Egle Nursing Home

In the surveyor’s words

From the most serious findings on record at Egle Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 9, 2024

  Based on surveyor observation and staff interview, it was determined that the facility staff 1) failed to properly store food items in the kitchen's walk-in refrigerator, and 2) failed to have a process in place to determine the expiration date of food procured from vendors. This was evident during the initial tour of the kitchen and had the potential to affect all residents. The findings include: On [DATE] at 10:35 AM, accompanied by Staff #7, Certified Dietary Manager (CDM), an initial tour of the kitchen by two surveyors identified the following concerns: 1) An observation of the kitchen's walk-in refrigerator revealed there was an uncovered, large rectangle, shallow pan that appeared to be filled with cooked food product. […]

• No harm, potential for more than minimal, patternF628Oct 9, 2025

  Based on record reviews and interviews, it was determined that the facility failed to provide residents or resident representatives with written notice of transfer. This was evident for 1 (Resident #66) of 2 residents reviewed for hospital transfers.The findings include:On 10/06/25 at 4:10 PM, the Surveyor conducted a closed record review for Resident #66 related to a hospital transfer. A progress note dated 9/24/25 documented that staff heard a loud thump and found the resident (#66) on the bathroom floor. It was determined that the resident had fallen and was transferred to the hospital following an assessment. […]

• No harm, potential for more than minimal, patternF657May 9, 2024

  Based on observation, medical record review and staff interview, it was determined the facility failed to review and revise resident care plans after each assessment. This was evident for 1 (#39) of 7 residents reviewed for accidents, and 1 (#45) of 5 residents reviewed for unnecessary medications. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. […]

• No harm, potential for more than minimal, patternF693May 9, 2024

  Based on record review, observation, and interviews, it was determined that the facility staff failed to ensure that the head of bed (HOB) was properly elevated for a resident during medication administration and infusion of a percutaneous endoscopic gastrostomy (peg) feeding. This was evident for 1 (#43) of 3 residents reviewed for tube feeding. The findings include: A percutaneous endoscopic gastrostomy (PEG) feeding tube is placed into the stomach through an opening in the stomach wall. If one cannot eat or drink all the nutrients they need, liquids such as formula, fluids, and medicines are put through the PEG tube. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. […]

• No harm, potential for more than minimal, isolatedF604Oct 9, 2025

  Based on observations, record reviews, and interviews, it was determined that the facility failed to identify Lap Buddy as a physical restraint, assess the resident for its use, and provide ongoing monitoring and evaluation for its continued use. This was evident for 1 (Resident #26) or 1 resident reviewed for physical restraints. The findings include:A lap buddy is a cushion placed in a resident's wheelchair between the armrest and in front of the resident. A lap buddy is considered a physical restraint when it is attached to a wheelchair, preventing a resident from moving freely in the chair or getting up, and it cannot be easily removed. An observation on 10/1/2025 at 11:13 AM, noted Resident #26 sitting in a wheelchair by his/her bedside, with a lap buddy in front of him/her. […]