Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eskridge Care And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain proper food serving temperatures, placing residents at risk of unpalatable food and food-borne illness. A dietary staff member was unaware of the correct serving temperatures, leading to pureed turkey and corn being served at inadequate temperatures. The facility's food safety policy lacked specific holding/serving temperature guidelines.
The facility did not retain evidence of required QAA and QAPI members attending meetings at least quarterly, as they could not provide attendance sheets for the past year. This failure to document attendance, as required by the facility's policy, placed residents at risk of unidentified quality care services.
The facility failed to ensure the acting Infection Preventionist, Administrative Nurse D, was certified, as she temporarily assumed the role without the necessary qualifications. This deficiency placed residents at risk due to the lack of proper identification and treatment of infections, as the designated Infection Preventionist had not yet started.
The facility did not complete the required annual performance reviews for two CNAs who had been employed for over a year. This was confirmed by Administrative Nurse D, who noted that two of the five randomly selected staff members lacked these evaluations. The facility's policy requires nursing staff to demonstrate competency in skills necessary for resident care, and the absence of these evaluations placed residents at risk of impaired care.
The facility failed to provide two residents with the necessary CMS-approved forms related to their Medicare coverage. The residents did not receive the Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and the Notice of Medicare Non-Coverage (NOMNC) form 10123 lacked the Quality Improvement Organization (QIO) contact information. This placed the residents at risk of making uninformed decisions about their skilled services.
The facility failed to notify the LTCO of the discharges of two residents to an acute care hospital, contrary to its policy. One resident, with intact cognition and multiple mental health diagnoses, was hospitalized for two days, while another, with memory and decision-making impairments, was hospitalized for three weeks. The facility only sent a Continuation of Stay form to KDADS monthly and did not inform the LTCO, placing both residents at risk for uninformed decision-making.
A facility failed to assess and maintain urinary continence for a resident with a history of mental and movement disorders. The resident, initially documented as continent, later experienced occasional incontinence without a toileting program trial. Despite care plan instructions, the facility did not implement measures to address the incontinence, leading to multiple incidents over a 30-day period. Staff noted nocturnal incontinence and the resident's need for linen changes, but the facility did not assess causation factors, risking embarrassment and complications.
A resident with a history of mental health disorders experienced significant weight loss due to the facility's failure to address his food preferences. Despite being identified as a picky eater, the resident's care plan lacked specific food preferences, and he frequently refused meals. Staff interviews revealed a lack of communication and documentation regarding the resident's dietary needs, contributing to ongoing weight loss.
The facility failed to ensure the safety of bed rails for two residents, placing them at risk for accidents or injuries. Both residents required significant assistance with bed mobility and transfers, yet the facility did not adequately assess the stability and safety of the bed rails. Observations revealed unstable rails with large openings, and the facility did not conduct further assessments as required by their policy.
A facility failed to ensure the correct administration of a subcutaneous insulin injection, risking a resident receiving less than the ordered dose. An LN administered insulin using a Novolog pen but did not prime the needle with waste insulin as required by the facility's policy. The LN admitted to being nervous and forgetting this step.
The facility failed to label insulin flex pens for three residents with the date opened and discard date, as observed on two nurse medication carts. This oversight was confirmed by both a licensed nurse and an administrative nurse, violating the facility's medication storage policy and placing residents at risk for ineffective medication.
A resident with a known allergy to mushrooms was served a meal containing mushrooms, leading to a severe allergic reaction. Despite the resident's immediate notification to staff, the resident experienced anaphylaxis and required emergency medical intervention. The dietary staff failed to check the ingredient label, and the facility's policy on food allergies was not followed.
Failure to Maintain Proper Food Serving Temperatures
Penalty
Summary
The facility failed to store, prepare, and serve food at the required serving temperature, which placed residents at risk of unpalatable food and food-borne illness. During an observation, Dietary Staff (DS) CC was preparing to serve the noon meal, and DS BB checked the serving temperature, finding the pureed turkey at 110 degrees Fahrenheit and the pureed corn at 115 degrees Fahrenheit. DS CC was unaware of the correct holding/serving temperature for hot food. The surveyor informed the kitchen supervisor, Social Service Staff X, who instructed DS CC to reheat the food to the proper temperature of 160 degrees Fahrenheit before serving. The facility's Food Safety Requirements policy, dated 10/2024, did not specify the holding/serving temperature, contributing to the deficiency.
Failure to Document QAPI Meeting Attendance
Penalty
Summary
The facility failed to retain evidence that the required Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) members attended meetings at least quarterly. This deficiency was identified during a survey when the facility could not provide QAPI meeting attendance sheets for the past year. Administrative Staff A confirmed the absence of these records from 2024. According to the facility's QAPI Committee policy dated October 2024, the committee should include the Director of Nursing, the Medical Director or designee, the Infection Preventionist, and at least three other staff members, and should meet monthly while maintaining records of attendance. The lack of documentation placed the residents at risk of unidentified quality care services.
Inadequate Certification of Acting Infection Preventionist
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist, responsible for the Infection Prevention and Control Program, completed the specialized training required for the role. At the time of the survey, Administrative Nurse D was acting as the Infection Preventionist but admitted to lacking the necessary certification. This situation arose because the designated Infection Preventionist was not yet in place, and Administrative Nurse D had assumed the responsibilities temporarily without the appropriate qualifications. The facility's policy, dated August 2024, outlined the responsibilities of the Infection Preventionist, which included assessing, implementing, developing, and monitoring the infection prevention and control program. The policy also required the Infection Preventionist to report compliance information to the Administrator and Quality Assurance and Assessment Committee, stay updated on infection control guidelines, and provide education and training. However, the facility's failure to ensure that the acting Infection Preventionist was certified placed residents at risk for inadequate identification and treatment of infections.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct the required annual performance reviews for two Certified Nurse Aides (CNAs) who had been employed for over a year. This deficiency was identified during a review of the facility's nurse aide performance evaluations, which revealed that CNAs M and N did not have their annual reviews completed. On February 20, 2025, Administrative Nurse D confirmed that two of the five randomly selected staff members lacked these evaluations. The facility's Staff Competency policy, dated June 2024, mandates that nursing staff demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and resulting plans of care. The absence of these evaluations placed residents at risk of receiving impaired care, as the facility did not ensure that nurse aide performance reviews were conducted in relation to the special needs of the resident population.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide two residents, R9 and R111, with the necessary CMS-approved forms related to their Medicare coverage. Specifically, the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, which is required to inform residents of potential liability for services not covered by Medicare. Additionally, the Notice of Medicare Non-Coverage (NOMNC) form 10123, which was given to the residents, lacked the Quality Improvement Organization (QIO) contact information necessary for residents to request an expedited review of Medicare decisions. The facility's policy, dated August 2024, mandates that residents be informed at least three days prior to the termination of Part A covered services, and that they receive the NOMNC form with QIO contact details. However, the administrative nurse confirmed that the QIO phone number was omitted from the forms provided to R9 and R111, and the CMS form 10055 was not used. This oversight placed the residents at risk of making uninformed decisions regarding their skilled services.
Failure to Notify LTCO of Resident Discharges
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman (LTCO) of the discharges of two residents, R26 and R111, to an acute care hospital. R26, who had diagnoses including bipolar disorder, schizoaffective disorder, chronic tension-type headache, and PTSD, was hospitalized for two days. Despite having intact cognition and requiring staff setup for all activities of daily living, the facility did not provide proof of sending a notice to the LTCO regarding her discharge. Social Services Staff X confirmed that the facility only sent a Continuation of Stay form to the KDADS offices monthly and did not send information to the LTCO regarding hospitalizations, which was against the facility's Transfer or Discharge policy. Similarly, R111, who had diagnoses of schizoaffective disorder, diabetes mellitus, and COPD, was hospitalized for approximately three weeks. The resident had long-term memory problems, moderately impaired decision-making skills, and an acute mental status change, requiring staff assistance for all activities of daily living. Upon return from the hospital, there was no evidence that the facility notified the LTCO of her discharge. The facility's failure to send a notice to the LTCO for both residents placed them at risk for uninformed decision-making, as the facility's policy required such notifications.
Failure to Maintain Urinary Continence for a Resident
Penalty
Summary
The facility failed to assess and maintain urine continence for Resident 51, who had a history of schizoaffective disorder, bipolar type, autism, insomnia, extrapyramidal and movement disorder, constipation, and encopresis. The resident's Minimum Data Set (MDS) initially documented that they were always continent of urine and bowels, but later indicated occasional urinary incontinence without a trial of a toileting program. Despite the resident's care plan instructing staff to observe patterns of incontinence and initiate a toileting schedule if indicated, the facility did not implement these measures. Observations and interviews revealed that Resident 51 experienced incontinence 18 days during a 30-day period, with incidents of nocturnal incontinence noted. Staff reported that the resident sometimes needed to change clothes and requested linens. The facility's policy required ensuring continence unless the resident's clinical condition made it impossible, but the facility did not assess causation factors or maintain the resident's urinary continence, placing them at risk for embarrassment and complications.
Failure to Address Resident's Food Preferences Leads to Weight Loss
Penalty
Summary
The facility failed to adequately address a resident's food preferences and dislikes, resulting in significant weight loss. The resident, who had a history of schizoaffective disorder, bipolar disorder, autism, and other conditions, experienced an 11.3% weight loss over six months. Despite being identified as a picky eater and having specific food preferences, the facility did not document these preferences in the resident's care plan or nutritional assessments. The resident's care plan mentioned the need to honor food preferences, but it lacked specific details about what those preferences were. The resident's weight fluctuated significantly, with a notable decrease from 176 lbs at admission to 153 lbs over the course of a year. The resident frequently refused meals, particularly breakfast, and expressed dissatisfaction with the food provided, preferring items like peanut butter and jelly sandwiches. Despite these preferences being known, the facility did not consistently provide meals that aligned with the resident's likes, contributing to the ongoing weight loss. Interviews with staff revealed a lack of communication and documentation regarding the resident's food preferences. Dietary staff admitted to not having discussed food preferences with the resident, and the resident himself reported not receiving many of the supplement drinks he liked. The facility's policy required nutritional assessments to include food preferences, but this was not adhered to, leading to the resident's continued weight loss and placing him at risk for further health decline.
Failure to Ensure Bed Rail Safety for Residents
Penalty
Summary
The facility failed to adequately assess the safety of bed rails for two residents, R7 and R1, which placed them at risk for accidents or injuries. R7, who had diagnoses of dementia, schizophrenia, and tremors, required substantial assistance with bed mobility and transfers. Despite the care plan documenting the use of grab bars for safety and mobility, the facility did not ensure the stability and safety of the bed rails. Observations revealed that the side rails on R7's bed were unstable and had large openings, which were not addressed in further assessments. Similarly, R1, diagnosed with Parkinson's disease, dementia, schizophrenia, and anxiety, also required significant assistance with bed mobility and transfers. The facility's failure to document the use of side rails in the MDS and to assess the safety of the rails placed R1 at risk. Observations showed that the side rail on R1's bed was unstable and had a large opening, similar to R7's situation. The facility did not conduct further assessments to ensure the safe use of the side rail. The facility's Bed Safety-Bed Rails policy required evaluations and assessments of bed rails upon admission, quarterly, and with any change in condition. However, the facility did not adhere to these guidelines, as evidenced by the lack of proper assessments and documentation for R7 and R1. This oversight in following the policy and ensuring the safety of bed rails contributed to the deficiency identified by the surveyors.
Failure to Properly Administer Insulin Injection
Penalty
Summary
The facility failed to ensure the correct administration of a subcutaneous insulin injection, which placed a resident at risk of receiving less than the ordered dose. During an observation, a Licensed Nurse (LN) administered insulin to a resident using a Novolog insulin pen dialed to five units. However, the LN did not prime the insulin needle with two units of waste insulin before administration, as she usually did. The LN admitted to being nervous and forgetting to perform this step. The facility's Insulin Administration policy required nursing staff to follow specific instructions for insulin delivery systems, but this was not adhered to during the incident.
Failure to Label Insulin Pens Properly
Penalty
Summary
The facility failed to properly label insulin flex pens for three residents, identified as R7, R12, and R23, with the date opened and the discard date. This oversight was observed on two nurse medication carts during a survey. Specifically, R7's Novolog flex pen, as well as R12's and R23's Basaglar flex pens, were not labeled with the necessary information. This deficiency was confirmed by both a licensed nurse and an administrative nurse, who acknowledged that the insulin pens should have been labeled with the date they were opened and their expiration date. The facility's policy on the storage of medication mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner, and that outdated or deteriorated drugs should not be used. According to Medlineplus.gov, open and unrefrigerated Lantus, Novolog, and Basaglar insulin should be used within 28 days, after which they must be discarded. The failure to label the insulin flex pens appropriately placed the residents at risk for receiving ineffective medication.
Failure to Accommodate Resident's Food Allergy
Penalty
Summary
The facility failed to accommodate a resident's known food allergy to mushrooms, resulting in a severe allergic reaction. The resident, who had a documented allergy to mushrooms, was served a meal containing mushrooms. Despite the resident's immediate notification to staff about the allergy, the resident experienced symptoms of anaphylaxis, including itching, swelling of the tongue, and throat. The resident required administration of diphenhydramine and an epinephrine pen, followed by transfer to the Emergency Department for further evaluation and treatment. The resident's medical records, including the Physician Order Sheet and care plans, clearly documented the allergy to mushrooms. The dietary staff failed to check the ingredient label of the oriental vegetables served, which contained mushrooms. This oversight occurred despite the allergy being listed on the resident's tray card and care plan. The dietary staff admitted to not noticing the mushrooms in the meal and failing to offer an alternative meal. The facility's policy on food allergies and intolerance was not followed, leading to the resident's exposure to the allergen. The incident was reported by various staff members, and it was confirmed that the dietary staff did not check the ingredient label before serving the meal. The failure to adhere to the resident's dietary care plan and the facility's policy placed the resident in immediate jeopardy, resulting in a severe allergic reaction and emergency medical intervention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eskridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Gardens At Aldersgate | 19.8 mi | — | 32 | 0 |
| Rolling Hills Health Center | 20.7 mi | — | 9 | 1 |
| Rossville Healthcare And Rehabilitation Center | 20.8 mi | — | 0 | 0 |
| Excel Healthcare And Rehab Topeka | 21.4 mi | — | 0 | 0 |
| Osage Nursing & Rehabilitation Center | 22.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.