Town East Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Town East Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 6, 2025

  Based on observation, interview and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care on the bed by herself on 11/13/2025 which led to Resident #1 falling off the bed and sustaining a left forehead injury.An IJ was identified on 12/05/25 at 09:50 a.m. The IJ template was provided to the facility on [DATE] at 12:33 p.m. […]

• Immediate jeopardy, isolatedF689Sep 5, 2025

  Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of thirteen (Resident #97) residents reviewed for accidents and supervision. The facility failed to prevent Resident #97's elopement from the facility on 6/12/25 without staff being aware that she had eloped. An Immediate Jeopardy (IJ) situation was identified on 8/13/25. While the IJ was removed on 09/05/25, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need of corrective systems. This failure could place residents at risk for serious injuries, serious harm and death. […]

• Actual harm, isolatedF689Dec 6, 2025

  Based on observation, interview and record review, the facility failed to ensure the residents received adequate supervision and assistance to prevent accidents and hazards for 1 of 6 ( Resident #1) reviewed for accidents and hazards. CNA A failed to have another staff member help her with care, and as a result, the resident rolled out of bed and sustained a laceration on the forehead. This failure could place resident at risks for accidents and injuries. A review of the MDS quarterly assessment dated [DATE] reflected Resident#1 was a [AGE] year-old male admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including cerebrovascular accident (a medical emergency where blood flow to the brain is suddenly interrupted, causing brain cells to die from lack of oxygen,… […]

• No harm, potential for more than minimal, widespreadF761Dec 2, 2025

  Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for 6 medication carts (MC#1, MC#2, MC#3, MC#4, MC#5, and MC#6) of 6 medication carts observed for medication storage. -The facility failed to lock medication carts #1, # 2, 3, #4, #5, and #6 at the nurses' station on 10/15/25 at 6:10 AM. These failures could place residents at risk of a drug diversion, or ingesting medications not prescribed for them.Findings included: During an observation on 10/15/25 at 6:10 am, medication carts #1, # 2, 3, #4, #5, and #6 were unlocked at the nursing station with drawers facing outward toward the hallways. No staff was present at the nursing station. […]

• No harm, potential for more than minimal, patternF677May 14, 2026

  Based on observation, interview and record review the facility failed to provide the necessary services to residents who were unable to carry out activities of daily to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 6 residents (Resident #1 and Resident #2) reviewed for ADL activities. The facility failed to change Resident #1's brief within a timely manner on either Monday or Tuesday of the week 05/03/26. The facility failed to provide Resident #2 assistance with brief change within a timely manner. These failures could place residents who required assistance with ADL's at risk for unmet care needs.Findings included: Record review of Resident #1's face sheet, dated 05/14/26, reflected a [AGE] year-old female that was admitted to the facility on [DATE]. […]