East View Healthcare

Based on record review and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 4 (CMA D, RN L, LVN B, DES G) of 16 staff reviewed for abuse prevention. -The facility failed to check the EMR every twelve months for staff members CMA D by 8/28/2025 and RN L, LVN B and DES G by 8/29/2025.This failure could place residents at risk of abuse and neglect.Record review of the facility's personnel files, the following staff were identified as having EMRs conducted more than 12 months apart:-CMA D was hired on 6/9/2016 and had EMR checks on 8/28/2024 and 12/15/2025. CMA D was employable.-RN L was hired on 02/07/2024 and had EMR checks on 8/29/2024 and 12/17/2025. RN L was employable.-LVN B was hired on 07/11/2023 and had EMR checks on 8/29/2024 and 12/17/2025. LVN B was employable.-DES G was hired on 8/18/2022 and had EMR checks on 8/29/2024 and 12/15/2025. DES G was employable.Interview with HR Manager A on 12/18/2025 at 2:25pm, when HR Manager A said…

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 necessary services to maintain good grooming and personal hygiene for 1 (Resident #51) of 5 residents reviewed for activities of daily living. -The facility failed to remove unwanted facial hair from Resident #51's chin area and above resident's mouth observed on 12/16/2025 and 12/17/2025.This failure placed residents at risk for psychological embarrassment, sadness, and decrease in quality of life. Record review of Resident #51's face sheet dated 12/17/2025, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses included type 2 diabetes mellitus (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (prolonged excessive worry), and hypertension (high blood pressure).Record review of Resident #51's care dated 09/01/2023 for ADL self-care performance deficit, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #51) of 5 residents reviewed for pharmacy services. -Resident #51 did not receive Ozempic on 11/12/2025 and 12/17/2025 as ordered by the physician.The deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order. Record review of Resident #51's face sheet dated 12/17/2025, she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE] with medical diagnoses included type 2 diabetes mellitus (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (prolonged excessive worry), and hypertension (high blood pressure).Record review of…

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 and record review, the facility failed to dispose of garbage and refuse properly for 1 of 3 dumpsters (Dumpster #2) reviewed for garbage disposal.-The facility failed to close the facility dumpster when not in use on 12/16/2025 when the outside dumpster #2's right sliding door was left open. This failure could place residents at risk of contact with pests and associated diseases. Observation and interview on 12/16/2025 at 8:45a.m., the right sliding door of Dumpster #2 was open. MS A said the dumpster doors should have been closed. When asked what kind of negative effects it could cause, he did not answer the question. Interview with the Dietary Manager on 12/16/2025 at 10:40a.m., she said that the dumpster doors should have been closed. Animals and rodents could get in the trash.Interview with the DON and Administrator on 12/17/2025 at 3:19pm, the DON said the dumpster doors should not have been open. The Administrator said it was infection control. When asked if there could be any risks to residents, she said no and that she did not see residents…

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 prevent complications of enteral feeding including but not limited to dehydration in one of two residents (Resident #52), in that: - Resident #52's pump history reflected the resident only received 37.5% of his enteral order in the past 24 hours. - Resident #52's pump history reflected the resident's tube feeding was stalled for 3 hours. - LVN B and ADON B were unaware of the resident's inadequate intake. The failures placed all resident on tube feedings at risk of malnutrition and dehydration. Findings included: Record review of Resident #52's face sheet revealed [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with dysphagia (difficulty swallowing) following cerebral infarction (heart attack), hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body). Record review of Resident #52's MDS, dated [DATE], revealed the resident had a BIMS score of 3, indicating…

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 that drugs and biologicals used in the facility were secured properly for Resident #1 (one of eleven residents) as evidenced by: -Resident #1 had pills in a plastic cup in her right hand and was unattended. This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] including diagnoses: Alzheimer's disease (a brain disorder that gets worse over time), Rheumatoid Arthritis (is an autoimmune disorder where the immune system mistakenly attacks the joints, causing inflammation, pain, and potential joint damage). Record review of the Minimum Data Set (MDS) dated [DATE] for Resident #1 with a BIMS score 10 (moderate cognitive impairment). Observation and interview on 4/24/24 at 10:45 a.m. revealed in Resident #1's hand a plastic cup with 5…

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, interview, and record review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: - Food was found unsealed in dry storage - Food was found not labeled and dated in the walk-in cooler - Meals from the kitchen were served without first taking temperatures of the food. - Dietary aide A was touching her face mask and handling ready-to-eat foods without proper hand hygiene. These failures increased residents' risks of consuming contaminated foods and getting a foodborne illness. Findings included: Observations of the kitchen and interview with Dietary Aide A on 08/15/2023 at 8:15 AM revealed Dietary Aide A plating food from the breakfast line. Dietary Aide A was seen wearing gloves, shifting around her mask, and touching ready-to-eat toast to add to the plate. When asked about temperature for their breakfast line, she stated she knew how to use a thermometer, but she did not use it prior to serving breakfast because she did not know where it 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, interview and record review, the facility failed to implement its infection control policies for 6 of 7 residents (Residents #11, #71, #74, CR #69, CR #1 and CR #2) reviewed for infection control, in that: - The facility failed to ensure Residents #71, #74 and #11's rooms had isolation precautions in place on 08/15/2023 despite their being orders for contact isolation. - The facility failed to prevent CNA F from serving a meal tray to a contact isolation room on 08/15/2023 without using necessary PPE. - The facility failed to ensure there was tracking and trending documentation for Resident #69, CR #1 and CR #2 during the months of January to April 2023. This failure placed residents an increased risk for continued infection and lack of proper treatment. Findings included: Record review of Resident #71's face sheet, dated 08/18/2023, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with mild vascular dementia and hypertension. Record review of…

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, interview, and record review, the facility failed to maintain an effective pest control program in the kitchen, in that: The facility failed to ensure 5 live roaches were not observed in the kitchen. This failure placed all residents who consume food prepared in the kitchen at increased risk of illness. Findings included: An observation of the kitchen on 08/15/2023 at 8:15AM, revealed 5 live roaches. In an interview with Resident #244 on 08/15/2023 at 2:37 PM revealed the resident reported she had seen a roach on her plate two days ago and sent the tray back to the kitchen because of it. In an interview with the Dietary Manager on 08/15/2023 at 8:30AM, she stated she was aware the kitchen had roaches but she did not believe it to be a major issue. In an interview with the Cluster Dietary Resource on 08/18/2022 at 12:58PM, she stated it was important to maintain effective pest control to prevent diseases from the kitchen to the residents. The facility's policy on pest control, dated 2013, revealed, . If pests are seen in the kitchen, the food service manager 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 that drugs and biologicals used in the facility were secured properly for Resident #10 reviewed for pharmacy services as evidenced by: The facility failed to ensure Resident #10's liquid intravenous medication bag hanging on the pole at bedside and unattended on top of the bedside table was labeled with the name of nurse, time or date of reconstitution (restoring something dried to its original state by adding water to it). This deficient practice could place residents at risk for harm and place the facility at risk for a possible drug diversion. The findings include: Record review of Resident #10 face sheet, dated 8/15/23, reflected a [AGE] year old male, admitted to the facility on [DATE] with diagnoses Chronic kidney disease (CKD) is a long-term condition where the kidneys do not work as well as they should, Peripheral vascular disease (PVD) is a slow and progressive circulation disorder. Narrowing, blockage, or spasms in 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.