East Lake Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure blood pressure parameters were followed as ordered for 2 of 3 residents reviewed for blood pressure parameters. The facility also failed to ensure areas of bruising were assessed and monitored and heel boots were applied as ordered for 2 of 4 residents reviewed for skin conditions non-pressure related. (Residents 10, 6, 62, and 110)Findings include:1. The record for Resident 10 was reviewed on 4/15/26 at 3:52 p.m. Diagnoses included, but were not limited to, hypertension and atherosclerotic heart disease. A Care Plan, dated 5/17/18 and reviewed on 4/1/26, indicated the resident was at risk for ineffective tissue perfusion related to the diagnoses of hyperlipidemia (elevated lipids), history of stroke, cardiomyopathy, coronary artery disease, and hypertension. Interventions included, but were not limited to, administer medications as ordered. The Quarterly Minimum Data Set (MDS) assessment, dated 3/31/26, indicated the resident was…

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 observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and physician orders were obtained for the use of oxygen for 3 of 5 residents reviewed for respiratory care. (Residents 110, 109, and 74)Findings include:1. During random observations on 4/13/26 at 3:30 p.m., and 4/14/26 at 10:39 a.m. and 3:17 p.m., Resident 110 was observed wearing oxygen via nasal cannula. The oxygen was set at seven liters per minute and connected to the concentrator in the room. The record for Resident 110 was reviewed on 4/14/26 at 3:42 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cellulitis of the left lower limb, chronic respiratory failure with hypoxia (low oxygen levels), heart disease, peripheral vascular disease, and heart failure. The admission Minimum Data Set (MDS) assessment, dated 4/7/26, indicated the resident was cognitively intact for daily decision making, had no skin issues, and received oxygen…

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, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to wear the correct personal protective equipment (PPE) for residents in enhanced barrier precautions and droplet isolation for 1 of 3 pressure ulcer treatments observed and 3 of 9 residents observed during medication administration. The facility also failed to ensure multi-use equipment was disinfected after each use for 3 of 3 residents who were observed having their vital signs checked. (Residents 43, 117, 74, 109, 108, 54, and 40)Findings include: 1.On 4/16/26 at 9:51 a.m., the Wound Nurse and the Assistant Director of Nursing (ADON) entered Resident 43's room to complete a treatment to the resident's sacrum. The Wound Nurse washed her hands and the ADON sanitized her hands prior to donning gloves. Neither one of the nurses donned a gown at that time. The ADON repositioned the resident to his right side and the Wound Nurse pulled down the resident's pants and removed the dressing to the sacrum. After removing 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 observation, record review, and interview, the facility failed to ensure pressure ulcer treatments were completed as ordered by the physician for 1 of 3 residents reviewed for pressure ulcers. (Resident 109)Finding includes:During an interview on 4/13/26 at 11:00 a.m. Resident 109 indicated her pressure ulcer bandage does not get changed every day. During a random observation on 4/13/26 at 12:41 p.m., CNA 1 assisted the resident to the bathroom. At that time, the resident had a bandage observed to her sacrum with a date of 4/11/26. The CNA observed the bandage as well and indicated the date was 4/11/26. On 4/13/26 at 3:30 p.m., LPN 1 was asked to perform a skin assessment for the resident. At that time, the resident was assisted to her right side and the LPN removed her pants and brief. The bandage on the resident's sacrum was dated 4/11/26. During an interview at that time, LPN 1 indicated she had not changed the bandage and she believed the treatment was supposed to be done every day. During a wound treatment on 4/16/26 at 7:17 a.m., the Wound Nurse removed the resident's…

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 record review and interview, the facility failed to ensure food and/or fluid intake was documented for residents with a history of weight loss for 3 of 3 residents reviewed for nutrition. (Residents 4, 6, and 74)Findings include: 1. The record for Resident 4 was reviewed on 4/16/26 at 3:07 p.m. Diagnoses included, but were not limited to Alzheimer's disease with early onset and end stage renal disease with dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 3/13/26, indicated the resident was cognitively impaired for daily decision making. He had sustained an unplanned weight loss and was receiving dialysis. A Nutrition At Risk (NAR) progress note, dated 4/9/26, indicated the resident had a significant weight loss of 10.9% within the last 90 days. A Care Plan, reviewed on 4/10/26, indicated the resident was at risk for altered nutritional status due to Alzheimer's disease, type 2 diabetes, dementia, end stage renal disease, hyperlipidemia, depressive disorder, and anxiety. Interventions included, but were not limited to, monitor food 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 observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADLs) for a dependent resident timely related to nail care and shaving for 1 of 3 reviewed for ADLs. (Resident 35) Finding includes: During an observation and interview, on 1/23/2025 at 10:21 A.M., Resident 35 had a full beard and his nails were jagged with a brown substance under them. Resident 35 indicated he received bed baths twice a week and did not have any problems with them but preferred to have assistance with shaving and nail care. Resident 35 indicated staff had only offered to assist him with shaving once or twice a month. During an observation and interview on 1/24/2025 at 9:11 A.M., Resident 35 had a full beard and jagged nails with a brown substance under them. He indicated that no one had offered to assist him with shaving or nail care. During an observation and interview on 1/27/2025 at 9:27 A.M., Resident 35 indicated the night shift CNA had shaved him and he was happy that his goatee…

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 observation, interview, and record review, the facility failed to follow the plan of care for a resident who required two staff present for care for 1 of 3 residents reviewed for care plans. (Resident 34) Finding includes: During an observation on 1/27/2025 at 9:27 A.M., CNA 8 exited Resident 35's room by herself. During an interview on 1/27/2025 at 9:29 A.M., Resident 35 indicated the CNA that had just left the room had helped him with toileting. He indicated he usually only had one caregiver in the room providing assistance because that was usually all they had working on the floor. He indicated it was rare that two staff members assisted him with care in his room, but occasionally two staff providing transfer assistance with the mechanical lift. During an observation on 1/28/2025 at 9:13 A.M., CNA 2 answered Resident 35's call light and asked the resident what he needed. The resident informed the CNA that he needed to use the urinal and CNA 2 proceeded into the resident's room and closed the room…

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 and interview, the facility failed to infection control measures were followed during medication administration observation for 1 of 8 residents observed receiving medications (Resident 17) and a linen cart was covered for 1 of 5 halls. (Hall 500) Findings include: 1. During an observation of a medication pass for Resident 17 on 1/24/2025 at 10:22 A.M., QMA 7 dropped a calcium tablet onto the medication cart. She picked up the tablet with her bare hand and placed it into a medication cup with Resident 17's other medications. During an interview with QMA 7 during the medication pass, she indicated she should not have administered the medications to the resident and should have destroyed all of the resident's medications once she had put the calcium table into the medication cup with the other medications. During an interview on 1/24/2025 at 10:26 A.M., QMA 17 indicated she was unsure of the facility policy for destruction of contaminated medications. During an interview with the Assistant Director of Nursing, who was present at the time, she indicated she was…

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 and interview, the facility failed to date multi-dose medication containers when opened, for 2 of 3 medication carts observed. (100 hall & 600 hall) Findings include: 1. During an observation of a 100 hall medication cart with LPN 6, on 1/24/2024 at 9:58 A.M., the following multi-dose medication containers lacked a date that indicated when it was opened: 1 bottle of atropine eye drops, and 1 bottle of Mylanta. 2. During an observation of a 600 hall medication cart with LPN 5, on 1/24/2024 at 10:17 A.M., the following multi-dose medication containers lacked a date that indicated when it was opened: 3 bottles of polyethylene glycol, 1 bottle of simethicone, 1 bottle of icosapent ethyl, and 1 bottle of potassium. A policy, titled, Storage and Expiration Dating of Medications, Biologicals, and dated 7/21/2022, was provided by the Director of Nursing on 1/26/2024 at 9:15 A.M. as current. The policy indicated, .Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date…

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 record review, observation, and interview, the facility failed to ensure a person-centered care plan was developed for 1 of 26 residents whose care plans were reviewed. (Resident 12) Finding includes: A record review was completed on 1/25/2024 at 1:14 P.M. Resident 12's diagnoses included, but were not limited to: acute and chronic respiratory failure with hypoxia, Atrial Fibrillation, Congestive Heart Failure, and chronic Pleural Effusion (build up of fluid between lungs and chest). A Physicians' Order, dated 1/15/2024, indicated Resident 12 had a PleurX Drain (an indwelling suction tube used to remove excess fluid or air) to drain fluid and record output every day. A hospital Discharge Note, dated 12/12/2023, indicated the resident still required a PleurX catheter for daily drainage upon admission to the facility for chronic right pleural effusion. Resident 12's current care plans lacked a specific care plan for the use and care the PleurX drain, including potential respiratory complications and interventions. A Care Plan, dated 12/20/2023, indicated the resident was at…

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 interview, observation, and record review, the facility failed to ensure residents received showers or complete bed baths as scheduled for 2 of 4 residents reviewed for Activities of Daily Living. (Residents 12 and 22) Findings include: 1. During an interview, on 1/22/2024 at 1:37 P.M., Resident 12 indicated he had received only one shower since admitting to the facility on [DATE]. An admission MDS (Minimum Data Set) Assessment, dated 12/19/2023, indicated the resident was dependent on staff for bathing and showering needs. A Significant Change MDS, dated [DATE], indicated it was very important to choose between tub bath, shower or bed baths. A review of the facility January 2024 shower binder, on 1/25/2024 at 3:00 P.M., indicated Resident 12 had the following shower sheets documented in the binder: 1/5/24 - shower 1/7/24 - shower 1/8/24 - complete bed bath 1/19/24 - shower During an interview, on 1/25/2024 at 3:54 P.M., Unit Manager 11 indicated the resident should have had more documented showers or…

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 observation, interview, and record review, the facility failed to ensure Oxygen usage signage was posted outside resident rooms and failed to ensure residents had current Physician Orders for the use of oxygen for 2 of 3 residents reviewed for respiratory care. (Residents 12 and 136) Findings include: 1. During an observation, on 1/23/2024 at 2:38 P.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. During an observation, on 1/24/2024 at 9:30 A.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. During an observation, on 1/25/2024 at 9:13 A.M., Resident 12 was observed receiving oxygen. There was no oxygen signage posted in or outside of room. During an interview, on 1/25/2024 at 9:55 A.M., LPN 3 and LPN 12 both indicated there should have been oxygen signage posted outside of Resident 12's door indicating oxygen use. During an observation, on 1/26/2024 at 2:35 P.M., Resident 12 was observed…

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 and interview, the facility staff failed to perform proper hand hygiene when preparing medications for administration to residents, for 2 random infection control observations during medication administration. Findings include: 1. During an observation of medication pass, on 1/23/2024 at 11:41 A.M., LPN 3 approached the medication cart and failed to perform hand hygiene before setting up medications for a resident. Alcohol based hand rub (ABHR) was available on the medication cart. During an interview on 1/23/2024 at 11:42 A.M., LPN 3 indicated she should have used the ABHR to clean her hands before setting up medications. 2. During an observation of medication pass, on 1/24/2024 at 8:45 A.M., LPN 4 made notes and documented medication for one resident, and failed to perform hand hygiene before setting up medications for another resident. ABHR was available on the medication cart. During an interview on 1/24/2024 at 8:47 A.M., LPN 4 indicated she should have washed her hands before preparing medications for the next resident. On 1/26/2024 at 9:15 A.M., the DON…

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.