Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastwood Manor during CMS and state inspections, most recent first.
RN coverage was not maintained for 8 consecutive hours each day. Facility records showed multiple days without evidence of the required RN coverage, and the Administrator confirmed the gaps. The BOM stated the facility sometimes had the coverage and sometimes did not, while the ADON, DON, and Administrator all stated their expectation was that an RN be on duty for 8 consecutive hours every day.
A Dietary Manager plated mashed potatoes using a #16 scoop instead of the utensil needed to match the menu portion. The menu called for one-half cup, but the DM acknowledged only a two-ounce portion was served. The RD and Administrator stated staff were expected to follow the menu and posted utensil guide to serve the correct portion.
Improper food storage and expired items in refrigeration: A survey found multiple refrigerated food items stored without required labels or dates, including tortillas, cucumber, turkey, cheese, and onion, along with several spoiled or expired items such as celery, strawberries, peppers, sour cream, tomato, and cucumbers. The DM stated some items were expired or should not be served, and also noted pre-cooked sausage was stored with uncooked bacon, contrary to facility policy.
The facility failed to complete annual performance reviews for 2 CNAs whose personnel files were reviewed. The ADON said CNAs received in-service training but there was no documentation of performance reviews and gave mixed statements about responsibility. The DON said she had not completed the reviews and was not aware they were required, while the Administrator stated reviews were expected upon hire and annually to ensure staff could perform their jobs.
Failure to investigate an RSV outbreak and complete respirator fit testing: Multiple residents developed RSV, including one resident with RSV and pneumonia, but the IP did not conduct a comprehensive outbreak investigation or employee health surveillance. The DON stated staff were not assessed as possible sources of transmission, employee screening and illness tracking were not done, and respirator fit testing was not completed as required by policy.
Failure to Offer Ongoing Activities: A resident with depression, muscle weakness, and intact cognition was identified as needing an ongoing activity program and 1:1 activities based on care plan and activity review documentation. However, progress notes showed no evidence that 1:1 activities were offered or provided, and the resident stated no one offered any activities. The AD acknowledged she was not tracking participation and had not offered 1:1 activities, while the DON and Administrator stated they expected ongoing activity provision and documentation.
Failure to Post Nurse Staffing Data: The facility did not post the required nurse staffing data during multiple observations, and the Administrator confirmed the posting was absent. The ADON was unaware of the posting requirement, the CNO had not discussed it with the ADON, and the Business Office Manager stated she tracked and completed the staffing report but did not post it. The DON and Administrator later stated the staffing data was expected to be posted every day.
A facility failed to include a resident's continuous oxygen use in their care plan, despite the resident having chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The resident's oxygen concentrator was found turned off, and the care plan lacked documentation of the oxygen order, which was confirmed by an LPN and the ADON. The DON acknowledged a communication breakdown that prevented the order from being included in the care plan and EHR.
A resident with chronic respiratory conditions did not receive the correct oxygen level as ordered by a physician due to documentation errors. The oxygen concentrator was observed to be off or set incorrectly on multiple occasions. The order was misplaced in the EHR, leading to confusion among staff, including temporary nurses, who rely on standard documentation practices.
The facility failed to limit PRN psychotropic medications to a 14-day course for two residents. One resident with anxiety received lorazepam beyond the 14-day limit, and another with insomnia received temazepam without reassessment. Despite pharmacy consults recommending adherence to the 14-day rule, the orders remained unchanged, and the residents continued receiving the medications. The ADON and DON acknowledged the lack of required documentation and rationale for extending the PRN orders.
The facility failed to monitor dish machine temperatures and sanitizer concentrations, label open food containers with dates, prevent food storage on the floor, and document food storage temperatures. These deficiencies were observed during a kitchen tour, affecting 36 residents who received meals from the kitchen. The DM confirmed the required practices were not followed.
A facility failed to ensure proper placement of a catheter bag for a resident with an indwelling urinary catheter. During catheter care, a CNA and an LPN were observed allowing the catheter bag to rest on the floor, contrary to the facility's policy. The resident had diabetes mellitus and a urinary tract infection. Both staff members and the ADON acknowledged that catheter bags should not be on the floor.
A facility failed to complete an admission MDS assessment within the required 14-day period for a newly admitted resident with pulmonary fibrosis and diabetes mellitus. Instead, a significant change assessment was being completed, which was inappropriate for a new admission. This deficiency was identified during a record review and interview with the ADON.
A facility failed to complete a baseline care plan within 48 hours of admission for a resident with pulmonary fibrosis and diabetes mellitus. The ADON confirmed the absence of the care plan, despite the facility's policy requiring its completion within the specified timeframe. The facility census was 36 residents.
RN Coverage Not Maintained for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure there was a registered nurse (RN) on duty for eight consecutive hours each day. A facility policy titled, Policy Regarding Facility Staffing, stated it was the policy of the facility to employ sufficient, adequately trained staff to be on duty 24 hours a day to meet resident needs as determined by the Administrator and/or Director of Nursing. Review of the facility's Time & Attendance - Detail Report for 01/01/2026 through 07/22/2026 showed no evidence of RN coverage for eight consecutive hours on 01/17/2026, 01/18/2026, 03/08/2026, 04/12/2026, 04/16/2026, 04/17/2026, 04/19/2026, 04/26/2026, and 06/28/2026. During interviews, the Administrator confirmed there was no evidence of eight consecutive hours of RN coverage on those dates, and the Business Office Manager stated the facility sometimes had RN coverage for eight consecutive hours each day and sometimes did not. The Assistant Director of Nursing, Director of Nursing, and Administrator each stated their expectation was that the facility had RN coverage for eight consecutive hours every day.
Incorrect Portion Served for Mashed Potatoes
Penalty
Summary
The facility failed to follow the posted menu and portion-control guidance during the lunch meal by serving mashed potatoes in the wrong amount. The weekly menu indicated that one-half cup of mashed potatoes was to be served, and the facility policy on Food Preparation stated that portion-control methods would be used to assure the correct quantities were served to residents according to the menu. A kitchen conversion/measurement guide posted in the facility indicated that a #16 scoop yielded one-quarter cup, equivalent to two ounces. During tray line observation, the Dietary Manager was seen plating mashed potatoes with a blue-handled scoop. In interview, the Dietary Manager acknowledged using a #16 scoop for the mashed potatoes and stated she made a mistake and used the wrong serving utensil. She stated she should have served one-half cup but only served a two-ounce portion. The Registered Dietician stated staff were expected to use the menu as a guide for portions and the utensil guide posted in the kitchen to ensure the correct utensil was used. The Administrator stated staff should follow the menus and provide food in the portion according to the menu, using the utensil guide and menu together.
Improper food storage and expired items in refrigeration
Penalty
Summary
The facility failed to ensure food items were stored with dates and labels and that expired food items were discarded. Facility policies titled Sanitation and Infection Control stated refrigerated foods should be covered, labeled, and dated, and leftover foods must be covered, labeled, dated, refrigerated immediately, and used within three days of the original cooking date. During a concurrent observation and interview of the reach-in refrigerator, the surveyor found eleven pre-cooked sausage patties stored in an opened bag in a box with approximately 50 pieces of uncooked bacon, and the Dietary Manager stated the sausage should not have been stored with the bacon. The surveyor also observed multiple food items that were expired, spoiled, or missing required labels or dates. These included cut celery with a best-by date of 06/03/2026 and brown liquid, flour tortillas without a label or date, a peeled cucumber without a use-by date, sliced turkey with an opened date but no use-by date, strawberries with mold, green bell peppers with black, white, and green discoloration, a slice of turkey deli meat without a label or date, Swiss cheese without a label or use-by date, sour cream past its best-by date, a peeled white onion with an opened date, a cut tomato with brown liquid and white fuzzy growth, and nine cucumbers with black and white discolored spots. The Dietary Manager stated several of these items were expired or should not be served, and the Administrator stated staff were expected to monitor refrigeration units daily for expired food items and ensure each item placed in the refrigerator had an opened date and an expiration date.
Failure to Complete CNA Annual Performance Reviews
Penalty
Summary
The facility failed to complete an annual performance review for 2 of 3 certified nurse aides whose personnel files were reviewed. CNA #7’s file showed a hire date of 08/16/2022, but there was no evidence that an annual performance or skills review had been completed. CNA #25’s file showed a hire date of 05/08/2023, but there was no evidence that an annual performance or skills review had been completed. During interviews, the ADON stated the CNAs received 12 hours of in-service training, but there was no documentation of performance reviews, and she gave differing statements about who was responsible for them, including the Administrator, then a shared responsibility between herself and the DON. The DON stated she had not completed CNA performance reviews and was not aware they were not being completed or that she was supposed to do them. The Administrator stated performance reviews were to be completed upon hire and annually to ensure staff could continue to perform their assigned job.
Failure to Investigate RSV Outbreak and Complete Respirator Fit Testing
Penalty
Summary
The facility failed to implement its infection prevention and control program during an RSV outbreak that involved multiple residents. Facility records showed Resident #40 developed wheezing on 01/23/2026 and was diagnosed with RSV, and in 03/2026 seven additional residents, including Residents #1, #3, #11, #14, #22, #28, and #41, were diagnosed with RSV. Resident #3, #11, #14, #22, #28, and #41 each had an onset of cough on 03/04/2026 and were diagnosed with RSV, while Resident #1 developed cough, sore throat, diminished lung sounds, and slight wheezing on exhale on 03/10/2026 and was diagnosed with RSV and pneumonia. Facility policy required the Infection Preventionist to coordinate an outbreak investigation when an outbreak was established, including developing a case definition based on person, place, time, and clinical features. However, the Assistant Director of Nursing, who served as the Infection Preventionist, stated employee health surveillance and a comprehensive outbreak investigation were not conducted during the RSV outbreak. The DON stated there was no comprehensive investigation to determine the source of transmission, staff were not investigated as possible sources, employee screening and monitoring were not conducted, and staff illnesses were not tracked through the infection prevention and control program. The DON also stated employee respirator fit testing was not completed during the outbreak, despite the facility policy requiring fit testing before use, annually, and when physical condition changes could affect fit.
Failure to Offer Ongoing Activities
Penalty
Summary
The facility failed to ensure that Resident #21 was offered an ongoing program of activities. The resident was admitted on 01/05/2026 and had diagnoses including depression and muscle weakness. A quarterly MDS with an ARD of 04/20/2026 showed a BIMS score of 15, indicating intact cognition. The resident’s care plan identified a need for staff support with emotional, intellectual, physical, and social needs, and interventions directed staff to provide a program of activities that matched the resident’s interests and encouraged choice, self-expression, and responsibility. The resident’s Activities Quarterly/Annual Participation Review dated 03/30/2026 and 06/23/2026 showed the resident enjoyed 1:1 activities, but the resident’s progress notes for 02/01/2025 through 04/30/2026 contained no evidence that 1:1 activities were offered or provided. During interview, the resident stated no one offered any activities. The Activities Director stated she had not been tracking activity participation for each resident and had not offered 1:1 activities to Resident #21. The DON stated she expected the Activities Director to ensure all residents received some type of activity on an ongoing basis, and the Administrator stated she expected the Activities Director to document activity participation for all residents.
Failure to Post Nurse Staffing Data
Penalty
Summary
The facility failed to post the nurse staffing data on 2 of 5 survey days, specifically on 07/20/2026 and 07/21/2026. During observations on 07/20/2026 at 10:48 AM and 3:18 PM, and on 07/21/2026 at 8:32 AM, the required nurse staffing data was not observed posted in the facility. During a concurrent observation and interview on 07/21/2026 at 8:34 AM, the Administrator observed the billboard and stated the facility did not have a post of the nurse staffing data, and said it was her understanding the facility never posted it. The ADON stated she was not aware of the requirement to post the nurse staffing data, and the CNO stated she had not yet discussed posting the data with the ADON and acknowledged the facility did not post it. The Business Office Manager stated she tracked the nurse staffing data and completed a report, but did not post it. The DON and Administrator later stated their expectation was that the nurse staffing data would be posted every day.
Failure to Include Continuous Oxygen Use in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's continuous oxygen use was included in their care plan, which was a deficiency identified during a survey. The resident, who had diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed by a family member and a surveyor to have their oxygen concentrator turned off, despite having a verbal order for continuous oxygen at 2 liters per minute. The care plan for this resident, dated several months prior, did not include any interventions related to the use of oxygen, which was confirmed by both an LPN and the ADON during interviews. The ADON acknowledged that the care plan lacked documentation regarding the resident's oxygen use, which was a critical oversight given the resident's medical condition. The DON later stated that there was a breakdown in communication that prevented the oxygen order from being included in the care plan and the electronic health record (EHR). This deficiency was particularly concerning as temporary nursing staff relied on the care plan to determine a resident's oxygen level, highlighting the importance of accurate and complete documentation in the care plan.
Oxygen Administration Error Due to Documentation Issues
Penalty
Summary
The facility failed to ensure a resident received the correct amount of oxygen as ordered by a physician. Resident #7, who had diagnoses including chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed on multiple occasions receiving incorrect oxygen levels. On one occasion, the oxygen concentrator was turned off, and on others, it was set to 3.5 and 3 liters per minute, despite the physician's order for 2 liters per minute. This discrepancy was noted during observations on two consecutive days. The issue was compounded by a lack of proper documentation and communication. The order for 2 liters of oxygen per minute was not found in the resident's electronic health record (EHR) or care plan by the staff initially. It was later located in the miscellaneous section of the EHR, which is not a standard location for such orders. This misplacement led to confusion among staff, including temporary agency nurses, who typically rely on the orders section of the EHR and the care plan to administer care. The Director of Nursing acknowledged a communication breakdown between facility staff and hospice staff, which contributed to the oversight.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that psychotropic medications ordered on an as-needed (PRN) basis were limited to a 14-day course for two residents. Resident #7, diagnosed with an anxiety disorder, had a physician's order for lorazepam 0.5mg every 4 hours as needed, with an indefinite end date. Despite a pharmacy consult report recommending adherence to the 14-day rule and requiring a prescriber evaluation before extending the order, the medication order remained unchanged, and the resident received doses beyond the 14-day limit. The physician's response to the pharmacy consult was to change the order to a scheduled dose, but the PRN order persisted in the medication administration records (MAR) for several months. Similarly, Resident #31, diagnosed with insomnia, had a physician's order for temazepam 15mg every 24 hours as needed, also with an indefinite end date. A pharmacy consult report highlighted the need for a 14-day limit and reassessment, but the physician did not document a rationale for maintaining the PRN order or provide an end date. The resident received 81 doses over several months without the required reassessment or documentation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the failure to meet regulatory requirements, as the physician did not address the pharmacy consult reports or provide the necessary rationale and end date for the PRN psychotropic medications.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards in food procurement, storage, preparation, and service, affecting 36 residents who received meals from the kitchen. During an initial tour of the kitchen, it was observed that the Dish Machine Monthly Check Sheet had not been updated with temperatures or chemical concentrations since February 19, 2025. Additionally, open containers of 2% milk, cranberry juice, mayonnaise, and ketchup were found in a refrigerator without labels indicating when they were opened. A large bag of blueberry muffin mix was improperly stored on the floor in the storage room. Furthermore, the Regular/Pureed Meal Temperature Log lacked documentation of meal holding temperatures for several days in February 2025. The Dietary Manager (DM) confirmed that the dish machine's temperature and chemical concentration should be checked three times daily, food items should be labeled with the date they were opened, food holding temperatures should be recorded for each meal, and food should not be stored on the floor.
Failure to Maintain Proper Catheter Bag Placement
Penalty
Summary
The facility failed to ensure that catheter bags were not placed on the floor for a resident with an indwelling urinary catheter. During an observation on February 26, 2025, a CNA and an LPN were seen providing catheter care to a resident, during which the catheter bag was initially found on the floor. The CNA moved the bag but placed it back on the floor, and only after completing the care did the LPN hang the bag off the floor. The following day, the catheter bag was again observed on the floor under the resident's bed. The facility's Catheter Care Policy explicitly states that drainage bags should not touch the floor. The resident involved had diagnoses including diabetes mellitus and a urinary tract infection, and a care plan was initiated on February 24, 2025, indicating the presence of an indwelling urinary catheter. Both the CNA and LPN acknowledged that catheter bags should not be on the floor, and the ADON confirmed this policy.
Failure to Complete Timely Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment within the required 14-day period for a resident who was newly admitted. The facility's policy mandates that new residents be assessed no later than 14 days after admission, with a possible extension to the 21st day. However, for a resident with diagnoses including pulmonary fibrosis and diabetes mellitus, the admission MDS assessment was not completed within this timeframe. Instead, the Assistant Director of Nursing (ADON) was in the process of completing a significant change assessment, which was inappropriate as the resident was a new admission. This oversight was identified during a review of the resident's records and an interview with the ADON.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident, as required by their policy effective November 28, 2017. The resident, who had diagnoses including pulmonary fibrosis and diabetes mellitus, did not have a baseline care plan documented in their medical record. During an interview, the Assistant Director of Nursing (ADON) confirmed that a baseline care plan could not be located for the resident and acknowledged that such plans should be completed within the specified timeframe. The facility census at the time was 36 residents.
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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 Commerce
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windridge Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Miami Nursing Center, Llc | 4.6 mi | ★★★★★ | 3 | 0 |
| Higher Call Nursing Center | 4.9 mi | ★★★★★ | 7 | 0 |
| Quaker Hill Manor | 12.5 mi | ★★★★★ | 20 | 0 |
| Maple Healthcare And Rehab | 12.5 mi | ★★★★★ | 0 | 0 |
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