Eastbrook Healthcare Center

In the surveyor’s words

From the most serious findings on record at Eastbrook Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 23, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of Emergency Department notes, review of facility investigative information, review of facility elopement and missing resident policy and procedures and interviews, the facility failed to provide adequate supervision to prevent Resident #92, who had cognitive impairment, wandering behaviors and diagnoses of schizophrenia and dementia, from eloping from the facility. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm on 08/18/23 at approximately 8:30 P.M. […]

• Immediate jeopardy, isolatedF678Sep 22, 2021

  Based on observation, medical record review, interviews with facility staff, review of facility policy, and review of American Heart Association guidelines, the facility failed to ensure a 911 call was immediately placed for Emergency Medical Services (EMS) when Resident #92 was found in his bed unresponsive and without vital signs. Cardiopulmonary Resuscitation (CPR) was initiated, but a 911 call for Emergency Medical Services (EMS) was not placed until 5:39 A.M., 39 minutes after Resident #92 was found unresponsive. The EMS crew arrived at 5:47 A.M. and at 5:54 A.M. Resident #92 was pronounced dead on arrival. This affected one resident (Resident #92) of three residents reviewed for CPR. On [DATE] at 4:51 P.M. […]

• Actual harm, isolatedF686Sep 15, 2022

  Based on observation, interview, record and policy review, the facility failed to monitor and consistently implement treatment to Resident #26's avoidable pressure ulcer. This resulted in actual harm when an in-house acquired pressure ulcer to the coccyx declined to a Stage 4 pressure ulcer with recommendation for surgical debridement and [CONDITION(S)]. In addition, the facility failed to consistently provide treatment to Resident #92's pressure ulcers. This affected two, Resident #26 and Resident #92 of three residents with pressure ulcers reviewed. The facility census was 91. Findings include: 1. […]

• Actual harm, isolatedF686Sep 22, 2021

  Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure appropriate care and services were provided for one resident (Resident #37) to prevent a deep tissue injury to the left plantar foot. Actual harm occurred when care planned interventions were not implemented, physician orders were not followed, and a pressure injury to Resident #37's foot was not treated or documented before it was identified as an unstageable deep tissue injury. This affected one resident (Resident #37) out of three residents reviewed for pressure injury. […]

• No harm, potential for more than minimal, widespreadF835Jan 23, 2025

  Based on observation, review of the facility's contract with therapy services, resident interview, and staff interview, the facility failed to administer the facility in a manner to maintain therapy equipment in proper working order. This affected one resident (#51) and had the potential to affect all 91 residents in the facility. Findings include: Review of the medical record for Resident #51 revealed an admitted [DATE] with diagnoses including encounter for other orthopedic aftercare, person injured in unspecified motor-vehicle, colostomy status and anxiety disorder. […]