Eskridge Care and Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria.

Inspectors wroteBased on observation and interviews, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident (R)5 with a dignified existence by not calling her by the name she wished to be called.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate activity of daily living (ADL) assistance for Resident (R) 40, regarding appropriate positioning while in her wheelchair, and R 50 for failure to assist with urinary incontinence.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure staff implemented interventions per the plan of care for Resident (R) 50 to prevent further falls and possible injuries.

Inspectors wroteBased on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents. Based on observation and interview, the facility failed to store, prepare, and serve food at the required serving temperature. This deficient practice placed the residents at risk of unpalatable food and food-borne illness.

Inspectors wroteThe facility had a census of 58 residents. Based on record review and interview, the facility failed to retain evidence of the required Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) members attended meetings at least quarterly, which placed residents at risk of unidentified quality care services. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 58 residents. Based on record review and interview, the facility failed to ensure the staff member designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the required annual performance review was completed for two of the five staff reviewed. This deficient practice placed the residents at risk of receiving impaired care.

Inspectors wroteThe facility had a census of 58 residents. Based on record review and interview the facility failed to provide two of three sampled residents, Resident (R)9 and R111 (or their representative) the CMS (Center for Medicaid/Medicare Services) approved Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055. The facility failed to provide R9 and R111 the contact phone numbers on the Notice of Medicare Non-Coverage (NOMNC) Form-10123 which informed the beneficiary of the right to an expedited review by a Quality Improvement Organization (QIO). This placed the residents at risk of uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents, with two reviewed for discharge from the facility to an acute care hospital. Based on observation, interview, and record review the facility failed to notify the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of the discharges for Resident(R) 26 and R111. This placed the two residents at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 58 residents, and the sample included 16 residents. Based on observation, record review, and interview, the facility failed to assess and maintain urine continence for Resident (R) 51. This deficient practice placed R51 at risk of embarrassment and complications from incontinence.

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to address Resident (R) 51's food preferences and dislikes with continued weight loss resulting in a significant weight loss of 11.3 percent (%) in six months.

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents, with two reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess the actual rail being used to assure safety for Resident (R) 7 and R1. This placed the residents at risk for accident or injury due to unidentified risks associated with side rail use.

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents. Based on observation and interview, the facility failed to ensure the correct use of a subcutaneous (beneath the skin) injection of insulin (a hormone that lowers the level of glucose in the blood) during the observation of administration. This placed the resident at risk of receiving less than the ordered dose.

Inspectors wroteThe facility had a census of 58 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 7, R12, and R23s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with the date opened and the discard date on the two nurse medication carts. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility identified a census of 57 residents, with three residents reviewed for food allergies. Based on record review, observation, and interview, the facility failed to accommodate R1's known food allergy to mushrooms which caused anaphylactic (severe life-threatening allergic reaction) allergic reaction. The facility failed to follow R1's dietary care plan, when staff served R1 facility food (oriental vegetables) for lunch, that contained mushrooms. R1 advised Certified Nurse Aide (CNA) M her mouth and throat were itching, and she was severely allergic to mushrooms. R1 required administration of diphenhydramine (antihistamine), administration of an epinephrine (adrenaline use to treat anaphylaxis) pen, and transfer by Emergency Medical Services (EMS) to the Emergency Department (ED) for evaluation and treatment. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility identified a census of 56 residents. Based on observations and interviews, the facility failed to store & prepare food to prevent the spread of food borne illness to the residents of the facility.

Inspectors wroteThe facility reported a census of 58 residents with 17 residents sampled. Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for the residents of the facility.

Inspectors wroteThe facility reported a census of 58 residents. Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment for the residents and staff related to items/areas in the facility laundry.

Inspectors wroteThe facility reported a census of 58 residents with 17 residents sampled which included two residents reviewed for dignity. Based on observation, interview, and record review the facility failed to ensure the two sampled residents were treated with dignity in a manner to promote, maintain, or enhance their quality of life for Resident (R)7 related to providing a dignity bag to cover his urine collection bag and R 2 related to personal hygiene, (chin hairs).

Inspectors wroteThe facility reported a census of 58 residents with 17 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (R)12, regarding a wound to the right great toe.

Inspectors wrote- Review of Resident (R )13's Physician Orders, dated 03/16/23, documentation included diagnoses of abnormal posture, difficulty walking, gait abnormalities, impulse disorder, unsteadiness on her feet, and lack of coordination. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status Score (BIMS) of 15, indicating cognition was intact. She required supervision of staff for bed mobility, transfer and locomotion. The staff provided extensive assistance with her walking and dressing. The had functional limitation in range of motion of her lower extremity of one side of her body. Her balance during transition was not steady. She could stabilize without staff assistance. The clinical formal skin assessment revealed no skin conditions. The Quarterly MDS, dated [DATE], revealed no changes from the above MDS. [...]

Inspectors wroteThe facility reported a census of 58 residents with 17 residents sampled which included two residents reviewed for urinary catheters. Based on observation, interview, and record review, the facility failed to ensure the two sampled Residents (R)7 and R 8, with indwelling catheters, received appropriate treatment and services to prevent urinary tract infections to the extent possible, related to the positioning of the residents' catheters below the bladder during care to promote drainage of the urine from the bladder to prevent the potential for infection.