Eastgate Village Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Eastgate Village Care & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 2, 2025

  On 07/01/25, a past non-compliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure the safety of residents at risk for elopement. On 06/19/25, Resident #1 eloped from the property through the front entrance at approximately 6:30 p.m. by following out a food delivery person. Resident #1 had a history of threatening to elope and wandering. The police found and returned Resident #1 to the facility at approximately 7:30 p.m. and reported Resident #1 was located in a field near the facility. Based on record review and interview, the facility failed to provide supervision to ensure the safety of a resident for 1 (#1) of 2 sampled residents reviewed with exit seeking behaviors. The DON identified one resident wandered. […]

• Immediate jeopardy, isolatedF689Jun 24, 2021

  On 06/23/21, an Immediate Jeopardy (IJ) situation was determined to exist when the facility failed to ensure residents received adequate supervision while smoking to prevent accidents. Resident #5 was admitted to the facility on [DATE] and was assessed to require supervision while smoking on 12/17/20. On 06/14/21, resident #5 went outside to smoke with his hospice aide. The resident and hospice aide failed to completely turn off his oxygen and remove the nasal cannula from his face. […]

• Actual harm, isolatedF689May 25, 2021

  Based on observation, interview, and record review, it was determined the facility failed to: ~ implement interventions to aid in the prevention of injury with falls for one (#66) of three sampled residents who were reviewed for falls. The resident suffered three falls from rolling out of the bed within ten hours. The resident sustained a [CONDITION(S)], a fractured clavicle, and fractures to the left superior and inferior pubic rami. The facility identified ten residents who had falls with injury; and ~ provide an environment free of accident hazards for one (#11) of one sampled resident who was reviewed for wandering. The facility identified five residents as wanderers. Findings: The facility's standard statement related to accidents and incidents, dated 12/2018, docoumented, . […]

• No harm, potential for more than minimal, widespreadF812Nov 6, 2023

  Based on record review, observation, and interview, the facility failed to prepare and serve food for the residents in a sanitary manner. The administrator identified 82 residents who resided in the facility. Findings: A policy titled, PERSONAL ALLOWED IN THE DIETARY DEPARTMENT, read in part, .All unauthorized persons are to be discouraged from entering the Dietary Department .Everyone that enters the Dietary Department must wash their hands and wear a hair net. On 10/31/23 at 11:37 a.m., CNA #1 was observed assisting in the dining room with meal service. […]

• No harm, potential for more than minimal, patternF641Feb 6, 2025

  Based on observation, record review, and interview, the facility failed to ensure resident assessments were accurate for 3 (#1, 52, and #60) of 18 sampled residents whose assessments were reviewed. The administrator identified 75 residents who resided in the facility. Findings: An MDS 3.0 policy, dated 04/2023, read in part, 2 The MDS Coordinator and/or IDT [interdisciplinary team] will use the following when completing the assessment as directed by the RAI User's Manual: Direct Observation, Communication with Residents, Family and Staff, Documentation in the Medical Record 3. MDS assessments will be completed per the 3.0 RAI User's Manual guidelines. 1. […]