Eastgate Health Care Center

Review of the progress note for Resident #120 dated 04/02/25 at 1:30 A.M. per Licensed Practical Nurse (LPN) #10 revealed staff heard the resident yelling and requesting staff get him/her off of me. LPN #10 observed Resident #120 lying in bed, and their roommate was standing over the resident hitting Resident #120 on the arm with a plastic cup. Resident #120 stated they had also been hit on the left arm and left leg.

Review of the progress note for Resident #117 dated 04/02/25 at 1:31 A.M. per LPN #10 revealed Resident #117 was standing over their roommate hitting the roommate on the arm with a plastic medicine cup. LPN #10 asked Resident #117 why they were hitting their roommate and the resident stated they did not know.

Review of the Interdisciplinary Team (IDT) note for Resident #117 dated 04/13/25 revealed a resident-to-resident incident occurred.

Staff observed Resident #117 standing over their roommate and hitting them with a plastic cup.

The note indicated the new behavioral intervention for the resident was a room change.

Interview on 08/20/25 at 8:37 P.M. with LPN #10 confirmed on 04/02/25 she heard yelling out from a resident room and found Resident #117 standing at Resident #120's bedside hitting them with a plastic cup.

LPN #10 stated she informed the charge nurse and the Director of Nursing (DON) of the resident-to resident incident.

Interview on 08/22/25 at 11:00 A.M. with the DON confirmed the IDT met two times per week to review incidents.

She stated that she deferred to the Administrator to decide which incidents should be reported to the SSA.

Interview on 08/22/25 at 12:23 P.M. with LPN #9 confirmed she was a night shift team leader, and staff were to report all falls and incidents to her. LPN #9 confirmed she immediately notified the on-call person, the DON or Administrator of resident-to-resident altercations, which required two-hour reporting.

She further stated the staff were to write witness statements about the incidents. LPN #9 stated that she did not recall an incident involving Resident #117 in an altercation with another resident Interview on 08/22/25 at 1:58 P.M. with RN #8 confirmed incidents were discussed during IDT meetings, and the Administrator made the decision on which incidents were to be reported to the SSA.

She stated that resident-to-resident altercations were to be reported to the SSA within two hours of being notified of them.

Interview on 08/22/25 at 3:06 P.M. with the Administrator confirmed the facility did not report the resident-to-resident incident between Resident #120 and #117 to the SSA nor did the facility conduct a thorough investigation to include measures to protect residents during the course of the investigation.

Review of the facility policy titled Abuse/Neglect/Misappropriation of Property revised September 2022 revealed the facility would investigate all allegations of abuse and would ensure residents were protected from further potential abuse during the course of the investigation.

This deficiency represents noncompliance investigated under Complaint Number 1301484 (Complaint OH00165616.)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Eastgate Health Care Center

4400 Glen Este Withamsville Road Cincinnati, OH 45245

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited EASTGATE HEALTH CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-08-28.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of EASTGATE HEALTH CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Based on record review, interview, and facility policy review, the facility failed to prevent a significant medication error that placed 1 (Resident #132) of 1 resident reviewed for insulin administration at risk for hypoglycemia.

Specifically, Resident #132 received short-acting insulin (Humalog) instead of long-acting insulin (Lantus) and required transfer to a hospital emergency department for observation.The findings included:

Review of the medical record for Resident #132 revealed an admission date of 07/11/25 with diagnoses including myocardial infarction, chronic kidney disease, and type 2 diabetes mellitus.

Review of the Minimum Data Set (MDS) assessment for Resident #132 dated 07/17/25 revealed the resident had intact cognition.

Review of the care plan for Resident #132 revealed the resident had diabetes mellitus with diabetic polyneuropathy.

Interventions directed staff to administer diabetes medication as ordered by clinicians.

Review of the physician's orders for Resident #132 revealed an order dated 07/11/25 for Lantus insulin subcutaneously 95 units at bedtime.

Review of the physician's orders for Resident #132 revealed an order dated 07/24/25 for Humalog insulin 15 units with meals, hold if the blood sugar is below 150.

Review of the progress note for Resident #132 dated 07/24/25 at 10:08 P.M. revealed Resident #132 was given 60 units of Humalog instead of 95 units of Lantus by mistake.

Staff called the resident's physician and the resident showed no signs or symptoms of hypoglycemia.

Review of the progress note for Resident #132 dated 07/24/25 at 11:00 P.M. revealed the physician gave an order to send the resident to the hospital for an evaluation.

Review of the hospital after visit summary for Resident #132 dated 07/24/25 revealed the resident was seen for an accidental medication error.

The hospital performed point of care glucose testing 10 times for Resident #132.

Interview on 08/18/2025 at 2:27 P.M. with Resident Representative (RR) #6 confirmed she received a call from a facility nurse reporting Resident #132 had been given the wrong insulin and was being sent to the hospital for observation.

Interview on 08/19/25 at 5:45 P.M. with Licensed Practical Nurse (LPN) #2 confirmed on 07/24/25 she mistakenly administered 60 units of Humalog insulin to Resident #132 instead of Lantus insulin.

Interview on 08/20/25 at 9:43 A.M. with LPN #1 stated LPN #2 reported the medication error involving Resident #132 immediately and stayed with the resident until emergency medical services (EMS) transported the resident to the hospital.

Interview on 08/20/25 at 10:27 A.M. with the Director of Nursing (DON) confirmed LPN #2 reported a medication error with Resident #132 on 07/24/25 in which the resident received Humalog insulin instead of Lantus insulin Interview on 08/21/25 at 3:59 P.M. with the Medical Director confirmed the facility notified him on 07/24/25 that Resident #132 received the wrong insulin. MD confirmed he gave an order for Resident #132 to be transferred to the emergency department for monitoring in a controlled environment.

Review of the facility policy titled Medication Error dated May 2025 revealed medication errors would be prevented and reported.

This deficiency represents noncompliance investigated under Complaint Number 2579530.

Facility ID:

Federal health inspectors cited EASTGATE HEALTH CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-28.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of EASTGATE HEALTH CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited EASTGATE HEALTH CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-28.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of EASTGATE HEALTH CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.

Federal health inspectors cited EASTGATE HEALTH CARE CENTER in CINCINNATI, OH for a deficiency under regulatory tag F-F0921 during a complaint investigation conducted on 2025-08-28.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of EASTGATE HEALTH CARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-22.