Eskaton Village Care Center

In the surveyor’s words

From the most serious findings on record at Eskaton Village Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657Mar 20, 2026

  Based on interviews and record reviews the facility failed to ensure care plans (CP, a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive) were reviewed and revised in a timely manner, for two of 12 sampled residents (Resident 5 and Resident 2), when:Resident 5's urinary catheter (a flexible tube inserted into the bladder to drain urine into a drainage bag) care plan was not updated or revised after removal;Resident 2's urinary catheter care plan was not revised after removal; andResident 2's trazodone care plan had not been reviewed or revised after 21 days, as indicated.These failures had the potential for Resident 5 and Resident 2 to receive inaccurate care and interventions.3. […]

• No harm, potential for more than minimal, patternF658Mar 20, 2026

  Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the professional standards of nursing practice for two out of 12 sampled residents (Resident 5 and Resident 2), when the physician's orders (PO) were not updated and the care plans (CP, a personalized document outlining a person's health conditions, care goals, and necessary services to maintain quality of life) were not revised after urinary catheters (a flexible tube inserted into the bladder to drain urine into a drainage bag) had been discontinued.This failure had the potential for Resident 5 and Resident 2 to receive inadequate and unnecessary care. […]

• No harm, potential for more than minimal, patternF755Mar 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications with discontinued orders were removed from facility drug supply and destroyed in a timely manner. This failure had the potential to result in medication errors and adverse events from residents receiving discontinued medications and the potential for diversion (the illegal transfer, theft, or misuse of medications) from medications not being disposed of.Findings: During an inspection of the Medication Storage Room on 3/17/26 at 9:58 a.m. with the Director of Nursing (DON), a three-drawer cart positioned immediately to the right of the entrance filled with medications was observed. […]

• No harm, potential for more than minimal, patternF806Mar 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure food textures and preferences were accommodated for four of 12 sampled residents (Resident 2, Resident 50, Resident 51, Resident 38) when:1. Resident 2's food texture was not accommodated; 2. Resident 50 did not receive food items indicated on the daily menu;3. Resident 51's food preferences were not followed when she received food items that were identified as disliked; and,4. Resident 38's did not receive her preference of biscuit listed on the meal ticket. This failure had the potential to negatively impact Resident 2's, Resident 38's, Resident 50's, and Resident 51's nutritional status.Findings: 1. […]

• No harm, potential for more than minimal, patternF812Mar 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety in a census of 33 residents, when: The interior dispenser of ice machine had black, brown, and white substances on its surfaces in the facility kitchen; One kitchen staff touched the prepped food area with solid gloves after touching multiple surfaces in the kitchen;Ice buildup was found on the edge and frame of the doors of freezer in the main kitchen; andWet, dirty pans were found stored on the ready-to-use rack next to cooking area in the main kitchen. These failures had the potential risk for the spread of food-borne illnesses in a vulnerable population.Findings: 1. […]