Eastland Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Eastland Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 5, 2023

  Based on medical record review, interviews with facility staff, review of laboratory test results, review of hospital records, and review of facility policies, the facility failed to provide timely, adequate, and necessary care and treatment to Resident #74 following laboratory notification of a critically low potassium level. This resulted in Immediate Jeopardy and Actual Harm on 09/08/23 when a Basic Metabolic Panel (BMP) laboratory blood test showed a critically low potassium level of 2.7 milliequivalents (meq)/hour (hr) (normal 3.5 to 5.3 meq/hr), and the facility failed to notify the physician or provide treatment until 09/15/23. On 09/15/23 Resident #74 was assessed to be dehydrated and had increased confusion which had worsened over the previous week. […]

• Immediate jeopardy, isolatedF686Apr 25, 2023

  Based on closed medical record review, hospital record review, review of Centers for Disease Control (CDC), National Health Institutes of Health, and National Pressure Injury Advisory Panel (NPIAP) information, review of the facility policy and procedure titled Prevention of Pressure Ulcers/Injuries, review of the facility policy and procedure titled Perineal Care, facility and staff interviews, the facility failed to implement a comprehensive and effective pressure ulcer treatment program to prevent the development of an avoidable pressure ulcer for one newly admitted resident, Resident #14, who was admitted with intact skin, assessed to be at risk for pressure ulcer development, incontinent of bowel and bladder and dependent on staff for bed mobility and personal care. […]

• Immediate jeopardy, isolatedF689Sep 15, 2022

  Based on record review, review of the facility's investigation, review of an employee personnel file, observation, resident interview, family interview, staff interview, and policy review, the facility failed to provide the appropriate level of supervision necessary to prevent a cognitively impaired resident (who resided on the secured behavior unit and was known to the facility as having a previous elopement from the facility) from eloping from the facility on 09/02/22. This resulted in Immediate Jeopardy when Resident #5 was left unsupervised in the facility's secured unit's adjoining courtyard and was able to exit the courtyard through a gate that had been known by the facility to be in disrepair and unable to be properly secured. […]

• Actual harm, isolatedF686May 28, 2025

  Based on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to prevent the development and/or worsening of pressure ulcers and to ensure adequate and appropriate interventions/treatments were in place as ordered and to promote healing. This affected two residents (#40 and #49) of two residents reviewed for pressure ulcers. The facility census was 76. Actual harm occurred beginning on 04/10/25 when Resident #49, who was cognitively impaired, rarely/never understood and dependent on staff for activities of daily living was assessed by Wound Certified Nurse Practitioner (CNP) #1200 to have a Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or… […]

• Actual harm, isolatedF686Sep 5, 2023

  Based on observation, record review, review of the facility Perineal Care policy and procedure and family and staff interview, the facility failed to implement adequate skin risk interventions, including timely incontinence care and treatment for Resident #34, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's coccyx. Actual harm occurred on 08/13/23 at 7:04 A.M. when a reddened area was noted to Resident #34's coccyx area without evidence of effective preventative measures being in place or additional interventions implemented at that time. On 08/14/23 at 10:13 P.M. […]