Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastland Subacute And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain dignity, communication, and privacy for three residents when one resident with CHF and DM, who had an order to attend adult day care twice weekly, was dressed and ready but not picked up and was never informed of the cancellation or the reason, nor was the responsible party notified. In a separate situation, two residents, one with Afib and pneumonia and another with dementia and overactive bladder, were routinely relocated to a hallway during room repairs, where their beds were separated only by curtain dividers with gaps, offering limited privacy, no television, and allowing others to see and overhear them. Staff interviews confirmed that residents were not asked for consent to the hallway move, that one resident refused a shower due to lack of privacy, and that this practice conflicted with facility policies requiring respect, dignity, and informing residents when they are taken out of their usual surroundings.
A resident with systolic CHF, diabetes, moderately impaired cognition, and multiple ADL dependencies had a physician’s order to attend an adult day care center twice weekly, but no corresponding care plan was found in the EMR. The DON stated that care plans serve as a blueprint for staff and acknowledged that the resident should have had a care plan specifying days of attendance, transportation, and assistance with preparation. Facility policy required comprehensive, person-centered care plans with measurable objectives and timetables to address each resident’s physical, psychosocial, and functional needs, but this ordered service was not incorporated into the resident’s care plan.
Surveyors found that an LVN and the SSD were using N95 respirators without achieving a proper facial seal due to their beards. The LVN, despite recent in‑service training on infection control and N95 donning and doffing, wore an N95 that did not fit tightly against the face. The SSD was observed discarding one N95 and donning a new one that also rested on facial hair and failed to seal. The IP acknowledged she had not considered the impact of facial hair on N95 fit, and the DON reported that staff had been instructed only to check for air leaks at the bridge of the nose, contrary to the facility’s policy requiring proper PPE use and monitoring.
A resident's legal representative submitted a written request for medical records, but the facility did not provide the records within the required timeframe. The Medical Records Director delayed processing by sending the request to the facility's attorney and requiring additional approvals, resulting in the records not being released as of the time of review, despite facility policy mandating timely access.
Two residents with significant physical and cognitive impairments did not have call lights or pad sensors within reach, contrary to their care plans and facility policy. In one case, a resident with quadriplegia could not access the pad sensor due to its placement on the side of her contracted arm, while in another, a resident's call light was stored in a bedside drawer, making it inaccessible. Staff confirmed that these devices should have been within reach to allow residents to request assistance.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that the coffee maker and ice machine in the facility's kitchen had visible brown build-up and a slimy substance, respectively. The Dietary Supervisor could not confirm when the equipment was last cleaned, despite being responsible for ensuring cleanliness, resulting in a failure to follow professional food service safety standards.
A resident with severe cognitive impairment and multiple diagnoses was found to be living in a room with peeling and chipped paint on the walls and closet door. The resident expressed a desire for a clean and neat environment, and both a CNA and maintenance staff acknowledged the room's condition was not homelike and could negatively affect the resident's well-being. Facility policy required a clean, comfortable, and homelike setting, which was not provided in this case.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with severe cognitive impairment and complex medical conditions had their MDS assessments submitted to CMS more than 14 days after completion, contrary to required timelines. The MDS Coordinator confirmed the late submissions, and facility policy references the 14-day requirement for transmitting assessment data.
A resident with multiple chronic conditions was not taken out of bed for several days despite a physician's order allowing out-of-bed activity. Staff confirmed there was no specific schedule for this care, and the resident remained in bed during the day, contrary to facility policy requiring support for ADLs to prevent functional decline.
A resident with limited range of motion and a history of shoulder injury did not consistently receive physician-ordered splints and orthotic devices, as observed and confirmed by staff interviews. The required hand and elbow splints were not applied daily, contrary to orders, and staff acknowledged lapses in following the prescribed restorative care.
A resident with a history of falls, lack of coordination, and cognitive impairment did not have a fall mat at the bedside as ordered by the physician and outlined in the care plan. Despite being assessed as high risk for falls and unable to stand or transfer independently, staff failed to implement this intervention, and a CNA confirmed the absence of the mat during observation.
A resident receiving oxygen therapy via nasal cannula did not have their oxygen tubing labeled with the date and staff initials as required by facility policy. This omission was confirmed through observation and staff interviews, indicating a failure to follow infection control procedures for respiratory care equipment.
A resident with thyrotoxicosis did not receive routine Total T3 lab tests every two weeks as ordered by the physician. Despite a care plan and physician order for regular thyroid monitoring, only one test was completed, and staff confirmed the omission. Facility policy required staff to arrange for ordered tests, but this was not followed, resulting in missed monitoring of the resident's thyroid function.
A resident with diverticulosis and paraplegia was found with an opened bottle of prune juice on their nightstand that had not been refrigerated for nearly two weeks, despite the product label and facility policy requiring refrigeration after opening. Staff confirmed that education and refrigeration options were available, but the perishable item remained unrefrigerated.
The facility did not complete or post nurse staffing information in accordance with its policy, failing to display actual staffing numbers in prominent and accessible locations for multiple shifts. Staffing details for the 3-11 pm shift were incomplete, and information was not visible at skilled nursing stations, as confirmed by interviews with the DSD and DON.
Seven rooms in the facility were found to house more residents than allowed by the minimum square footage requirement, with each room measuring 300 square feet and accommodating up to four residents, resulting in less than 80 square feet per resident. Although the rooms were observed to provide adequate space for movement and care, the facility did not meet the regulatory standard and had requested a waiver for these rooms.
Two residents' privacy was compromised during care procedures when staff failed to close privacy curtains, exposing them to others. One resident's back and buttocks were exposed during a gown change, while another's abdominal area was exposed during a gastrostomy tube check. Both residents had severe cognitive impairments and were dependent on staff for care. Staff acknowledged the oversight, and the DON confirmed the need for privacy during care.
The facility failed to ensure call lights were within reach for four residents, including those with end-stage renal disease, functional quadriplegia, and impaired cognition, leading to a deficiency in accommodating their needs. Observations revealed call lights were inaccessible, contrary to care plans and facility policy, as confirmed by staff.
The facility failed to provide Advance Directive information to two residents, resulting in incomplete Advance Directive Acknowledgement forms. One resident with Alzheimer's and dementia had severely impaired cognition, while another with respiratory failure and a tracheostomy tube also had cognitive impairments. The Social Services Director and Director of Nursing acknowledged the oversight, which violated the facility's policy requiring residents or their representatives to receive written information about their rights to refuse or accept treatment and formulate an AD.
The facility failed to adhere to professional standards for oxygen therapy management, affecting four residents. A resident's nasal cannula tubing was found on the floor, risking contamination. Another resident did not receive continuous oxygen therapy as ordered, with tubing improperly stored. A third resident received oxygen at a higher rate than prescribed, and a fourth resident lacked a spare tracheostomy tube at the bedside, contrary to care plan requirements.
The facility failed to attempt appropriate alternative interventions before installing bedrails for five residents, including those with respiratory failure, diabetes, epilepsy, dementia, and end-stage renal disease. This lack of documentation and assessment placed residents at risk for entrapment and injury, as confirmed by nursing staff.
The facility failed to follow safe food handling practices by not discarding leftover egg salad within the required time frame and not maintaining the ice scoop in a sanitary condition. The egg salad was stored beyond the three-day limit, and the ice scoop container had brown stains, indicating improper cleaning. These deficiencies posed a risk of food-borne illnesses to residents.
A facility failed to follow a physician's order to apply heel protectors for a resident with a history of skin breakdown, risking pressure injuries. The resident, who required substantial assistance, was observed without the prescribed protectors. An LVN confirmed the oversight and the necessity of following physician's orders, as per the facility's policy on pressure injury prevention.
A facility failed to adhere to its policy on Foley catheter care for a resident with obstructive uropathy and acute kidney failure. The resident's catheter bag was observed at the same level as the bed, contrary to the policy requiring it to be below the bladder to prevent backflow and infection. Staff interviews confirmed the correct procedure, aligning with the facility's revised policy.
A facility failed to elevate a resident's head of bed to the required 30-45 degrees during GT feeding, as per policy. The resident, with COPD and gastrostomy, was observed lying almost flat, contrary to orders. An LVN confirmed the need for elevation to prevent aspiration, highlighting a deficiency in care.
A facility failed to perform post-hemodialysis assessments for a resident with ESRD on three occasions. The resident's care plan required documentation of their condition after dialysis, but records were left blank. Interviews with staff confirmed the oversight, and the facility's policy mandated such assessments, which were not completed.
A facility failed to include a convenient venue selection in its arbitration agreement for a resident with severe cognitive impairment. The outdated form used did not specify a mutually convenient location for arbitration, as acknowledged by the Admission Coordinator.
The facility did not post accurate nurse staffing information, failing to include the total number and actual hours worked by licensed and unlicensed nursing staff per shift. The posted data only showed minimum required hours, not actual staffing details, as observed during a recertification survey. The Director of Staff Development was unaware of the federal requirements, and the facility's policy was not adhered to.
The facility failed to meet the required square footage per resident in seven rooms, as identified during a Health Recertification Survey. Despite this, observations and interviews indicated that the rooms provided adequate space for residents and staff to perform necessary activities and care. The facility plans to request a waiver for these rooms, asserting that resident health and safety are not compromised.
The facility's voicemail system for the Director of Social Service was not functioning, preventing callers from leaving messages. This issue was confirmed during a test call, and the Social Services Assistant acknowledged the malfunction, noting no recent voicemails had been received. The Maintenance Assistant indicated that phone issues are reported to a corporate technician for resolution.
Failure to Maintain Resident Dignity, Communication, and Privacy During Missed Day Care and Hallway Relocation
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity, respect, self-determination, and communication for three sampled residents. One resident, with systolic congestive heart failure and diabetes mellitus, had an order to attend an adult day care center every Monday and Tuesday. On one such scheduled day, the resident was dressed and ready to go but was not picked up, and neither the resident nor the responsible party was informed of the cancellation or the reason for it. A CNA reported that the resident repeatedly asked if she was going to the adult day care center, but the CNA and the charge nurse did not know and did not provide an explanation. An LVN acknowledged that she was supposed to notify the resident and the responsible party about the missed adult day care attendance but did not do so. The resident and the responsible party both stated that the resident was disappointed and was not given any reason for not attending. The deficiency also includes the temporary relocation of two residents’ beds to a hallway area while their shared room was being repaired. One of these residents had atrial fibrillation and pneumonia, with intact cognitive skills and a need for assistance with activities of daily living. The other resident had overactive bladder and dementia, with severely impaired cognitive skills and a need for assistance with daily care. During observation, both residents’ beds were placed in the hallway behind screen dividers or small curtains that did not fully prevent visualization of at least one resident in bed. Staff confirmed that when residents were relocated to the hallway, they did not have a television and that the area was only semiprivate, with small curtains separating the residents. Multiple staff interviews confirmed that relocating residents to the hallway was a routine practice when rooms required repair and that only curtain dividers with gaps were used for privacy. The Maintenance Director stated that residents were always relocated to the hallway during room repairs and acknowledged that the dividers had small gaps. A CNA stated that placing residents in the hallway did not offer respect and dignity, that residents could feel uncomfortable being watched by others, and that one resident refused a shower because of not wanting to undress without privacy. An LVN stated that conversations in the hallway could be heard by everyone and that she did not ask residents how they felt about being relocated. An RN stated that staff should have checked for vacant beds before using the hallway and that consent should have been obtained from residents prior to relocation. The DON acknowledged that the hallway area lacked full privacy, that the curtains had gaps, and that placing residents in the hallway was not an acceptable practice because it did not provide dignity or respect, contrary to the facility’s policies on resident rights and dignity, which require residents to be treated with kindness, respect, and dignity and to be informed in advance when they are taken out of their usual surroundings. The facility’s written policies on Resident Rights and Dignity state that employees must treat all residents with kindness, respect, and dignity, that residents have the right to be informed of and participate in their care and treatment, and that procedures should be explained before they are performed, including advance notice when residents are taken out of their usual environment. In the case of the resident scheduled for adult day care, staff did not inform the resident or responsible party about the missed attendance or the reason, despite the resident’s expressed interest and questions. In the case of the two residents relocated to the hallway, staff did not obtain consent, did not ensure privacy, and did not provide an environment consistent with the facility’s own dignity policy, resulting in residents being placed in a semiprivate hallway area where they could be seen and overheard by others.
Failure to Care Plan for Resident Attendance at Adult Day Care
Penalty
Summary
Surveyors identified that the facility failed to develop a care plan for a resident’s attendance at an adult day care center, despite having a physician’s order for this service. The resident was admitted and later readmitted with diagnoses including systolic congestive heart failure and diabetes mellitus. A history and physical dated 12/1/2025 documented that the resident had the capacity to understand and make decisions, while an MDS dated 3/25/2026 showed moderately impaired cognitive skills for daily decision-making and multiple ADL dependencies, including the need for setup assistance with eating, supervision for oral hygiene, moderate assistance for upper body dressing and personal hygiene, and maximal assistance for lower body dressing, bathing, toileting hygiene, and footwear. An order summary dated 4/1/2026 indicated the resident was to attend an adult day care center every Monday and Tuesday. During review of the electronic medical record, surveyors were unable to locate any care plan addressing the resident’s attendance at adult day care, including the ordered days of attendance. In an interview, the DON described the care plan as a blueprint of care that guides staff interventions and stated that if something is not on the care plan, nursing staff would not know what interventions to follow. The DON acknowledged that the resident should have had a care plan for attending adult day care, including days of attendance, transportation arrangements, and assistance with preparation, and stated that without such a care plan, the service might not be provided consistently. The facility’s policy on comprehensive, person-centered care plans, dated 3/2022, required development and implementation of a care plan with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, describing services to attain or maintain the resident’s highest practicable well-being.
Improper N95 Respirator Use by Bearded Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of N95 respirators by staff with facial hair. During an unannounced complaint visit focused on infection control, an LVN was observed wearing an N95 respirator that did not have a tight seal to his face because of his beard. The LVN reported having attended an in‑service in February 2026 on infection control, including proper use of PPE, handwashing, and N95 donning and doffing, yet the respirator still did not fit properly due to facial hair. The observation showed that the N95 was not achieving the required tight seal as intended for effective use. Later the same day, the SSD was observed near Nursing Station 1 removing an N95 respirator and discarding it, then placing a new N95 respirator on his face. The new respirator also did not achieve a complete seal because it rested on top of his facial hair rather than directly on the skin. During an interview at the time of this observation, the IP stated she had not considered that the N95 mask would not allow for a complete seal with the SSD’s beard and acknowledged that the N95 would not provide protection due to the incomplete seal. The DON stated that staff had been instructed to check N95 masks for proper seal by checking for air leaks at the bridge of the nose. Review of the facility’s Infection Prevention and Control Program policy showed that the program was intended to prevent transmission of communicable diseases by educating staff and ensuring adherence to proper techniques, and by providing PPE and checking for its proper use, but staff practices observed did not align with these requirements.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records upon written request, violating the resident's right to access their own records. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, altered level of consciousness, hypertension, diabetes mellitus, and stroke, was discharged to another facility at the family's request. The resident's legal representative submitted a written request for the medical records, which was personally served to the Medical Records Director (MRD). Despite the facility's policy stating that records should be provided within 24 to 48 hours of a completed request form, the MRD sent the request to the facility's attorney for review several days after receipt. The process also required approval from the Director of Nursing before release. As of the date of the interview, the complainant had not received any records. The facility's policies confirmed the resident's right to access and obtain copies of their records with appropriate notice, but the records were not provided as required.
Failure to Ensure Call Lights and Pad Sensors Were Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights and pad sensors were within reach for two residents with significant physical and cognitive impairments. For one resident with quadriplegia, contractures, and severely impaired cognition, the pad sensor call light was observed placed above and on the right upper part of the bed, next to the resident's pillow, despite the resident only being able to move her left arm and hand. The Infection Prevention Nurse confirmed that the resident could not move her right arm and hand and could not reach the pad sensor call light, which should have been placed near her left arm and hand as per her care plan. The care plan specifically required the call light to be within easy reach due to the resident's high risk for falls and dependency on staff for all activities of daily living. For another resident with respiratory failure, GERD, dysphagia, and dependency on staff for personal hygiene and dressing, the call light was found inside the bedside table drawer and not within reach during two separate observations. Both a CNA and an LVN confirmed that the call light should have been accessible to the resident, and its placement in the drawer meant the resident could not call for help if needed. Facility policies reviewed indicated that call lights must be accessible to residents when in bed or in a wheelchair, and alternative communication methods should be provided and documented for residents unable to use standard call systems.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Improper Sanitation of Kitchen Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain proper sanitation and safe handling practices in the kitchen, specifically regarding the coffee maker and ice machine. During an observation with the Dietary Supervisor, the site glass tube on the coffee machine was found to have a thick, brown build-up, and the supervisor was unable to state when it was last cleaned, acknowledging that it should be deep cleaned weekly. Additionally, the ice machine was found to contain a light brown slimy substance when wiped with a clean towel, and the supervisor confirmed that this substance should not be present and could contaminate the ice. The Dietary Supervisor's job description indicated responsibility for ensuring food service equipment cleanliness at all times.
Failure to Maintain Clean, Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified when a resident's room was observed to have peeling and chipped paint on the walls and closet door. The resident, who had been in the facility for four months, confirmed that the paint had been in this condition since admission and expressed a preference for a neat and clean room. The resident's medical record indicated diagnoses of dementia, schizoaffective disorder, and GERD, with severe cognitive impairment and a need for substantial to maximal assistance with daily activities. Staff interviews corroborated the observation, with a CNA stating that the room should look nice and that the current condition could negatively affect the resident's mood. The maintenance assistant also acknowledged the room was not homelike and should be prioritized for painting, noting that the chipped paint could upset both the resident and visitors. Review of facility policy confirmed the expectation for a clean, comfortable, and homelike environment, which was not met in this instance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Late Submission of MDS Assessments to CMS
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the required timeframe for two of four sampled residents. For one resident with diagnoses including Alzheimer's disease, arthritis, and anemia, the MDS assessment indicated severe cognitive impairment and was submitted more than 14 days after the completion date. The resident's history and physical also documented an inability to understand and make medical decisions. For another resident with hemiplegia, sepsis, and pneumonia, the MDS assessment showed severe cognitive impairment and limitations in movement, and was also submitted late, more than 14 days after the assessment completion date. The Minimum Data Set Coordinator confirmed during an interview that the facility is required to submit MDS assessments within 14 days of completion, and acknowledged that the assessments for these residents were submitted late. Review of the facility's policy and procedures indicated that the timing and submission of assessments should follow the Resident Assessment Instrument (RAI) User's Manual, which specifies the 14-day submission requirement.
Failure to Support Resident's ADL Abilities by Not Following Out-of-Bed Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including peripheral vascular disease, chronic kidney disease, and diabetes mellitus was not provided with necessary care and services to maintain their ability to perform activities of daily living (ADLs). The resident was observed lying in bed for three consecutive days during the day shift and was not taken out of bed as permitted by a physician's order. The resident's Minimum Data Set indicated a dependence on staff for personal hygiene, showering, and dressing, and a preference for participating in favorite activities and spending time outdoors. Despite these needs and preferences, the resident remained in bed from morning until late afternoon on multiple days. Interviews and record reviews revealed that there was no specific schedule in place for taking the resident out of bed, and staff confirmed that the resident had not been out of bed during the observed period. The facility's policy required care and services to be provided to maintain or improve residents' ability to carry out ADLs and to prevent or minimize functional decline. The lack of adherence to the physician's order and facility policy resulted in the resident not receiving appropriate support to maintain their functional abilities.
Failure to Apply Physician-Ordered Splints for Resident with Limited ROM
Penalty
Summary
A resident with a history of respiratory failure and a dislocated right shoulder was admitted to the facility and had physician orders for the application of bilateral hand splints, a right elbow splint, and bilateral ankle-foot orthosis (AFO) boots to be applied daily, six days a week. The resident was dependent on staff for personal hygiene, showering, and dressing, and had limited range of motion in both upper and lower extremities. Observations over two days revealed that the resident did not have the full set of splints applied as ordered by the physician. During interviews, the Restorative Nurse Assistant (RNA) acknowledged not placing all the required splints on the resident and admitted to inconsistency in following the physician's orders. The RNA specifically noted that the left-hand splint and right elbow splint were missing. A Licensed Vocational Nurse (LVN) also confirmed the absence of the required splints and stated that RNAs were responsible for reporting missing devices. Facility policies reviewed indicated that assistive devices and equipment should be maintained and supervised to support resident mobility, safety, and independence.
Failure to Provide Fall Mat as Ordered for High-Risk Resident
Penalty
Summary
A facility failed to ensure that a resident with a history of falls had a fall mat at the bedside as ordered by the physician. The resident was admitted and readmitted with diagnoses including lack of coordination, history of falling, and schizophrenia, and was documented as not having the capacity to make decisions. Physician orders and the resident's care plan both specified that the bed should be kept at the lowest position and a floor mat should be used to prevent injury. The resident's assessments indicated a high risk for falls, including a recent actual fall, and the resident was unable to stand, transfer, or walk independently. During an observation and interview, it was found that there was no floor mat present at the bedside, contrary to the physician's order and care plan. A CNA confirmed that the resident was supposed to have a floor mat due to a history of climbing out of bed and previous falls, and acknowledged that the absence of the mat could result in injury if the resident fell. The facility's policy required staff to implement interventions based on specific fall risks, but this was not followed in this case.
Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
A deficiency occurred when staff failed to label the nasal cannula tubing used for oxygen therapy for a resident with chronic respiratory failure, tracheostomy, and other significant medical conditions. The resident was dependent on staff for all activities of daily living and was receiving oxygen at 2 liters per minute via nasal cannula, as ordered by the physician. During an observation, it was noted that the nasal cannula was not labeled with the date it was changed or the initials of the staff member who changed it, contrary to the facility's policy and procedure. Interviews with the infection prevention nurse and the Director of Nursing confirmed that the facility's policy requires oxygen equipment to be labeled with the date, time, and staff initials when changed, to support infection control practices. Review of the resident's records and direct observation confirmed that this labeling was not done, resulting in a failure to follow established infection control protocols for respiratory care equipment.
Failure to Complete Routine Thyroid Lab Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of thyrotoxicosis received Total T3 laboratory tests every two weeks as ordered by the physician. The resident was admitted with diagnoses including thyrotoxicosis and hypertension, and the care plan specifically indicated that labs would be completed if ordered by the physician. The physician's order summary documented a standing order for routine Total T3 level testing every two weeks due to abnormal thyroid function studies. However, a review of the resident's lab results showed that the Total T3 test was only completed once, with no further testing conducted during the month of April 2025. During an interview and record review, an LVN confirmed that the required T3 level tests were not completed as ordered and acknowledged the purpose of the test was to monitor the resident's thyroid levels. The facility's policy and procedure required staff to process test requisitions and arrange for tests, but this was not followed in this case. As a result, the resident's thyroid function was not monitored according to the physician's orders during the specified period.
Failure to Refrigerate Opened Perishable Food Brought by Family
Penalty
Summary
A deficiency was identified when an opened and partially consumed bottle of prune juice was observed on a resident's nightstand during two separate observations. The product label on the bottle clearly indicated that it should be refrigerated after opening, but the bottle remained unrefrigerated for an extended period. The resident stated that the bottle had been there for almost two weeks, and it was brought in by family. Staff interviews confirmed that the facility had a refrigerator available for residents' food items and that education was provided to residents regarding the importance of refrigerating perishable items. However, the prune juice was not stored as required by the manufacturer's instructions. The resident involved had a history of diverticulosis and paraplegia, and records showed that the resident was cognitively intact and had no impaired movement of the upper or lower body. The facility's policy required perishable foods to be stored in resealable containers with tightly fitting lids in a refrigerator, and any potentially hazardous foods left out for more than two hours were to be discarded. Despite these policies and the resident's ability to understand instructions, the prune juice was left unrefrigerated, contrary to both the product label and facility policy.
Failure to Post and Complete Nurse Staffing Information as Required
Penalty
Summary
The facility failed to ensure that nurse staffing information was completed and posted in accordance with its policy and procedures for three consecutive recertification days. Observations and interviews revealed that staffing information was not posted in the skilled nursing stations 1, 2, and 3, and was only available in the sub-acute station and on a side wall near the front office, which was not a prominent or easily accessible location. Additionally, the daily shift nurse staffing information for the 3-11 pm shifts did not indicate the number of licensed and unlicensed nursing staff directly responsible for resident care in both the skilled nursing and sub-acute stations. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the posted staffing information was not visible or accessible to residents, visitors, or staff, and that it should have been filled out and posted within two hours of the beginning of each shift in a prominent location. Review of the facility's policy indicated that the number of licensed and unlicensed nursing personnel responsible for resident care must be posted in a clear and readable format in a location accessible to residents and visitors. These actions and omissions resulted in the facility not meeting its own requirements for posting accurate and accessible nurse staffing information.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that seven of its resident rooms (Rooms 114, 115, 116, 117, 119, 121, and 123) met the required minimum square footage of 80 square feet per resident in multiple occupancy rooms. During a recertification survey, it was observed that these rooms each measured 300 square feet and housed four residents per room, except for one room with two residents, resulting in less than the required space per individual. Despite the rooms being observed to have adequate space for movement and care, the actual measurements did not comply with regulatory requirements. Interviews and record reviews revealed that the facility administrator acknowledged the deficiency and stated that a room waiver had been requested for the affected rooms. The waiver request letter indicated that the rooms provided reasonable privacy, sufficient storage, and adequate space for nursing care and resident equipment, and asserted that resident health and safety would not be jeopardized. However, the physical dimensions of the rooms remained below the mandated standard for square footage per resident at the time of the survey.
Failure to Ensure Resident Privacy During Care Procedures
Penalty
Summary
The facility failed to uphold the dignity and privacy of two residents during care procedures. For Resident 55, the privacy curtain was not completely closed while a Certified Nursing Assistant (CNA 3) changed the resident's gown and linen, exposing the resident's back and buttocks to the roommate's family members. Resident 55 had severe cognitive impairments and was dependent on staff for personal care, as indicated in the Minimum Data Set (MDS). The CNA acknowledged the oversight and the importance of ensuring complete privacy during such procedures. Similarly, Resident 13's privacy was compromised when a Registered Nurse (RN 1) checked the resident's gastrostomy tube site without closing the privacy curtain, exposing the resident's abdominal area. Resident 13, who had severe cognitive impairments and was dependent on staff for daily activities, was unable to make decisions independently. Both the CNA and RN admitted to not closing the curtains completely, and the Director of Nursing (DON) confirmed that staff should ensure privacy during care to maintain resident dignity. The facility's policy on dignity, revised in February 2021, emphasizes the importance of protecting resident privacy during personal care and treatment procedures.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, leading to a deficiency in accommodating their needs and preferences. Resident 24, who was admitted with end-stage renal disease and required assistance for personal hygiene and transfers, was observed in bed without access to the call light, which was hanging behind the headboard. The Director of Nursing (DON) acknowledged that the call light should have been within reach to prevent potential falls. Resident 99, diagnosed with functional quadriplegia and blindness in one eye, was also found without access to the call light. The care plan for Resident 99 indicated a risk for falls and required the call light to be within easy reach. However, during an observation, the call light was positioned out of reach, and the Certified Nursing Assistant (CNA) confirmed that the resident could not extend their arms to reach it. The DON reiterated the importance of having the call light accessible to ensure timely assistance. Similarly, Resident 5 and Resident 21, both at risk for falls due to impaired cognition and mobility issues, were observed without accessible call lights. Resident 5's call light was clipped to a curtain, making it unreachable, while Resident 21's call light was dangling out of reach. Both residents' care plans emphasized the need for the call light to be within reach to maintain safety. The facility's policy also required call lights to be accessible, but this was not adhered to, as confirmed by the DON.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information regarding Advance Directives (AD) to two residents, which is a violation of their policy and procedure. Resident 23, who was diagnosed with Alzheimer's disease and dementia, had an incomplete Advance Directive Acknowledgement (ADA) form. The resident's records indicated severely impaired cognition and total dependence on assistance for daily activities. During an interview, the Social Services Director (SSD) acknowledged that the ADA form was not filled out completely, which meant that Resident 23 was not given written materials or information about their rights to accept or refuse treatments and formulate an AD. The Director of Nursing (DON) confirmed that the ADA form should be filled out completely to ensure the resident or responsible party is informed of the resident's rights. Similarly, Resident 65, who was admitted with respiratory failure and a tracheostomy tube, also had an incomplete ADA form. The resident's Minimum Data Set (MDS) indicated severely impaired cognitive abilities. The SSD was unsure why the ADA form was not filled out and emphasized the importance of having it completed to ensure staff follow the resident's wishes. The DON stated that the ADA form should have been filled out upon admission or shortly after, and the lack of a completed form posed a risk of not following the resident's AD preferences. The facility's policy requires that residents or their representatives be provided with written information about their rights to refuse or accept treatment and to formulate an AD prior to or upon admission.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide necessary care and services for residents on oxygen therapy in accordance with professional standards of practice. For Resident 321, the nasal cannula tubing was observed touching the floor, which was acknowledged by the Registered Nurse and Director of Nurses as a potential source of cross-contamination. The facility's policy indicated that oxygen tubing should not touch the floor, yet this standard was not maintained. Resident 113 did not receive continuous oxygen therapy as ordered by the physician. The nasal cannula tubing was found hanging on a wheelchair metal frame and not stored in a transparent bag, which was against the facility's policy. The Infection Preventionist Nurse and Director of Nurses confirmed that the tubing should be stored properly to prevent infection, and any discontinuation of orders should be clarified with the attending physician. Resident 7 was receiving oxygen at a higher rate than prescribed, with the oxygen inhalation set at four liters per minute instead of the ordered two liters per minute. This discrepancy was noted by the Licensed Vocational Nurse, who admitted to not checking the oxygen level during her shift. Additionally, Resident 65 did not have a spare tracheostomy tube at the bedside, as required by the care plan and facility policy, which posed a risk in the event of accidental decannulation.
Failure to Attempt Alternatives Before Bedrail Installation
Penalty
Summary
The facility failed to attempt appropriate alternative interventions before installing bilateral bedrails for five residents, placing them at risk for entrapment and physical injuries. Resident 373 was admitted with respiratory failure and used a tracheostomy tube. Despite being able to make decisions for daily activities, bilateral side rails were installed without documented attempts of alternative interventions. The Registered Nurse acknowledged the lack of documentation and the potential risk of unnecessary bedrail use. Resident 101, admitted with diabetes mellitus and hypertension, had bedrails installed without documented evidence of alternative interventions. The Assistant Director of Nursing noted the absence of alternatives like concave mattresses or low beds, which could prevent the resident from rolling off or getting out of bed unassisted. The lack of alternatives and documentation posed a risk of serious injury or death if the resident attempted to climb over the bedrails. Similarly, Resident 78, with epilepsy and hypertensive heart disease, had bedrails installed without attempts of alternative interventions. The Assistant Director of Nursing confirmed the absence of documentation and highlighted the risk of entrapment. Resident 14, with dementia and Alzheimer's, also had bedrails installed without documented alternatives, increasing the risk of entrapment. Lastly, Resident 24, with end-stage renal disease, had bedrails installed without a physician's order, consent, or assessment, which was deemed inappropriate and dangerous by the Director of Nursing.
Deficient Food Handling Practices
Penalty
Summary
The facility failed to adhere to safe food handling practices, as observed during a survey. In the facility's kitchen, a bowl of egg salad was found in the walk-in refrigerator with a date of 8/9/2024, indicating it was leftover food. According to the Dietary Supervisor, the facility's policy allows leftover food to be stored for a maximum of three days, meaning the egg salad should have been discarded by 8/12/2024. This oversight in discarding the egg salad in a timely manner was a violation of the facility's policy on leftover food storage. Additionally, the facility did not maintain the ice scoop in a sanitary condition. The ice scoop was stored in a container with brown stains at the bottom, which was not cleaned properly. The Dietary Aid admitted to missing the cleaning of the inner side of the scoop container, despite the facility's policy requiring daily cleaning and sanitization of the ice scoop and its container. These practices placed residents at risk for food-borne illnesses due to potential contamination.
Failure to Apply Heel Protectors as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order to apply heel protectors for a resident, identified as Resident 33, which was intended to maintain skin integrity and prevent pressure injuries. Resident 33 was readmitted to the facility with diagnoses including type 2 diabetes mellitus and dysphagia. The Minimum Data Set (MDS) assessment indicated that Resident 33 had clear speech but was unable to make themselves understood and required substantial assistance for personal hygiene and transfers. Despite these needs, during an observation, it was noted that Resident 33 was lying in bed without the prescribed heel protectors. Licensed Vocational Nurse 3 (LVN 3) confirmed that Resident 33 had a history of skin breakdown and acknowledged the necessity of applying heel protectors to prevent further pressure injuries. LVN 3 also stated that licensed nurses are required to follow physician's orders and should contact the physician if an order needs reevaluation or discontinuation. The facility's policy on the prevention of pressure injuries emphasized the importance of selecting appropriate support surfaces based on the resident's risk factors and reviewing interventions for effectiveness, which was not adhered to in this instance.
Improper Foley Catheter Placement in Resident Care
Penalty
Summary
The facility failed to provide necessary care and services for a resident's Foley catheter in accordance with its Policy and Procedure on Indwelling Catheter Urinary Drainage Bag Maintenance. The resident, who was admitted with obstructive uropathy and acute kidney failure, had an indwelling catheter due to an alteration in urinary elimination and was at risk for urinary tract infection. The care plan for the resident included maintaining proper alignment of the Foley catheter to promote proper drainage. During an observation, it was noted that the resident's Foley catheter collection bag was hanging on the metal frame of a wheelchair at the same level as the resident's bed, contrary to the facility's policy which requires the bag to be placed below the bladder to prevent backflow and potential infection. Interviews with staff, including a CNA, an Infection Preventionist Nurse, an LVN, and the Director of Nursing, confirmed that the catheter bag should be positioned below the bladder to facilitate proper drainage and prevent urinary tract infections. The facility's policy, revised in April 2024, also specified that the urinary collection bag should be placed below the bladder level.
Failure to Elevate Head of Bed During GT Feeding
Penalty
Summary
The facility failed to ensure the head of bed was elevated at 30 to 45 degrees for a resident with a gastrostomy tube (GT) in accordance with the facility's policy and procedure. This deficiency was identified during an observation where the resident was found lying almost flat in bed while receiving GT feeding, contrary to the order that required the head of bed to be elevated at least 30 degrees during feeding. The Licensed Vocational Nurse confirmed that the head of bed should be elevated to prevent aspiration, which could lead to aspiration pneumonia. The resident involved had been readmitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease and gastrostomy. The resident was dependent on staff for personal hygiene and movement, and had significant communication limitations. The facility's policy, revised in March 2023, required the head of bed to be elevated at least 30 degrees during feeding, which was not adhered to during the observation, posing a potential risk to the resident's health.
Failure to Perform Post-Dialysis Assessments
Penalty
Summary
The facility failed to perform post-hemodialysis assessments for a resident on three specific dates: 7/4/2024, 7/30/2024, and 8/10/2024. This deficiency was identified for a resident with End Stage Renal Disease (ESRD) who was dependent on hemodialysis. The resident's care plan required nursing staff to document the date, time, and condition of the resident after returning from hemodialysis. However, the Dialysis Communication Record for the resident showed that post-dialysis assessments were not completed on the specified dates, leaving the sections blank. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that post-dialysis assessments were missing and should have been conducted. The assessments were supposed to include checking the resident's vital signs, assessing the hemodialysis access site for bleeding, and ensuring there was no change in the resident's condition. The facility's policy on Hemodialysis Access Care also required documentation of observations post-dialysis, which was not adhered to in this case.
Arbitration Agreement Lacks Venue Specification
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement included the selection of a venue convenient to both the facility and the resident or the resident's responsible party. This deficiency was identified during a review of the arbitration agreement for a resident who was admitted with diagnoses including unspecified dementia, epilepsy, and a gastrostomy. The resident's medical records indicated severely impaired cognition and a lack of capacity to make decisions, necessitating a responsible party to act on their behalf. During an interview and record review with the Admission Coordinator, it was revealed that the arbitration agreement signed by the resident's responsible party did not specify a mutually convenient venue for arbitration. The Admission Coordinator acknowledged that the form used was outdated and did not meet current requirements, which could potentially lead to an unjust arbitration process and delays in arbitration hearings.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift daily. This deficiency was observed during a recertification survey on two consecutive days. The posted information, titled Census and Direct Care Service Hours Per Patient Day (DHPPD), was displayed at various stations and on the consumer board but did not include the required staffing details. The DHPPD only reflected the minimum hours required per resident based on the census, not the actual staffing data as mandated by federal regulations. During an interview and record review, the Director of Staff Development (DSD) admitted to posting the DHPPD daily, unaware that it did not meet federal requirements for staffing information. The DSD acknowledged that the DHPPD lacked details on the total number of staff and actual hours worked by nursing staff per shift. The facility's policy and procedures, dated August 2022, outlined the need for posting specific staffing information, including the type and category of nursing staff, actual time worked, and total number of staff per shift. However, this policy was not followed, leading to the deficiency.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that seven of its 63 resident rooms met the required square footage per resident, as mandated by regulations. Specifically, Rooms 114, 115, 116, 117, 119, 121, and 123 did not meet the 80 square feet per resident requirement for multiple resident rooms. This deficiency was identified through observation, interviews, and record reviews during a Health Recertification Survey. The facility's Administrator acknowledged the issue and expressed the intention to request a room waiver for these rooms, indicating that no changes had been made to the number of bed occupancies in these rooms. Despite the deficiency, observations during the survey noted that the rooms provided adequate space, nursing care, comfort, and privacy for the residents. Residents were observed to have enough space to move freely, and there was sufficient room for the operation and use of wheelchairs and walkers. Interviews with residents and staff, including a Certified Nurse Assistant, confirmed that the space was adequate for both residents and staff to perform necessary activities and provide care. The facility's waiver request letter also stated that the health and safety of residents would not be jeopardized by the waiver, and that the rooms were in accordance with the special needs of the residents.
Voicemail System Malfunction in Social Services Department
Penalty
Summary
The facility failed to ensure the proper functioning of the voicemail system for the Director of Social Service (DSS) in the social services department. During an observation and interview, it was discovered that calls transferred to the DSS's extension did not prompt a voicemail greeting, preventing callers from leaving messages. This issue was confirmed when a test call was made, and the phone line continued to ring without directing the caller to a voicemail. The Social Services Assistant (SSA) acknowledged the malfunction and noted that no voicemails had been received recently, indicating a potential communication breakdown. Further investigation revealed that the SSA was unaware of who was responsible for fixing the voicemail system. The Maintenance Assistant (MA) stated that any phone-related issues would be reported to a technician from the corporate office for resolution. The facility's policy on Resident Rights, revised in February 2021, emphasizes the importance of communication and access to services for residents, highlighting the significance of the voicemail system's functionality in maintaining these rights.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Monte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Penn Mar Healthcare Center | 0.3 mi | ★★★★★ | 21 | 0 |
| Madera Post Acute Center | 0.6 mi | ★★★★★ | 26 | 0 |
| The Gardens Of El Monte | 1.5 mi | ★★★★★ | 23 | 0 |
| Fidelity Health Care | 1.6 mi | ★★★★★ | 3 | 0 |
| Valley View Post Acute | 1.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.