Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Eastwood Manor during CMS and state inspections, most recent first.
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.
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 | ★★★★★ | 14 | 2 |
| Higher Call Nursing Center | 4.9 mi | ★★★★★ | 3 | 0 |
| Quaker Hill Manor | 12.5 mi | ★★★★★ | 20 | 0 |
| Maple Healthcare And Rehab | 12.5 mi | ★★★★★ | 0 | 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.