Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Eastside Center For Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Grievance process was not clearly implemented, with residents and staff giving inconsistent information about how to file complaints, including anonymously. In addition, a resident with moderately impaired cognition and impaired vision reported missing glasses for weeks, but the record showed no evidence the facility helped locate them or contacted dialysis when the glasses were reported missing.
Failure to recognize significant weight changes: A resident with DM2 and care plans for weight monitoring had a 30.6-lb weight loss followed by a 44.1-lb weight gain over a short period. The record showed no evidence that the care plan interventions were followed or that the weight changes were assessed for accuracy or evaluated for possible medical intervention; the finding was discussed with the DON.
A facility failed to ensure the attending provider signed physician block orders during required recertification and post-admission visits for several residents. In multiple cases, the provider progress note was completed after the block orders were signed, or the orders were signed without a documented provider visit. For one resident readmitted as skilled, the next required provider visit and signature were late, and one signature occurred without a visit.
Food Storage and Facial Hair Restraint Deficiencies: The facility left plastic scoops in flour and sugar bins, stored mixed produce items together in one container in the walk-in refrigerator, and allowed kitchen staff to perform food prep and tray service without proper facial hair restraints. A cook was observed with his mustache uncovered, and a dietary aide was observed with his beard and mustache uncovered while handling food.
Failure to resubmit PASRR for a resident with PTSD and anxiety. A resident was admitted with a PASRR Level I screening that did not include active PTSD or anxiety diagnoses, and the record lacked evidence that the resident was referred to the State mental health authority for a new PASRR determination. During review with the DNS, it was confirmed that the resident had not been resubmitted for PASRR to include the active mental health diagnoses.
A resident with an active diagnosis of Chronic PTSD had an initial assessment noting a history of physical and emotional trauma triggered by certain sounds, but the clinical record lacked evidence of interventions to prevent re-traumatization. The DON confirmed the care plan did not address PTSD, including goals or interventions related to re-traumatization prevention.
A resident who could not see without eyeglasses had them missing for weeks, but the facility did not reschedule the resident’s eye care appt or assist with obtaining replacement glasses. Staff interviews and record review showed the appt was crossed off with a note to reschedule when the glasses were found, no future appt was scheduled, and the clinical record lacked evidence that the family was notified of the missing glasses.
Failure to Follow Enhanced Barrier Precautions During Wound Care: A resident had an unstageable pressure ulcer on the spine, and the care plan required EBP with gloves and a gown for wound care. During an observed dressing change, an RN completed the procedure without wearing a gown, and later confirmed the finding in interview.
The facility failed to notify the Ombudsman of hospital transfers/discharges for two residents. Record review showed both residents were transferred and admitted to the hospital, and the RD of Clinical Services stated Ombudsman notifications were not sent for several months.
Incomplete and inaccurate resident records were identified for two residents. One resident’s missing glasses were reported by the resident and roommate, but the chart and CNA documentation still showed the glasses being used daily and did not document the loss or notification of the resident representative. Another resident’s record showed an antipsychotic medication recommendation for a more specific diagnosis, but the diagnosis was updated to behaviors rather than a true clinical diagnosis before later being changed to vascular dementia with behaviors by the provider.
Surveyors and facility leadership observed standing water in two basement areas, one beneath the kitchen and another below resident rooms. The Maintenance Director explained that the water originated from leaks at the loading dock and windows, as well as landscaping that directed runoff toward the building.
Surveyors and the Food Service Director confirmed that food was not stored, prepared, or served according to professional standards, as food debris was found on kitchen floors, utensils were partially buried in debris, and various food items were stored directly on the floor in both dry and cold storage areas.
A resident with dysphagia and a physician order for a minced and moist diet was given a roll, which is not permitted under IDDSI Level 5 guidelines. After attempting to eat the roll, the resident experienced vomiting and difficulty swallowing, resulting in another ED visit. Facility staff confirmed the dietary order was not followed.
Surveyors found that garbage and refuse were not properly disposed of, with trash bags left on the ground next to dumpsters, a dumpster lid with broken hinges, and uncovered trash barrels containing debris and frozen items near the loading dock. These conditions were confirmed by the Regional Director of Clinical Operations.
Surveyors found that slings used for resident transport were improperly stored on the floor and on wall hooks where they touched the floor and a lint-filled garbage can. Additionally, there was a buildup of lint behind the dryer and the laundry room floor was covered with dirt and debris, all of which were confirmed by the Regional Director of Clinical Operations.
A resident experienced severe pain due to constipation after the facility failed to monitor bowel movements and initiate the Bowel Regime protocol. Despite receiving scheduled Miralax and Senna plus, the resident did not have a bowel movement for 16 shifts, leading to significant distress. The facility's policy required CNAs to document bowel movements and Licensed Nurses to review alerts, but this was not done. The issue was only addressed after a medical provider was called, who ordered a suppository and x-ray, confirming constipation.
The facility did not maintain adequate staffing levels on weekends during the fourth quarter of 2024, as indicated by a PBJ report. The Administrator confirmed the issue, attributing responsibility for the PBJ data to Human Resources, who did not provide evidence to refute the low staffing findings.
The facility failed to provide written information on advance directives to four residents, as confirmed by the Administrator. Clinical records lacked evidence of offering advance directives or obtaining Power of Attorney paperwork, indicating a systemic issue in ensuring residents' rights to make informed care decisions.
The facility was found deficient in maintaining a safe and sanitary environment, with issues such as a torn vinyl door covering, broken wood trim, broken blind slats, chipped paint, and cracked wheelchair arms. These deficiencies were observed during a survey, highlighting inadequate housekeeping and maintenance services.
A resident with mental health diagnoses was not referred for a PASRR Level II evaluation after a 30-day exemption expired. The resident's record lacked evidence of re-evaluation for 8 months, which was confirmed by the DON.
A resident did not receive a scheduled dose of the antibiotic Meropenem for an ESBL infection, despite the medication being available in the facility's emergency supply. Additionally, the facility failed to administer Normal Saline Flushes as ordered, with no documentation of these treatments in the resident's EMAR.
The facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents whose Medicare Part A services were discontinued. This notice is essential for informing residents about their potential financial responsibility for services not covered by Medicare. The oversight was confirmed by the facility's Administrator.
A facility failed to develop a care plan for a resident's Atrophic Vaginitis, a condition requiring daily treatment as per physician orders. Despite documentation of the condition in physician progress notes and the resident experiencing symptoms, the care plan lacked any related problem, goal, or interventions. The DON confirmed the absence of this information during a surveyor interview.
A facility failed to follow physician orders for a resident requiring a low sodium diet and assistance to get out of bed for meals. The resident received a regular diet with salt packets and was not assisted out of bed for meals until 11 days after the order was given. Interviews and record reviews confirmed these discrepancies.
The facility failed to ensure a safe environment by having baseboard heaters with exposed heating elements in five rooms and the B-Unit dining room. One room also had a torn mattress bumper, creating an uncleanable surface. These hazards were observed and discussed with the DON.
A facility failed to follow a Physician Assistant's order for a neurological follow-up for a resident with post-COVID syndrome, neuropathy in the lower extremities, and autonomic dysfunction. The Administrator confirmed the absence of evidence that the order was followed.
Grievance Process Not Clearly Implemented and Missing Resident Glasses Not Located
Penalty
Summary
The facility failed to develop and/or implement policy and procedures for residents to file grievances and have concerns resolved in a timely manner. The grievance policy stated that residents or responsible parties could bring concerns verbally or in writing, that grievance forms were available on the nursing units and in the front lobby, and that staff should attempt to resolve verbal concerns promptly. However, during interviews, residents stated they did not know how to file a grievance anonymously, and staff gave inconsistent explanations about the process. The Activities Director said she would complete a grievance form and give it to the Administrator, while the Administrator stated anonymous complaints could be submitted through the facility website and that a name was not required. The Administrator also confirmed the written policy did not mention a way to file a grievance anonymously. The facility also failed to assist a resident with locating missing glasses. R3 had moderately impaired cognition and impaired visual function, with care plan interventions to ensure glasses were clean, available, and worn when up. CNA documentation indicated the resident wore glasses each morning and removed them each night, but the clinical record lacked evidence that the glasses were reported missing or that the facility took steps to locate them. R3 stated the glasses had been missing for more than 3 weeks and could not see well without them, and the roommate confirmed they had been missing for more than 3 weeks. The Administrator acknowledged the glasses were reported missing, that the facility did not know whether they were lost in the facility or at dialysis, and that dialysis was not contacted to help locate them.
Failure to Recognize Significant Weight Changes
Penalty
Summary
The facility failed to recognize a potential significant weight loss and a potential significant weight gain for Resident #12, who was care planned for diabetes and for overweight/obesity/risk of malnutrition related to chronic disease (diabetes mellitus Type II). The care plan included interventions to monitor, document, and report signs or symptoms of weight loss, as well as to monitor and evaluate weight and weight changes. Record review showed the resident weighed 294 pounds on 3/5/26, then 263 pounds on 3/12/26, indicating a potential significant weight loss of 30.6 pounds. The resident later weighed 266.1 pounds on 3/16/26 and 310.2 pounds on 3/26/26, indicating a potential significant weight gain of 44.1 pounds. There was no evidence that the care plan interventions were followed or that the weight changes were assessed for accuracy or evaluated for possible medical intervention. The finding was discussed with the DON during interview on 3/31/26 at 7:00 a.m.
Provider Signatures Missing or Delayed on Required Physician Block Orders
Penalty
Summary
The facility failed to ensure the attending provider signed the medication Order Review History Report (physician block orders) during required regulatory visits for multiple residents. For Resident #2, documentation showed a required visit was completed on 1/15/26, and a provider progress note was completed that day, but there was no evidence the physician block orders were signed. For Resident #6, the physician block orders were signed on 2/4/26, but the provider progress note for the required recertification visit was not completed and signed until 6 days later. For Resident #9, the physician block orders were signed on 1/13/26, but there was no evidence the provider progress note was completed and signed the following day. For Resident #14 and Resident #46, the physician block orders were signed on 1/28/26, but the provider progress notes were not completed and signed until 5 days later. The facility also failed to ensure the attending provider signed the physician block orders during a required visit for Resident #58 after readmission as a skilled resident. The record showed the resident was readmitted in early December 2025, and the medical provider visited and signed the physician block orders on 12/10/25, with the next required visit and signature due by 1/19/26. Although providers made multiple visits during the interval, the next physician block orders were signed on 1/7/26 without a documented visit that day, and the next documented provider visit with signed physician block orders occurred on 2/5/26, 17 days late. Surveyors confirmed a provider signed the physician block orders without a physician visit.
Food Storage and Facial Hair Restraint Deficiencies
Penalty
Summary
The facility failed to ensure that plastic scoops were not left in the flour and sugar bins, and failed to prevent cross contamination in the walk-in refrigerator where a plastic container held lettuce leaves, a bag of carrots, an unpeeled cucumber, and an onion wrapped in plastic wrap together in the same container. The facility also failed to ensure that all kitchen staff were wearing facial hair restraints during food handling tasks. During the initial kitchen tour, the surveyor observed the scoops left in the flour and sugar bins. The surveyor also observed a cook preparing food with his mustache uncovered because his facial hair restraint was not on completely, and a dietary aide preparing lunch trays and plated food without a facial hair restraint. On the following day, the cook was again observed with his mustache uncovered, and the dietary aide was observed with his beard and mustache uncovered while performing food handling tasks. The Food Service Director confirmed that the cook and dietary aide did not have facial hair restraints on while performing food handling tasks.
Failure to Resubmit PASRR for Resident With PTSD and Anxiety
Penalty
Summary
The facility failed to ensure that the State mental health authority was notified for a new PASRR determination after a resident was admitted with diagnosed and/or experienced symptoms related to a mental disorder or trauma event. Resident #8 was admitted with a PASRR Level I screening that did not include active diagnoses of PTSD or an anxiety disorder. The clinical record did not show evidence that the resident was referred to the State mental health authority for a new PASRR review to determine whether a change in level of service was required. During an interview with the surveyor and the DNS, the medical record and PASRR were reviewed, and it was confirmed that the resident had not been resubmitted for a PASRR determination to include the active diagnoses of PTSD and anxiety.
Care Plan Did Not Address PTSD Triggers
Penalty
Summary
The facility failed to ensure a care plan was developed and implemented to address the needs of a resident with an active diagnosis of Chronic Post Traumatic Stress Disorder (PTSD) and to minimize triggers that may cause re-traumatization. Record review showed the resident’s initial assessment documented a history of physical and emotional trauma that was triggered by certain sounds, but the clinical record lacked evidence that interventions were put in place to prevent re-traumatization. During interview, the Director of Nursing Services reviewed the medical record with the surveyor and confirmed that the care plan did not address PTSD, including goals or interventions to prevent re-traumatization.
Failure to Assist Resident With Lost Eyeglasses and Eye Care Follow-Up
Penalty
Summary
The facility failed to assist a resident with gaining access to vision services after the resident’s eyeglasses were lost. Resident #3 stated that he/she could not see without the glasses and that they had been missing for approximately 3 weeks. The resident reported that nursing staff and the Administrator had looked for the glasses, but the resident did not know whether there was a plan to find or replace them. Record review and staff interviews showed that the resident’s eye care appointment had been crossed off with a note stating, “Will need to reschedule. Call to reschedule when glasses are found,” and no future eye care appointments were scheduled. A CNA stated the glasses had been missing for a while and described a broken hinge screw issue, while the Administrator later stated the glasses had gone missing, were found at dialysis, and then were reported missing again. The clinical record lacked evidence that the glasses were missing or that the resident’s family was notified, and the facility did not follow up to reschedule the eye care appointment or assist the resident in obtaining new eyeglasses after they were lost.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions during a pressure ulcer dressing change for one resident with an unstageable pressure ulcer on the spine. The facility policy, revised 6/24, required gown and glove use for certain residents during high-contact care activities, including wound care and dressing changes for pressure injuries, even when the resident was not known to be infected or colonized with an MDRO. The resident’s clinical record showed that a medical provider documented the unstageable pressure ulcer on 3/25/26, and the care plan was updated on 3/31/26 to include Enhanced Barrier Precautions and the use of gloves and a gown for wound care. During an observation on 3/31/26 at 10:46 a.m., RN1 completed a dressing change to the resident’s spine pressure ulcer without wearing a gown, and RN1 later confirmed this during an interview at 11:25 a.m.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of transfers/discharges to a hospital for 2 of 3 residents reviewed, including R48 and R58. Record review showed that R48 was transferred and admitted to the hospital, and R58 was also transferred and admitted to the hospital. During an interview, the Regional Director of Clinical Services stated that Ombudsman notifications were not sent for the months of November through January.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records contained accurate, complete, and readily accessible information for 2 of 22 residents reviewed. For one resident, the clinical record and CNA documentation indicated that glasses were put on each morning and removed each evening, but the resident stated the glasses had been missing for more than 3 weeks and could not be found in the room. The roommate also stated the glasses had been missing for more than 3 weeks. The record lacked evidence that the glasses were missing, that the resident representative was notified, or that the grievance was documented in the clinical record, even though the Administrator stated the glasses had been reported missing on 2/6/26. For another resident, the clinical record contained a monthly pharmacist recommendation that the diagnosis for Olanzapine (Zyprexa) be made more specific than agitation/increased behaviors. The nurse later updated the diagnosis to behaviors such as hitting, punching, kicking, agitation, and screaming, which were documented as behaviors rather than a diagnosis. During interviews, the DON confirmed the finding, and the Regional Director of Clinical Operations stated the diagnosis for the use of Olanzapine was later updated to vascular dementia with behaviors by the in-house provider.
Standing Water Observed in Basement Areas Due to Leaks
Penalty
Summary
Surveyors observed and confirmed the presence of standing water in two separate basement areas of the facility during an environmental tour. One area of standing water was located in a basement storage room beneath the kitchen, which the Maintenance Director attributed to water leaking in from the loading dock and traveling through the wall. Another area of standing water was found in the basement space below resident rooms, which the Maintenance Director stated was due to leaking windows and landscaping that directed snow melt and runoff water toward the building. These conditions were directly observed and confirmed by surveyors and the Regional Director of Clinical Operations during the survey. No specific residents or staff were identified as being directly affected at the time of the deficiency, and no additional medical history or resident conditions were mentioned in the report.
Failure to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and kitchen sanitation during a tour of the facility's kitchen and food storage areas. Food debris was found on the floor under kitchen surfaces and shelves in the meal preparation area, not related to the current meal service. Behind the stove, a large pile of food debris was present against the wall, with cooking utensils partially buried in it. In the dry food storage area, loose fries and a biscuit were found on the floor. The walk-in freezer contained food debris, including a fish filet and loose fries on the floor, and an open box of green beans stored directly on the floor, along with boxes of hamburger patties, chicken breasts, and creamer stacked and stored on the floor. In the walk-in refrigerator, a large mesh bag of onions was also stored on the floor. These observations were confirmed by both the surveyor and the Food Service Director, indicating that food was not stored, prepared, or served in accordance with professional standards for food service safety.
Failure to Provide Physician-Ordered Minced and Moist Diet
Penalty
Summary
A resident with a history of dysphagia and recent emergency room visits for increased cough, congestion, and concerns for aspiration pneumonia was placed on a physician-ordered minced and moist diet with thin liquids. The order, based on the IDDSI Level 5 guidelines, specifically excluded regular, dry bread, sandwiches, or toast. Despite this, the resident was provided a roll for lunch while on the modified diet. Following the consumption attempt, the resident was unable to swallow secretions and vomited upon swallowing food or drink, which led to another emergency department visit. Interviews with facility staff, including the Rehab Director and Director of Nursing, confirmed that the dietary order was not followed and that bread is not permitted on the minced and moist diet per IDDSI standards.
Improper Disposal of Garbage and Refuse Observed
Penalty
Summary
Surveyors observed several deficiencies in the disposal of garbage and refuse at the facility. On the survey day, multiple bags of trash were found stored on the ground next to the facility dumpsters, rather than inside them. The hinges on the lid of one dumpster were broken, preventing the lid from covering the refuse. Additionally, in the outside area by the loading dock, a used food container was seen frozen in the snow on top of a snow-covered cooler, and a round trash barrel without a lid was found containing trash and debris, with a milk crate frozen in place and ice accumulating over the edges of the barrel. These findings were confirmed during an interview with the Regional Director of Clinical Operations.
Infection Control Deficiency in Laundry Room Storage
Penalty
Summary
Surveyors observed that the facility failed to maintain proper infection control practices in the laundry room. Specifically, there was a buildup of lint behind the dryer, and the floor was covered with dirt and debris. Slings used for resident transport were found piled on the floor between a door and a wall, and additional slings were hanging on wall hooks near the dryer in such a way that parts of the slings were touching the floor and the inside of a lint-filled garbage can. These observations were confirmed during a tour and interview with the Regional Director of Clinical Operations, who acknowledged the improper storage of slings on the floor and on hooks where they touched the floor.
Failure to Monitor and Initiate Bowel Regime Protocol
Penalty
Summary
The facility failed to monitor a resident's bowel movements and initiate the Bowel Regime protocol, resulting in significant discomfort for the resident. The resident, identified as R46, did not have a bowel movement for 16 shifts, leading to severe pain and distress. The facility's policy required Certified Nursing Assistants (CNAs) to document bowel movements accurately and for Licensed Nurses to review clinical alerts daily to identify residents needing bowel regime interventions. However, this protocol was not followed for R46, who was already receiving scheduled Miralax and Senna plus but did not receive additional PRN bowel regime medications until the situation escalated. On the day of the incident, a surveyor observed R46 in significant pain, crying out for help due to constipation. Despite the resident's visible distress, the facility staff did not initiate the bowel protocol until a medical provider was called, who then ordered a suppository and an abdominal x-ray. The x-ray confirmed a non-obstructive bowel gas pattern with fecal residue, correlating with clinical constipation. Interviews with staff revealed that the CNAs and nurses did not document or act on the lack of bowel movements, and the Director of Nursing confirmed the protocol was not initiated as required. The medical provider noted that R46 had a history of constipation and minimal oral intake, which contributed to the issue. Despite this, there were no nursing complaints or actions taken from the last medical review until the incident. The failure to follow the bowel regime protocol and the lack of communication between nursing staff and medical providers led to the resident's prolonged discomfort and pain.
Insufficient Weekend Staffing in Q4 2024
Penalty
Summary
The facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents during weekends in the fourth quarter of 2024. A Payroll Based Journal (PBJ) report indicated that the facility triggered for low weekend staffing during this period. During an interview, the Administrator acknowledged the issue and stated that Human Resources was responsible for the PBJ data. However, Human Resources did not provide any additional information to dispute the PBJ report findings, which confirmed low weekend staffing levels.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with written information to formulate an advance directive or appoint a surrogate. This deficiency was identified for four out of seven residents reviewed for advance directives. Specifically, the clinical records of these residents lacked evidence that the facility had provided or obtained the necessary documentation regarding the right to formulate an advance directive or appoint a surrogate. The residents involved were admitted to the facility between January and February 2025, with one resident having been admitted as early as 2020. During interviews with surveyors, the facility's Administrator confirmed the absence of evidence in the clinical records regarding the offering of advance directives or obtaining Power of Attorney paperwork, if applicable. This lack of documentation was consistent across the reviewed records, indicating a systemic issue in the facility's process for ensuring residents' rights to make informed decisions about their care and treatment preferences.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. On the first day of the survey, a torn vinyl covering on the inside of a bathroom door was noted, which was later removed by the Interim Maintenance Director. On the second day, an environmental tour revealed additional issues: broken wood trim behind a bed, broken blind slats in two rooms, chipped paint in a bathroom, and cracked, uncleanable wheelchair arms for a resident. These observations indicate a lack of adequate housekeeping and maintenance services necessary to keep the building and resident equipment in good repair and sanitary condition.
Failure to Conduct PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a specialized mental health diagnosis was referred for a Pre-Admission Screening & Resident Review (PASRR) Level II evaluation after the expiration of a Convalescence Categorical exemption. The resident, who was readmitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder, had a PASRR Level I evaluation dated 5/10/24, which granted a 30-day exemption. However, the resident's clinical record did not show evidence of a PASRR Level II re-evaluation after the exemption period ended on 6/11/24, leaving an 8-month gap without the necessary assessment. This deficiency was confirmed during an interview with the Director of Nursing Services, who acknowledged the oversight.
Failure to Administer IV Antibiotics and Saline Flushes as Ordered
Penalty
Summary
The facility failed to follow hospital discharge orders for a resident who required intravenous administration of the antibiotic Meropenem for the treatment of bilateral pyelonephritis with an ESBL infection. Despite having an emergency supply of the medication available, the resident did not receive the scheduled dose at 9:00 p.m. on the day of admission. Interviews with the Administrator, DON, and Infection Preventionist confirmed the availability of the medication in the emergency kit, yet there was no documentation in the clinical record or EMAR indicating that the resident received the required dose. Additionally, the facility did not adhere to physician orders for administering Normal Saline Flushes before and after each medication administration. The resident's EMAR lacked evidence of the Normal Saline Flush being completed as ordered from the date of admission to several days thereafter. This was confirmed during a review of the EMAR with a registered nurse, indicating a failure to provide the necessary intravenous care as prescribed.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents whose Medicare Part A services were discontinued. Resident #24's Medicare Part A services ended on December 20, 2024, and Resident #36's services ended on December 26, 2024. However, there was no evidence that either resident received the required SNFABN, which would have informed them of their potential financial responsibility for continued skilled services not covered by Medicare. This oversight was confirmed by the facility's Administrator during an interview with the surveyor on February 25, 2025.
Failure to Develop Care Plan for Atrophic Vaginitis
Penalty
Summary
The facility failed to develop a care plan for a resident's current medical problem of Atrophic Vaginitis, which required physician-ordered treatment. The resident's clinical record, reviewed on January 2, 2025, indicated that Atrophic Vaginitis was identified as a current problem in physician progress notes dated October 1, 2024, and December 5, 2024. The condition required daily treatment with creams and a gel, and the resident experienced vulva pain and vulvovaginal irritation. Despite this, the care plan lacked any problem, goal, or interventions related to the Atrophic Vaginitis. The Director of Nursing confirmed the absence of this information in the care plan during an interview with the surveyor.
Failure to Follow Physician Orders for Diet and Mobility Assistance
Penalty
Summary
The facility failed to follow physician orders for a resident who required a low sodium diet and assistance to get out of bed for meals. On 4/8/24, the resident's cardiologist ordered a low sodium diet, but the resident continued to receive a regular diet with salt packets on their meal trays from 4/15/24 to 4/22/24. Additionally, the same cardiologist ordered the resident to be assisted out of bed and into a chair for meals starting on 4/8/24. However, this order was not followed until 4/19/24, as indicated by the resident's Treatment Administration Record (TAR). Interviews with the resident and the Food Service Supervisor confirmed these discrepancies, and the Director of Nursing acknowledged the oversight during a discussion with the surveyor on 4/22/24.
Exposed Heating Elements in Baseboard Heaters
Penalty
Summary
The facility failed to ensure that the resident's environment was free from accident hazards related to baseboard heaters in disrepair with heating elements exposed. During observations on 4/22/24 between 11:30 a.m. and 11:50 a.m., it was noted that five rooms had baseboard heaters with missing connectors, exposing heating elements. Additionally, one room had a baseboard heater with an end cap off and a mattress bumper torn, creating an uncleanable surface. The B-Unit dining room also had baseboard connectors missing, exposing heating elements. These findings were discussed with the Director of Nursing at 12:45 p.m. on the same day.
Failure to Follow Physician Assistant's Order for Neurological Follow-Up
Penalty
Summary
The facility failed to follow a Physician Assistant's order for a resident. The resident had an order dated 3/14/24 for a neurological follow-up due to post-COVID syndrome, neuropathy in the lower extremities, and autonomic dysfunction. Upon review of the clinical record on 4/9/24, there was no evidence that an appointment with neurology had been made. The Administrator confirmed the absence of evidence that this order was followed during an interview with the surveyor on the same day.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bangor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maine Veterans Home - Bangor | 0.5 mi | ★★★★★ | 11 | 0 |
| Stillwater Health Care | 0.8 mi | ★★★★★ | 12 | 0 |
| Ross Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Westgate Center For Rehab & Alzheimers Care | 2.7 mi | ★★★★★ | 5 | 0 |
| Brewer Center For Health & Rehabilitation, Llc | 2.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Eastside Center For Health & Rehabilitation, Llc.
100% money-back within 48 hours.
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.