Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastridge during CMS and state inspections, most recent first.
Staff left a steam table heated to 180°F unattended and accessible in the dining room, despite the presence of cognitively impaired, independently mobile residents who could access it without supervision. Additionally, an unlocked blanket warmer with internal temperatures over 150°F was found in an open, unattended room on a low shelf. These actions failed to meet the facility's own safety policies regarding accident hazards and supervision.
The facility did not have an RN on duty for at least eight consecutive hours on one day, as confirmed by payroll records and staff interviews. This was not in accordance with the facility's staffing policy, which requires daily RN coverage.
The facility did not accurately submit direct care staffing information to CMS, resulting in missing RN hours and lack of documented 24-hour licensed nurse coverage on several occasions. Administrative staff confirmed that, except for one day, licensed nurse coverage was present but not properly reported, and the facility lacked a policy for PBJ reporting.
A medication cart was left unlocked and unattended near a cognitively impaired, independently mobile resident, contrary to facility policy requiring secure storage of medications. Both a nurse and an administrative nurse confirmed that the cart should always be locked when not attended.
A resident with multiple chronic conditions and on hospice services did not have a hospice plan of care provided by the hospice provider, as required. The care plan referenced hospice involvement and specific services, but the actual hospice plan of care was missing from the resident's binder, and staff confirmed it had not been supplied.
The facility did not consistently post daily nurse staffing data as required, with missing records for two days and an outdated staffing sheet observed. An administrative nurse reported that the lapse occurred during her absence, and no policy for posting the data was available.
Unattended Hot Equipment Creates Accident Hazards for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by leaving an active steam table, which reached temperatures up to 180 degrees Fahrenheit, unattended and accessible in the dining room. At the time, the dining room was empty of both residents and staff, and the steam table was accessible from all sides. The facility had three cognitively impaired, independently mobile residents who could potentially access the steam table without staff knowledge. Dietary staff reported turning on the steam table early in the morning and leaving it on throughout the day without monitoring its temperature. Additionally, the facility did not ensure that residents were protected from another accident hazard involving an unlocked blanket warmer. The blanket warmer was located in an open, unattended room without a door, and was placed on a shelf approximately 2 ½ feet from the floor. The temperature of the blanket warmer was measured at over 150 degrees Fahrenheit, and the metal shelf inside was hot to the touch. Staff confirmed that the blanket warmer was accessible and that the room was not secured, although they stated they had not observed residents entering the room. The facility's own safety policy required that all electrical machines with heat-producing elements be turned off when not in use, and that unsafe conditions be reported to supervisors. Despite this, the steam table was left on and unattended, and the blanket warmer was left accessible in an unsecured area. The facility was unable to provide an accident policy when requested.
Removal Plan
- A staff member was placed in the dining room to ensure no residents got close to the steam table.
- The steam tables have been shut off. Once it is cool, staff will not be in the area until the table is turned back on for the evening service meal.
- A temporary barrier with cones, chairs, and caution tape to keep folks away from the area.
- A board barrier will then be put up as a more secure yet temporary fix.
- A long-term plan will be put in place, likely building up the partial wall that was already in place, to shield the steam table.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, as required by regulation. Review of the Payroll Based Journaling (PBJ) report and the facility's nursing schedules for November and December 2024 revealed that there was no RN coverage on 12/28/24. Administrative staff confirmed that, despite efforts to cover RN shifts, there was no RN present in the facility on that date. The facility's staffing policy requires an RN to be present daily, but this standard was not met on the identified day.
Failure to Accurately Report Staffing Data to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) through Payroll Based Journaling (PBJ). Specifically, the PBJ Staffing Data Report (CASPER Report 1705D) for two consecutive fiscal quarters showed that the facility did not report registered nurse (RN) hours on several dates and failed to demonstrate licensed nurse coverage 24 hours a day on multiple occasions. The report identified specific dates where no RN hours were documented and additional dates where there was no evidence of 24-hour licensed nurse coverage. Administrative staff confirmed that, except for one date, the facility did have 24-hour licensed nurse coverage, but the correct hours were not always submitted to CMS due to issues with the reporting process. The facility did not have a policy in place regarding PBJ reporting, which contributed to the inaccurate submission of staffing data. The administrative nurse stated that all nursing hours were sent to a corporate human resources person at a sister facility, and acknowledged there had been problems with submitting the correct hours to CMS. The lack of a formal policy and the reliance on external staff for reporting led to discrepancies in the reported staffing data, resulting in a one-star staffing rating and multiple triggered deficiencies in the CMS report.
Medication Cart Left Unlocked and Unattended Near Cognitively Impaired Resident
Penalty
Summary
A medication cart located near the nurse's station was observed to be left unlocked and unattended by staff while a cognitively impaired and independently mobile resident was nearby. This incident occurred despite the facility's policy requiring that medication carts, rooms, and supplies be locked or attended at all times by authorized personnel. Interviews with a licensed nurse and an administrative nurse confirmed that the cart should always be locked when not attended. The facility census included 17 residents, and the policy in place emphasized the secure storage of medications and biologicals in accordance with professional standards.
Failure to Ensure Hospice Plan of Care Provided for Resident
Penalty
Summary
The facility failed to ensure that the hospice provider supplied the hospice plan of care for a resident who was receiving hospice services. The resident had diagnoses including dementia, hypertension, and congestive heart failure, and required substantial assistance with all activities of daily living. The care plan indicated that the resident was on hospice, outlined the services and medications to be provided by hospice, and directed staff to work with the hospice team. However, upon review, it was found that the hospice provider had not placed the hospice plan of care in the resident's binder as required. Staff interviews confirmed that the hospice plan of care was missing from the binder, and the hospice provider had not initially provided it. The absence of the hospice plan of care was identified during a review of the hospice provider binder, and staff acknowledged that the plan should have been present. The facility's agreement with the hospice provider specified that the hospice was responsible for developing and communicating the hospice plan of care, but this was not done in this instance.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing data was updated and displayed as required. During an initial tour, it was observed that the nurse staffing hour sheet posted was outdated, showing a date from two days prior. Upon request, the facility was unable to provide the daily posted nurse staffing sheets for two specific days, despite being able to produce records for the previous 18 months. An administrative nurse confirmed that the process for posting the staffing sheets was disrupted due to her absence on vacation, resulting in the weekend sheets not being completed. The facility also could not provide a policy regarding the posting of daily nurse staffing data. The sample included eight residents out of a census of 17, but no specific resident medical history or condition was mentioned in relation to the deficiency.
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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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| Life Care Center Of Seneca | 8.4 mi | ★★★★★ | 0 | 0 |
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| Frankfort Community Care Home | 15.3 mi | ★★★★★ | 20 | 1 |
| Onaga Operator, Llc | 16.2 mi | ★★★★★ | 10 | 0 |
| Sabetha Manor | 20.7 mi | ★★★★★ | 7 | 0 |
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