Eastgate Health Care Center

Based on observation, staff interview, facility document review, and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect all the residents who received nourishment from the kitchen.Findings include:Observation on 08/18/25 at 9:40 A.M. of the walk-in refrigerator revealed it included the following: a large container of pancake batter with an open date of 08/12/25 and a discard date of 08/17/25, a large, opened container of sour cream without an open date, a large, opened container of canola oil without an open date. Interview on 08/18/25 at 9:44 A.M. with the Corporate Chef (CC) confirmed items in the refrigerator should have an open date and a discard date and items should be discarded by the discard date. The CC confirmed the sour cream and canola oil lacked open dates, and the pancake batter should have been discarded by the discard date on the label. 2. Observation on 08/18/25 at 9:43 A.M. of the dry storage revealed there were 21 boxes of salt which…

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 medical record review, staff interview, facility document review, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the state survey agency (SSA). This affected two (Residents #156 and Resident #120) of three residents reviewed for abuse. Findings include:1. Review of the medical record for Resident #52 revealed an admission date of 12/26/2023 with diagnoses of schizophrenia and bipolar disorder. Review of the MDS for Resident #52 dated 05/21/25 revealed the resident had intact cognition. Review of the care plan for Resident #52 dated 04/16/24 revealed the resident had a history of behaviors which included wandering and making inappropriate comments to staff. Interventions included the following: direct staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, offer tasks that divert the resident’s attention. Review of the medical record for Resident #156 revealed an admission date of 09/20/23 with a diagnosis of dementia with…

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 medical record review, staff interview, facility document review, and review of the facility policy, the facility failed to thoroughly investigate allegations of resident abuse and ensure residents were protected from further potential abuse during the course of the investigation. This affected two (Residents #156 and Resident #120) of three residents reviewed for abuse. Findings include:1. Review of the medical record for Resident #52 revealed an admission date of 12/26/2023 with diagnoses of schizophrenia and bipolar disorder.Review of the MDS for Resident #52 dated 05/21/25 revealed the resident had intact cognition. Review of the care plan for Resident #52 dated 04/16/24 revealed the resident had a history of behaviors which included wandering and making inappropriate comments to staff. Interventions included the following: direct staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, offer tasks that divert the resident's attention. Review of the medical record for Resident…

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 medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide nail care for one (Resident #13) of four residents reviewed who were dependent on facility staff for activities of daily living (ADL). Findings include: Review of the medical record for Resident #13 revealed an admission date of 05/23/22 with diagnoses including dementia without psychotic disturbance, type two diabetes mellitus, blindness to the right eye, and bilateral glaucoma. Review of the care plan for Resident #13 dated 05/05/23 revealed the resident had a self-care performance deficit and staff were to assist with ADLs as needed. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 07/08/25 revealed the resident had severe cognitive impairment, was dependent on staff for personal hygiene, and had not rejected care during the assessment look-back period. Observation on 08/20/25 at 8:05 A.M. revealed Resident #13's fingernails on both hands were three to four inches long, extending beyond the fingertips. Resident #13's nails…

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, interview, and facility policy review, the facility failed to prevent a significant medication error that placed 1 (Resident #132) of 1 resident reviewed for insulin administration at risk for hypoglycemia. Specifically, Resident #132 received short-acting insulin (Humalog) instead of long-acting insulin (Lantus) and required transfer to a hospital emergency department for observation.The findings included: Review of the medical record for Resident #132 revealed an admission date of 07/11/25 with diagnoses including myocardial infarction, chronic kidney disease, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #132 dated 07/17/25 revealed the resident had intact cognition. Review of the care plan for Resident #132 revealed the resident had diabetes mellitus with diabetic polyneuropathy. Interventions directed staff to administer diabetes medication as ordered by clinicians. Review of the physician's orders for Resident #132 revealed an order dated 07/11/25 for Lantus insulin subcutaneously 95 units at bedtime. Review…

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 record review, staff interview, and facility policy review, the facility failed to maintain medical records that were complete and accurate. This affected one (Resident #154) of 48 sampled residents. Findings include: Review of the medical record for Resident #154 revealed an admission date of [DATE] with a diagnoses of protein-calorie malnutrition and a discharge date of [DATE]. Review of the Minimum Data Set (MDS) assessment for Resident #154 revealed the resident had severe cognitive impairment. Review of the do not resuscitate (DNR) order form for Resident #154 dated [DATE] revealed the physician signed an order for DNR comfort care indicating staff would not perform cardiopulmonary resuscitation (CPR.) Review of the order recap report for Resident #154 revealed an order dated [DATE] for the resident's code status as DNR comfort care. Review of the social service assessment for Resident #154 dated [DATE] per Social Worker (SW) #12 revealed the resident was a full code Review of the progress notes…

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 record review, observation, staff interview, and policy review, the facility failed to ensure the residents were treated with dignity and respect at meal service. This affected one (Resident #120) of 11 residents whom were eating lunch in the dining room. The facility census was 148. Findings include: Record review for Resident #120 revealed Resident #120 was admitted on [DATE]. Diagnoses included congestive heart failure, diabetes mellitus, hypertension, obesity, chronic kidney disease, and anemia. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 had no cognitive deficits and required supervision during eating. Observation of lunch service on 05/02/22 from 12:15 P.M. to 12:45 P.M. revealed State Tested Nursing Assistant (STNA) #46 brought Resident #120 into the dining room and placed Resident #120 at the table with Resident #20. Resident #20 was served her lunch at 12:15 P.M. and STNA #46 continued to serve the other nine residents (#14, #25, #31,…

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, and policy review, the facility failed to ensure the resident's foods were handled in a manner to prevent the potential spread of food borne illness. This affected three residents (Residents #7, #29, and #60) observed during the afternoon meal. The facility census was 148. Findings include: 1. Observations on 05/02/22 at 12:48 P.M. revealed the residents were being served their afternoon meal. The residents were receiving hamburgers on bun with condiments and toppings consisting of lettuce, tomatoes, mayonnaise and mustard in individual packs. State Tested Nursing Assistant (STNA) #63 was assisting Resident #60 with meal set up. STNA#60 asked Resident #60 what they wanted on their hamburger. The STNA opened the packs of mayonnaise and mustard put on the top bun. STNA# 63 then picked up the lettuce, and tomatoes with her bare hand and placed them on the hamburger, the STNA then wiped her hands on her scrub top and picked up the top bun placed it on the hamburger, used her bare hand to smash the sandwich down and then cut it with the knife.…

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 medical record review, staff interview and policy review, the facility failed to provide a copy of the transfer or discharge notification to the Ombudsman for discharges from the facility. This affected two (#24 and #114) of nine residents reviewed for discharge notification. The facility census was 167. Findings include: 1. Record review revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses include epilepsy, apraxia, weakness, pain, unspecified convulsions, abnormal findings of blood chemistry, non toxic multinodular goiter, muscle weakness, anemia, peripheral vascular disease, acquired absence of left leg below knee, essential hypertension, anxiety disorder, atrial fibrillation, type two diabetes mellitus with hyperglycemia and hyperlipidemia. Review of Resident #24's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be cognitively impaired and require limited assistance with personal hygiene. Resident #24 also required supervision with eating 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 medical record review, observation, staff interview, and policy review, the facility failed to ensure a nurse provided the correct pressure ulcer dressing for a resident in accordance with a physician order. This affected one (#84) out of four residents reviewed for pressure wounds. The facility census was 167. Findings include: Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include degeneration of brain, gastrointestinal hemorrhage, dysphagia, hyperlipidemia, electrolyte/fluid balance disorders, diabetes, chronic kidney disease, vitamin D, peripheral vascular disease, anxiety, hypertension, hypokalemia, transient ischemic attack, hemiplegia, anxiety, chronic obstructive pulmonary disease, osteoporosis, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 has severe cognitive deficits, and requires extensive assist to total dependence for activities of daily living, is frequently…

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.