Eastgate Nursing & Rehabilitation Center

Based on clinical record review and staff interview, the facility failed to ensure that the residents and/or their representatives participated in the comprehensive and quarterly care plan reviews for 3 of 6 residents, Resident ID #s 7, 8, and 10.Findings are as follows:Record review of a facility policy titled Comprehensive Care Plans last reviewed on 9/30/2025 states in part, .Frequent care plan meetings are to be encouraged to address changing circumstances which affect the residents' well-being. 1. Record review revealed Resident ID #7 was admitted to the facility in September of 2021 with a diagnosis including, but not limited to, abnormalities of gait and mobility.Record review failed to reveal evidence that the following Minimum Data Set (MDS - a federally mandated, standardized comprehensive assessment tool used in Medicare/Medicaid certified nursing homes to evaluate the clinical, functional, and psychosocial status of residents) Assessments included documentation of participation or an explanation of non-participation of the resident and his/her…

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 surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 6 residents reviewed for oxygen use, Resident ID #s 11 and 63. Findings are as follows: According to Lippincott Nursing Procedure Ninth Edition 2023, page 621, states in part, .Verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed . 1. Record review revealed Resident ID #11 was admitted to the facility in October 2017 with diagnoses including, but not limited to, diabetes, and dementia. During surveyor observations on the following date and times, Resident ID #11 was observed receiving 2 liters (L) of oxygen via a nasal cannula: 2/17/2026 at 10:45 AM, 12:00 PM, 1:15 PM, and 2:00 PM. Record review failed to reveal evidence of a physician's order for the use of oxygen, as required. During a surveyor interview on 2/17/2026 at 2:25 PM with Registered Nurse, Staff B, she acknowledged that the resident was receiving 2 L of 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 surveyor observation, clinical record review, and staff interview, the facility failed to assess one of three residents for the use of an air mattress (a pressure redistribution mattress that utilizes low air loss and pulsation) for the potential risk of entrapment related to bed rails, Resident ID # 2.Findings are as follows:Record review of a policy titled Side Rail Use last reviewed on 12/18/2025 states in part, POLICY: This facility recognizes the potential for the hazard of entrapment related to side rail use .PROCEDURE:4. The assessment is to assess the risk of entrapment and will specify the medical/physical conditions that make the rail necessary .8. Side rails are to be ordered by the resident's physician. The order shall include the reason the rail is to be utilized. 9. The care plan will reflect the use of the side rail. Record review revealed the resident was admitted to the facility in December of 2025 with diagnoses including, but not limited to, congestive heart failure (when the heart muscle is too weak or stiff to pump blood efficiently, causing blood 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 surveyor observation, clinical record review and staff interview, the facility failed to provide a safe and sanitary environment to help prevent the transmission of infections related to disinfecting blood glucose meters (a device used to monitor blood glucose) for 1 of 1 resident observed, Resident ID #32.Findings are as follows:According to the Centers for Disease Control and Prevention article titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 8/7/2024 states in part, If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents.Review of the facility's policy revised on December 2025, titled, Diabetes - Care of equipment states in part, .If a glucometer is to be used for one resident and then reused for another, the device must be cleaned and disinfected between uses.Follow the manufacturer's recommendations for cleaning.Review of 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed in accordance with professional standards for food safety relative to food handling, and 1 of 1 ice machines observed. Findings are as follows: 1. Record review of the Rhode Island Food Code 2018 Edition, 216-RICR-50-10-1 subchapter 10 titled food contamination, section 1.5.1 Preventing Contamination from Hands states in part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use .single-use gloves . During surveyor observations of the meal service in the main kitchen of cook, Staff F, he failed to follow the single-use gloves protocol on the following dates and times: - 11/18/2024 from 11:50 AM to 12:11 PM, Staff F was observed touching the following equipment (oven, microwave, knives, and tongs), and food with the same gloves. Staff F then removed salad from a salad bowl and plated it for lunch service. Further, Staff F, with the same gloves on, put on an oven mitt, over his gloved…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice relative to the failure to post cautionary and safety signs indicating that oxygen was in use for 3 of 3 residents observed, Resident ID #s 13, 36, and 52. Findings are as follows: 1. Record review revealed Resident ID #52 was admitted to the facility in May of 2024 with a diagnosis including, but not limited to, acute and chronic respiratory failure with hypoxia (low levels of oxygen in the blood). Record review revealed a physician's order dated 8/20/2024 to administer humidified oxygen at 2 liters per minute (LPM) continuously via a nasal cannula (a medical device used to provide supplemental oxygen therapy). Surveyor observation of the resident's room failed to reveal evidence that a cautionary and safety sign indicating oxygen was in use on the following dates and times: - 11/18/2024 at 9:09 AM and 11:31 AM - 11/19/2024 at 8:07 AM - 11/20/2024 at 8:02 AM During a surveyor interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan related to skin integrity for 1 of 1 resident observed, Resident ID #50, and a Hoyer lift (mechanical lift) transfer for 1 of 4 residents reviewed, Resident ID #48. Findings are as follows: Record review of the State Operations Manual (SOM) Appendix PP-Guidance to Surveyors for Long Term Care Facilities, updated on 8/8/2024, page 316 revealed that many clinicians recommended a position change (offloading) hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the wheelchair raised 30 degrees or more. Further review of the SOM revealed a micro shift, meaning a small change in the resident's position for a short period of time, may not be adequate since this approach does not allow sufficient capillary refill and tissue perfusion for a resident at risk of developing a pressure…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a resident with limited range of motion (ROM) appropriate treatment and services relative the use of a hand roll device (use to promote extension in contrasted hand) for 1 of 1 resident reviewed, Resident ID #32. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2017 with a diagnosis including, but not limited to, left hand contractures. Record review of the care plan dated 3/5/2024 revealed the resident is unable to be independent with self-care secondary to physical limitations. Record review of a physician's order dated 4/5/2024 revealed that the resident is to wear a left-hand roll with finger separators every morning for 6-8 hours, as tolerated. Record review of an Occupational Therapist (OT) note dated 11/11/2024, revealed that the resident was screened for the left-hand roll with finger separators and that s/he is appropriate to wear the device. During surveyor observations on the following dates 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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases, relative to the disinfection of a multiuse glucometer. Findings are as follows: Record review of a facility provided document titled, Facility's Competency Validation for Blood Glucose Testing, revealed the glucometer should be wiped down with a low-level disinfectant wipe (per the manufacturer's instructions) before and after each use. Record review of the McKesson's Manufacturer Instruction Manual revealed that the glucometer is to be cleaned and disinfected only with PDI Super Sani Cloth wipes (or any disinfectant product with the Environmental Protection Agency *reg. no. of 9480-4). Record review revealed Resident ID #10 has a physician's order dated 8/24/2024 to obtain a finger stick blood sugar (FSBS) once a day at 12:00 PM. During a surveyor observation on 11/19/2024 at 11:16 AM…

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 staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of an undated facility provided policy titled, Medication Administration Safety Program states in part, . 4. Prior to actually giving the resident the medication(s), the licensed staff member must confirm the residents' identity . Record review of a community reported complaint sent to the Rhode Island Department of Health on 2/28/2024 alleges that the Medication Technician, Staff A, gave Resident ID #1 medications that were prescribed for Resident ID #2. Record review for Resident ID #1 revealed that s/he was admitted to the facility in January of 2024 with diagnoses which include but are not limited to, spinal stenosis, muscle weakness and insomnia. During a surveyor interview on 2/29/2024 at 10:30 AM with Resident ID #1, s/he revealed that s/he was told by the facility staff that s/he was given someone else's medications in error 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 record review, and staff interview, it has been determined that the facility failed to ensure that a resident's drug regimen is free from significant medication errors for 1 of 1 resident reviewed who experienced a significant medication error, Resident ID #24. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2022 with a diagnosis, including but not limited to, hypertension. Record review revealed the resident has the following physician orders: -9/19/2023, to treat high blood pressure and chest pain: Amlodipine 5 mg (milligrams) to be administered once daily. -9/19/2023, to treat high blood pressure and heart failure: Lisinopril, 10 mg tablet to be administered once daily. Further review of the above-mentioned orders revealed parameters to hold the medication if the diastolic blood pressure (DBP, the bottom number of a blood pressure that measures the force exerted on the blood vessels when the heart is at rest) is less than 60 mm Hg (millimeters of mercury). Review of the 9/20/2023 through 9/30/2023 Medication…

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 surveyor observation and staff interview, it has been determined that the facility failed to provide a safe, sanitary, and comfortable environment for residents and staff, for 2 of 3 microwaves observed. Findings are as follows: Surveyor observation of the second floor, Unit 2A, on 11/29/2023 at 9:33 AM, revealed multiple rust spots on the inside ceiling of the microwave. One area, approximately the size of a half dollar, was located towards the front of the microwave and multiple small areas of rust were observed. Additionally, the rust debris was observed to flake off when touched. Further surveyor observation on the second floor, Unit 2B, on 11/29/2023 at 9:37 AM, revealed a brown and red colored buildup of an unidentified food substance on the inside ceiling and walls of the microwave. An additional surveyor observation of the microwave, located on the 2B Unit on 11/30/2023 at 7:59 AM, revealed the same brown and red colored food substance buildup on the inside ceiling and walls of the microwave as initially observed on the previous day. During a simultaneous surveyor…

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.