Eureka Nursing Center

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

Inspectors wroteBased on observation and interview, the facility failed to promote dignity for one resident, Resident (R)42, who was using her fingers to get thickened juice out of her cup because staff failed to identify and assist or offer a spoon.

Inspectors wroteBased on record review and interview, the facility failed to provide the resident (or their representative) a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) for skilled services when Resident (R) 54's skilled services ended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy for Residents (R)4 and R3, while staff performed cares in their rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Resident (R) 6 and R46 were free from antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication without an appropriate indication of use. Findings Included:- R6's Electronic Medical Record (EMR) documented diagnoses of insomnia, amnesia (inability to sleep), hostility, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic kidney disease, chronic anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) secondary to blood loss, and low back pain. [...]

Inspectors wroteBased on the record review and interview, the facility failed to provide a baseline care plan for Resident (R) 49.

Inspectors wroteBased on record review and interview, the facility failed to develop an individualized person-centered care plan for Resident 49's stay, which began on 12/17/25 and ended on 01/15/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activity of daily living (ADL) cares to Resident (R)5 regarding showering.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the effectiveness of fall interventions for Resident (R)8, who had multiple falls, and revise with person-centered fall interventions to prevent further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor R35's amlodipine (antihypertensive (high blood pressure medication). The facility failed to ensure R16 was free from unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display accurate posted nursing staff hours accessible to residents and visitors.

Inspectors wroteThe facility reported a census of 43 residents with five residents sampled and two residents reviewed for abuse. Based on observation, interview, and record review the facility failed to ensure staff identified and responded appropriately to all allegations of abuse, to include resident-to-resident sexual abuse, when independently mobile Resident (R) 2 (who had a history of hypersexual behaviors directed toward staff to include groping, sexual inuendo/comments, and attempting to pull staff into bed with him) grabbed R1's breast on 09/30/24, without her consent. This failure placed R1 in immediate jeopardy due to the lack of facility response and reasonable person concept regarding sexual assault, and the negative impact to R1's psychosocial well-being and feelings regarding her safety. [...]

Inspectors wroteThe facility reported a census of 43 residents with five residents sampled and one resident reviewed for sexual abuse. Based on observation, interview, and record review the facility failed to ensure staff protected residents from sexual abuse, when independently mobile Resident (R) 2 (who had a history of hypersexual behaviors directed toward staff to include groping, sexual inuendo/comments, and attempting to pull staff into bed with him) grabbed R1's breast on 09/30/24, without her consent. This failure placed R1 and other female residents in immediate jeopardy due to the facility did not place interventions to protect R1 and other female residents who resided in the facility, from R2's unwanted sexual abuse/assault. This failure placed the residents at risk for abuse and continued negative impact on their physical, mental, and psychosocial well-being. Findings Included: [...]

Inspectors wroteThe facility reported a census of 48 residents, with 13 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure resident safety for one of the six residents, during transfer of Resident (R) 30. On 04/11/24, staff used the facility shower chair to transport R30 and in doing so the wheel on the chair broke, the resident to fell forward to the floor, and sustained a fractured tibia (one of two long bones in the lower leg). In addition, on 06/04/24 the facility staff did not ensure a safe transfer for R30 into his electric wheelchair (which had exposed metal) while using the mechanical lift, which resulted in a laceration on his anterior (front) lower leg, that required sutures.

Inspectors wroteThe facility reported a census of 48 residents. Based on observation, interview, and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight continuous hours on 08/21/23, 08/22/23, 08/23/23, 08/30/23, 09/01/23, 09/04/23, 09/06/23, 09/08/23, 09/18/23, 09/20/23, 10/01/23, 10/04/23, 10/28/23, 12/01/23, 12/04/23, 12/13/23, 12/20/23, 12/23/23, 12/24/23, 12/24/23, 12/25/23, 12/26/23, 01/01/24, 01/03/24, 01/06/24, 01/07/24, 01/08/24, 01/10/24 and 01/12/24, a total of 29 days, as required. The facility may permit the DON to serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This placed the residents in the facility at risk for unsupervised nursing care and services.

Inspectors wroteThe facility reported a census of 48 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illnesses to the residents of the facility.

Inspectors wroteThe facility reported a census of 48 residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report 24 hour per day Licensed Nurse coverage on 16 dates between April 1, 2023 and March 31, 2024.

Inspectors wroteThe facility reported a census 48 residents. Based on observation, interview, and record review, the facility failed to provide a clean home-like and sanitary environment for the 11 residents who resided in the special care unit. Additionally, the facility failed to provide a sanitary environment for two residents who had cracked fall mats with uncleanable surfaces in their rooms.

Inspectors wrote- The Electronic Health Records (EHR) documented R2 had the following diagnoses that included anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The 12/26/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R2 was independent with eating and wheelchair mobility. R2 required moderate assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing. R2 was frequently incontinent of bladder. [...]

Inspectors wroteThe facility identified a census of 48 residents, which included 13 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident. Resident (R) 47 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission, as required. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

Inspectors wroteThe facility reported a census of 48 residents, with 13 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (R)30's controlled ankle movement (CAM) boot.

Inspectors wroteThe facility reported a census of 48 residents, with 13 residents in the sample selected for review. Based on observation, interview, and record review the facility failed to apply sheepskin padding to Resident (R) 34's arm rests of her wheelchair. This deficient practice had the potential to place R34 at an increased risk for additional skin injuries.

Inspectors wroteThe facility reported a census of 48 residents, with 13 residents in the sample, and one resident reviewed for trauma. Based on observation, interview, and record review the facility failed to develop and implement approaches to care that were both clinically appropriate and person centered for R47, who had a history of personal trauma.

Inspectors wroteThe facility reported a census 48 residents. Based on observation, interview, and record review, the facility failed to provide a sanitary environment when staff stored an unlined trash can in the soiled utility room of the 400-hall.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with six residents sampled for accidents. Based on observation, record review and interview, the facility failed to identify risks and implement safety interventions to prevent elopement (when a cognitively imapired resident exits the facility without staff knowledge ro supervision) for Resident (R)12. The facility failed to ensure staff stored bleach wipes in a safe manner. These deficient practices placed R12 at risk for elopement and 10 cognitively impaired, independently mobile residents at risk for chemical exposure and related accidents.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with one resident sampled for advance directives. Based on observation, record review and interview the facility failed to provide the resident or resident's responsible party with a lawfully recognized Out of Hospital Do Not Resuscitate (DNR-an order to withhold resuscitative measures) advance directive form for Resident (R) 13, which placed her at risk for her choice for a DNR not being honored. Findings Included: - The electronic medical record (EMR) for R13 identified diagnoses of Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), and dementia with mood disturbance ((progressive mental disorder characterized by failing memory, confusion and behaviors including agitation, verbal and physical aggression, wandering and hoarding). [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with two reviewed for care plan revisions. Based of observations, record review, and interviews, the facility failed to revise care plan interventions to include Resident (R)1's wheelchair seatbelt and R12's elopement attempt. This deficient practice placed the residents at risk for ineffective treatment and safety hazards. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of cerebral palsy (progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), muscle spasms, need for assistance with personal cares, abnormal posture, muscle weakness, and epilepsy (brain disorder characterized by repeated seizures). [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents with two reviewed for bowel and bladder management. Based of observations, record review, and interviews, the facility failed to provide sanitary Foley catheter care (tube inserted into the bladder to drain urine into a collection bag) for Resident (R)18 and failed to implement an individualized bowel and bladder toileting program for R20. This deficient practice placed the residents at risk for complications related urinary tract infections and incontinence. Findings Included: [...]

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to store oxygen tubing and nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) equipment in a sanitary manner for Resident (R) 100. This deficient practice placed R100 at increased risk to develop a respiratory infection.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents. Five sampled residents were reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported an inappropriate diagnosis for the antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) for Resident (R) 25 and R13. This failure had to potential of unnecessary antipsychotic medication use and related side effects for R25 and R13.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents which five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed ensure staff monitored physician-ordered parameters for Resident (R) 14's hypertensive medication (class of medication used to treat high blood pressure). This deficient practice had the potential of unnecessary medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 13 residents. Five sampled residents were reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure an appropriate diagnosis for an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) for Resident (R)25 and R13. This failure had to potential of unnecessary antipsychotic medication use and related side effects for R25,and R13.

Inspectors wroteThe facility identified a census of 47 resident and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to equipment cleaning during food preparation. This deficient practice placed the residents at risk related to food borne illnesses and cross-contamination concerns. Findings Included: - On 11/17/22 at 11:10AM, Dietary Staff CC prepared puree meals for the lunch service. Staff CC followed the dietary menu for making pureed portions of pork, potatoes, and carrots. Dietary Staff CC rinsed the bowl with plain water in between preparing each type of dish. Dietary Staff CC stated the bowl should be properly cleaned/sanitized between food types. [...]

Inspectors wroteThe facility identified a census of 47 residents. Based on observation, record review and interview, the facility failed to ensure staff followed infection control standard of practice when staff failed to ensure Resident (R)18's catheter (the insertion of a hollow tube into the bladder to drain the urine into a collection) bag remained off the floor. The facility staff failed to perform hand hygiene (a term used for cleaning your hands by handwashing with soap and water or the use of an alcohol-based hand rub ABHR) while providing catheter care to R18. This placed the resident at risk for increased infection and transmission of communicable disease.