The violations at Eliot Center for Health and Rehabilitation were among eight deficiencies found during a federal inspection completed January 21. Inspectors discovered the facility had incorrectly completed mandatory mental health screenings, skipped required care planning meetings with families, and left a dialysis patient without emergency medical equipment at his bedside.
The most serious problems involved the facility's handling of PASARR screenings — federally required evaluations to determine if nursing home residents need specialized mental health or developmental disability services.
Resident #57 arrived at the facility in February 2024 with multiple psychiatric diagnoses including major depressive disorder, unspecified psychosis, and PTSD. Hospital records showed the patient had been admitted with "confusion and agitation and mental status changes" and was prescribed anti-psychotic medication.
Yet the facility's PASRR screening indicated the resident had no serious mental illness.
The MDS nurse told inspectors she had added psychiatric diagnoses to the resident's clinical record after finding them in hospital notes. All of the mood and psychiatric diagnoses listed on the resident's assessment "were from the resident's records before or on admission to the facility," she said.
The Director of Nursing reviewed the admission screening and acknowledged "the PASRR should have been reviewed upon admission and then resubmitted to include the resident's SMI diagnoses and determination for a Level II evaluation, but it had not been."
A second resident faced similar screening failures. Resident #58 was admitted in April 2024 with PTSD and major depressive disorder. While hospitalized, the patient had been referred to the psychiatric team for agitation and mood changes, and was prescribed anti-psychotic and anti-depressant medications.
But the facility's screening form answered "No" to whether the resident had received psychiatric treatment in the past two years, despite the clear hospital documentation of psychiatric services.
Social Worker #1 told inspectors that based on the hospital discharge summary, the screening "should have been completed to indicate Resident #58 had a positive SMI screen" and referred for further evaluation to determine if specialized mental health services were needed.
The Admissions Liaison disagreed, saying she didn't feel the resident should have been referred for psychiatric evaluation despite the documented treatment for depression and other mental health conditions that prompted new psychiatric medications.
The screening failures meant both residents may have been denied access to specialized mental health services they were entitled to receive.
Care planning problems extended beyond mental health screenings. The facility failed to hold required quarterly care plan meetings with residents or their families for four different patients throughout 2024.
Resident #40, who had moderate cognitive impairment, never had care plan meetings following assessments completed in May and September 2024. The MDS nurse told inspectors "the care plan meetings should have been held" but couldn't provide evidence any had occurred.
Resident #57 confirmed the pattern during an interview, telling inspectors "he/she never goes to care plan meetings." The Director of Nursing acknowledged the facility "could provide no evidence a care plan meeting involving the resident and/or their representative was held" after the August 2024 assessment.
Most troubling was Resident #22, who had brain cancer and multiple sclerosis. The patient's activated health care proxy — the person legally authorized to make medical decisions — told inspectors "he/she had not been invited to attend or involved in care plans meetings at the facility."
The MDS nurses admitted they were "unable to provide evidence that Resident #22 or their Resident Representative had been invited to or participated in the care plan meetings" scheduled for April and July 2024.
Basic hygiene care also fell short. Inspectors found two residents with long, dirty fingernails and unkempt facial hair despite being completely dependent on staff for grooming.
Resident #15 was observed on consecutive days with "long facial hair on the chin, and fingernails that were long with debris under the fingernails" even after receiving morning care. The Director of Nursing acknowledged "the resident's fingernails should have been trimmed but had not been, and the resident's facial hair should have been removed but had not been."
A certified nursing assistant who had provided care to Resident #15 admitted he "did not notice the resident's fingernails or facial hair" and confirmed "the resident's nails should have been trimmed/cleaned and the facial hair removed during morning care but they had not been."
Resident #57 was observed with "fingernails to be long and jagged" and told inspectors "he/she needed the fingernails to be trimmed." Another nursing assistant said she was "rushing and didn't recall seeing that the resident's fingernails were long and jagged" during morning care.
Medical safety problems emerged with dialysis care. Resident #252, who required hemodialysis three times weekly, was supposed to have emergency clamps and pressure dressings at his bedside in case of catheter complications. Inspectors found no emergency equipment in the room on two consecutive days.
The Director of Nursing admitted "the clamp should have been at the resident's bedside, and they were not." She explained that facility staff had used the clamp for another resident's wound care and never returned it.
A nurse caring for the dialysis patient told inspectors she would use a tourniquet on the resident's arm in an emergency, apparently unaware that the patient's venous catheter was located in his chest, not his arm.
Food safety violations put residents at risk of foodborne illness. Inspectors found moldy cucumbers and ground beef past its use-by date in refrigerators, along with prepared sandwiches that were neither labeled nor dated.
In the dining room, staff contaminated ice by placing dirty cups and utensils on the same table as clean drinks being served to residents. An activities assistant was observed using a clean cup to scoop contaminated ice and serve it to a resident before the Director of Nursing intervened.
The facility also failed to follow COVID-19 isolation protocols for a resident who tested positive. Staff entered the patient's room without required eye protection and failed to perform hand hygiene after removing contaminated gloves.
Administrative failures included not posting required daily nursing staffing information for three consecutive days during the inspection, and failing to act on a pharmacist's recommendation to prevent oral thrush in a resident using inhaled steroids.
When a resident's guardian requested dental services in July 2024, the facility never followed through. Inspectors observed the patient had only three remaining teeth, two of which were dark and broken. The Director of Nursing found no evidence the resident had been offered dental services despite multiple visits by the facility's dental contractor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eliot Center For Health and Rehabilitation from 2025-01-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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