness and promotes safe food handling practices. The policy also revealed, Tray line: A temperature monitoring log should be maintained throughout meal service. Temperatures should be monitored frequently throughout meal service to ensure food quality and safety. A review of facility documents titled Hot/Cold Temperature Log from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to ensure Level 1 Preadmission Screening and Resident Reviews (PASARR) were accurate to ensure provision of the appropriate level of services for 2 of 3 residents (#8 and #35) whose PASARRs were reviewed. This failure had the potential to increase the risk for a resident with a mental illness diagnosis from not receiving specialized services. Findings included: Review of a Face Sheet indicated R#8 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and schizophrenia. Review of the Nurses Note, dated 03/28/2022, revealed R#8 was admitted to the facility on this date. The note indicated R#8 had a history of schizophrenia. Review of the Care Plan, with an onset date of 03/30/2022, revealed R#8 was taking a psychotropic drug related to schizophrenia. The most recent admission Minimum Data Set (MDS), dated [DATE], for R#8 was severely impaired in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Patient's Plan of Care, the facility failed to follow residents' individualized care plans directing staff to apply barrier cream after an incontinence episode for 2 of 3 residents (#24 and #31) who received incontinence care. This failure had the potential for residents to not receive treatment and/or care according to their needs and may cause adverse consequences. Findings included: The facility's policy titled, Patient's Plan of Care, with a review date of 12/04/2021, indicated, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. A review of R#24's Face Sheet revealed the facility admitted R#24 with a diagnosis of anoxic brain injury. The care plan revised on 11/22/2022 indicated R#24 was at risk for skin breakdown. Interventions included using barrier cream after each incontinent episode to protect the resident's skin.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and record review, the facility failed to ensure activities of daily living (ADLs) care were provided to maintain good grooming related to facial hair for 1 of 3 residents (R) (#22) reviewed for ADL care. Findings included: Multiple requests were made for a policy that addressed the intent for shaving for residents. On 03/01/2023 at 10:00 a.m. The Administrator presented a shaving procedure guide that only explained how to shave a resident. A review of the Face Sheet for R#22 revealed the facility admitted the resident with a diagnosis that included hemiparesis (lack of movement) on the dominant right side following a stroke. A review of the most recent quarterly Minimum Data Set (MDS), for R#22 dated 02/10/2023, indicated had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The MDS indicated the resident had no behaviors or rejection of care. The MDS indicated R#22 required extensive assistance with personal hygiene and had impairment in functional range of motion on one side of the upper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and a review of the facility's policy titled, Perineal care, the facility failed to provide proper incontinent care by not thoroughly removing urine from the resident's skin for 2 of 3 residents (R) (#24 and #31) reviewed for incontinent care. Findings included: The facility's policy titled, Perineal care, with a review date of 12/30/2022, indicated perineal care was to ensure adequate skin care, control odor, prevent skin damage, preserve dignity, and prevent urinary tract infections to the extent possible. Review of the most recent quarterly Minimum Data Sheet (MDS), for R#24 dated 12/20/2022, indicated R#24 was sometimes understood and rarely/never understood others. The staff assessed the resident as having short-term and long-term memory impairment. The resident was dependent on staff for all activities of daily living. The MDS indicated R#24 was always incontinent of bowel and bladder. Observation on 03/01/2023 at 9:40 a.m. Certified Nursing Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews and record review the facility failed to ensure 1 of 5 residents (R) (#30) was free from unnecessary medications. Specifically, the facility failed to discontinue buspirone (an anxiety medication) for R#30 as ordered by the resident's physician on 01/25/2023. As of 02/28/2023, the facility continued to administer the medication to the resident. Findings included: Interview on 03/01/2023 at 2:53 p.m. with the Director of Nursing (DON) revealed the facility had no policy related to unnecessary medications or following physician orders. Review of R#30's Face Sheet revealed the resident was admitted to the facility with a diagnosis including unspecified dementia with anxiety. Review of the most recent admission Minimum Data Set (MDS), for R#30 dated 11/10/2022, revealed R#30 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. Review of the electronic medication administration record (eMAR) indicated R#30 was started on buspirone (anti-anxiety medication) 10 milligram (mg) tablet, once daily by mouth on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews and record review the facility failed to ensure laboratory testing was performed timely and as ordered by the physician for 1 (Resident #35) of 5 residents (R) (#35). Findings included: During an interview with the Administrator on 03/01/2023 at 2:23 p.m., he stated there were no policies related to laboratory testing. Review of the Face Sheet for R#35 revealed the resident was admitted with diagnoses including bipolar disorder and iron deficiency anemia. Review of the physician's orders Summary Report for R#35 revealed an order dated 08/17/2022 for a complete blood count (CBC) every six months. Further review revealed orders, dated 08/15/2022, to start ferrous sulfate (iron) 325 milligrams, one tablet by mouth twice daily for anemia and valproic acid 250 mg by mouth three times daily for bipolar disorder. In addition, R#35 had a physician order dated 08/19/2022 to obtain a valproic acid level every three months related to bipolar disorder. Review of a Note to Attending Physician/Prescriber, for R#35 dated 10/11/2022, revealed the pharmacist had conducted a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident/staff interviews, the facility failed to ensure the right of one resident (R) (#1) to maintain personal property within her possession. The sample size was 22 residents. Findings include: Review of the clinical record for R#1 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include morbid obesity, anxiety disorder, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented R#1 possessed adequate hearing, impaired vision, clear speech, was understood and understandable. The Brief Interview for Mental Status (BIMS) score was documented at 12, indicating moderate cognitive impairment. During an interview on 8/15/21 at 5:01 p.m. in her room, R#1 stated she was moved from B-Hall to the A-Hall and her belongings have not been moved into her new room. During an interview with the Social Services Director (SSD) on 8/18/21 at 12:42 p.m., she stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to maintain a clean environment related to dirt buildup in six shared resident bathrooms (A14, A18, A19, A20, A30, and A34) of 33 rooms. Findings include: Observations of room A19 shared bathroom on 8/15/21 at 1:20 p.m. and 8/16/21 at 8:45 a.m. revealed brown/black stains in the base of the toilet and a large black stain on the floor around the bottom of the toilet. Observations of room A20 shared bathroom on 8/15/21 at 1:30 p.m. and 8/16/21 at 9:06 a.m. revealed a brown ring around the inside base of the toilet. Grime and buildup were noted to the base of toilet on the floor. Observations on 8/15/21 starting at 2:00 p.m. and 8/16/21 starting at 1:23 p.m. revealed the following: In the shared bathroom of room A14, dust buildup was observed in the vent in bathroom and missing wall tile by the toilet paper holder. In the shared bathroom of room A18, dark colored buildup was observed inside the toilet and dust on the vent in the bathroom. In the shared bathroom of room A30, dust buildup was observed on the bathroom vent.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to develop a care plan to address the behavioral needs of one resident (R) (#31) who removes his clothing. The sample size was 22 residents. Findings include: Observations on 8/15/21 at 1:40 p.m. and 8/16/21 at 10:44 a.m. revealed R#31 was observed with no pants on and brief exposed. During an interview on 8/17/21 at 2:10 p.m., Licensed Practical Nurse (LPN) AA stated that R#31 requires extensive assistance with care needs and does have some behaviors such as crawling on the floor and taking off his clothes at times, which is why staff usually dress the resident early. Interview on 8/17/21 at 2:20 p.m. with Certified Nursing Assistant (CNA) CC revealed that she works with R#31 frequently and he does require assistance with dressing. CNA CC stated that the resident does have pajamas to wear to bed and they are usually on him when she comes in in the mornings. Continued interview revealed that the resident will sometimes crawl around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.