Eastridge Nursing & Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety as evidence by:1. Storing expired foods;2. Not cleaning small appliances after each use; and3. Not covering food before being transportedThis had the potential to affect 83 residents who ate food prepared in the kitchen.

Inspectors wroteBased on records reviews and interviews, the facility failed to ensure the residents' Minimum Data Set (MDS) assessments were accurately coded to reflect the residents' status for 3 (#4, #23, #38) of 35 sampled residents, as evidenced by:1. Failing to code Resident #4 for Level II PASRR (Pre-admission Screening and Resident Review);2. failing to code Resident #38 for receiving dialysis treatment; and3. failing to code Resident #23 for bed mobility and transfers

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow the menu for 3 (#23, #36, and #71) out of 3 (#23, #36, #71) residents who required puree diets.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing appropriate Personal Protective Equipment (PPE) while providing high-contact care to 1 (Resident # 12) of 1 resident observed for facility staff adherence to EBPs. There was a finalized sample of 35 residents. FindingsReview of the facility's policy and procedure titled, Enhanced Barrier Precautions Policy and Procedure with a last reviewed date of 12/03/2025, revealed in part:Purpose to prevent the spread of potential infection by implementing Enhanced Barrier Precautions (EBP) when contact precautions do not apply. This approach recommends the use of EBP during high contact care activities for residents with indwelling medical devices. Procedure 1. EBP are indicated for residents with any of the following:1b. [...]

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to ensure allegations of neglect was reported to the State Survey Agency within 2 hours upon learning of the allegation for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents.

Inspectors wroteBased on observations, interviews, and policy and procedure reviews, the facility failed to: 1. Maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses; 2. Store food in accordance with professional standards for food service safety; and 3. Wear an appropriate hair restraint; This had the potential to effect the 83 residents who ate meals prepared from the facility's kitchen. The facility's census was 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe in order to meet the nutritional needs of the residents as evidenced by kitchen staff failing to: 1) Use the appropriate recipe to prepare a pureed food item 2) Ensure the appropriate sized scoops were used to serve pureed and mechanically soft food. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 8 residents who consumed pureed meals and mechanical soft meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident identified with a qualified mental disorder was referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1(#8) of 1 resident sampled for PASARR, out of a total sample of 23 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standard of practice for 2 (Resident #12 and #19) out of 3 (Resident #12, #19, and #37) residents investigated for respiratory care. The facility failed to: 1. Store Resident #12's oxygen equipment in a sanitary manner, and 2. Provide continuous oxygen therapy for Resident #19.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurately documented medical record in accordance with accepted professional standards and practices. The facility failed to document a fall in the resident centered plan of care for 1 (#1) out 3 (#1, #2, and #3) residents investigated for falls.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with a hospice agency to ensure a resident had a current hospice plan of care for 1 (#3 ) out of 3 (#1, #2, #3) residents investigated for hospice services.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately affected the resident's status for 2 (#1, #2) residents out of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility-wide assessment: 1. accurately identified the number of direct care nursing personnel needed to provide services; 2. included any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility; and 3. included an evaluation of its resources regarding its vehicles. This deficient practice affected 1 resident (#40) with a potential to affect a census of 81 residents currently residing in the facility.

Inspectors wroteBased on observation, record review and interviews, the facility failed to maintain dignity for 4 (Resident # 16, 19, 65, and 69) out of 33 sampled residents by failing to provide residents with homelike silverware/metal utensils for all meals.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective infection control and prevention program by failing to ensure staff performed hand hygiene when indicated according to accepted standards of practice and the facility's policy during medication administration. The deficient practice had the potential to affect a census of 81 residents.

Inspectors wroteBased on interview and record review the facility failed to assess 1 (#74) out of 1 sampled residents for self-administration of medication in a final sample of 81 residents. Findings Review of the facility's policy titled, Medications-Self Administration Policy and Procedures revealed in part, Policy: In order to maintain the resident's high level of independence, the residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility . Procedure: 1. If a resident desires to self-administer medications, an assessment is conducted by the Interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process-a. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and demonstrate the facility's response for such grievances in a facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the environment of a resident was free from accidents hazards by failing to lock a resident's bed. This deficient practice had the potential to affect 1 (#25) of 2 (#25 and #55) residents investigated for falls.

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) trainee was competent prior to performing resident care for 1 (#69) resident out of a finalized sample of 33 residents who were investigated for sufficient and competent staffing.