Eureka Rehabilitation & Wellness Center, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure the electronic submission of the Payroll Based Journal (PBJ, a system by which skilled nursing facilities submit staffing information to the Centers for Medicare and Medicaid [CMS]) data as required quarterly when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time reports that allows SNFs the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the fourth quarter (Q4-10/25 through 12/25). This failure prevented regulatory agencies, residents, and residents' families from being able to verify that facilities had enough staff to provide necessary care to residents. A review of CMS' PBJ Staffing Data Report indicated, No Data Submitted for Quarter. [...]

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to ensure appropriate treatment for an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) for one resident (Resident 1) of three sampled residents when Resident 1's indwelling urinary catheter bag was found on the floor. This failure placed Resident 1 at risk to develop an infection. A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of Retention of Urine (inability to fully or partially empty the bladder). A review of Resident 1's physician orders dated 6/15/26 indicated, Foley Catheter Care to be provided every shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement measures to prevent an avoidable fall for one resident (Resident 1) for a census of 71 residents, when Resident 1 was transferred from his bed to a chair using a Hoyer lift (a brand of portable patient lift (mechanical lift) designed to help caregivers safely transfer individuals with limited mobility between beds, chairs, and wheelchairs) with a one person assist and a frayed (material that is worn or unraveled at the edges) Hoyer lift sling (the crucial fabric interface that attaches a patient to a mechanical or hydraulic lift for safe transferring). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of resident-to-resident sexual abuse was timely reported to the California Department of Public Health (CDPH) for two of two sampled residents (Resident 1 and Resident 2). This failure had the potential to delay state agency awareness and oversight of an alleged abuse incident. A review of a facility reported incident received by the Department on 3/26/26 at 8:00 a.m., indicated that on 3/20/26 at approximately 10:00 p.m., staff observed Resident 1 placing Resident 2's hand on Resident 1's genital area while Resident 2 was asleep. During an interview on 4/22/26 at 11:45 a.m., the Regional Administrator stated the incident occurred at approximately 10:00 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one licensed nurse (Licensed Nurse 1 (LN 1)) of two licensed nurses maintained an appropriate Cardiopulmonary Resuscitation (CPR) certification when LN 1 did not obtain CPR certification through a provider with hands on training. This failure decreased the facility's potential to be able to implement of life saving measures and effective clinical interventions for all residents residing in the facility in the event of a respiratory or cardiac emergency. A review of LN 1's employee file indicated LN 1 was hired as a registry (agency that employs nursing staff for facilities with urgent staffing needs) nurse. Further review of LN 1's file indicated LN 1 obtained CPR certification through an online provider on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a professional standard of nursing care was provided to one resident (Resident 1) of two sampled residents when:- Licensed Nurse 1 (LN 1) did not document an assessment and Change of Condition (COC) of Resident 1 after Certified Nurse Assistant 1 (CNA 1) notified her that Resident 1 had a change in his breathing on [DATE] at approximately 3 p.m.;- LN 1 administered a medicated breathing treatment to Resident 1 without a physician's order and documented she administered the breathing treatment on the wrong day; and,- LN 1 called for a non-emergent ambulance when Resident 1 was found unresponsive with labored breathing and a faint pulse. [...]

Inspectors wroteBased on interview and record review, Licensed Nurse 1 (LN 1) failed to ensure one (Resident 1) of two residents' medical records were complete and accurate when:-LN 1 did not document an assessment and Change of Condition (COC) of Resident 1 after Certified Nurse Assistant 1 (CNA 1) notified her that Resident 1 had a change in his breathing on [DATE] at approximately 3 p.m.; and,- LN 1 administered a medicated breathing treatment to Resident 1 without a physician's order and documented she administered the breathing treatment on the wrong day. These failures decreased the facility's potential to facilitate communication among healthcare staff and decreased the facility's potential to investigate and determine if there was a correlation between facility staff's response to Resident 1's COC and Resident 1's need for cardiopulmonary resuscitation (CPR).

Inspectors wroteBased on observation, interview, and record review, the facility failed to comply with federal regulations related to the oversight of food service operations when the facility did not have a dedicated Registered Dietitian (RD, food and nutrition experts with a minimum of a graduate degree from an accredited dietetics program, who completed a supervised practice requirement, and passed a national exam) for a census of 87 residents. This failure had the potential to compromise dietary services rendered to the facility's residents. During the recertification survey conducted from 1/26/26 through 1/29/26, multiple dietary issues were identified including recipes not being followed (Cross Reference F803), dumpster lid not being closed (Cross Reference F814), and issues pertaining to kitchen sanitation, cleanliness, maintenance, equipment, and food storage (Cross Reference F812). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare meals using methods that conserved nutritive value, flavor, and appearance when the recipes were not followed for a facility census of 87 residents. This failure had the potential for leading to malnutrition, weight loss, impaired wound healing, and increased susceptibility to disease. During an observation in the kitchen on 1/27/26 at 9:35 a.m., [NAME] 2 (CK 2) was observed preparing food for the lunch menu, which included herb crusted beef roast, mashed potatoes with gravy, zesty spinach, and garlic bread. No recipes were present at the cook's station. During a concurrent observation and interview on 1/27/26 at 11:15 a.m. in the kitchen, CK 2 was seen adding an unmeasured amount of butter to a mixture of butter, garlic, and parsley using a spatula, without using any measuring tools. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food storage and preparation, sanitary conditions, as well as maintain kitchen equipment and the kitchen environment in accordance with professional standards for food service safety for a census of 87 residents when:1. Kitchen staff did not protect food from physical contaminants (e.g. hair nets and beard nets were not worn, and cook was wearing jewelry), 2. Kitchen environment was not maintained (e.g. kitchen walls had areas of missing paint),3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide services according to professional standards of practice for three of 21 sampled residents (Resident 4, Resident 14, and Resident 40) when:Medication was not administered to Resident 14 according to the recommended guidelines.72-hour monitoring was not performed for Residents 4 and 40 following a change of condition (COC),A care plan was not initiated for Resident 40 following a COC, and; Neurological (related to the nervous system, which includes the brain, spinal cord, and nerves that control body functions, movement, and sensation) checks were not completed for Resident 4 post-fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure completed annual performance reviews, commonly known as competency/skills checks, for two of five sampled Certified Nursing Assistants (CNAs, unlicensed healthcare staff providing direct, hands-on nursing or nursing-related services to the residents of the facility) (CNA 4 and CNA 6). Additionally, the facility did not ensure abuse and dementia training was provided for two CNAs in this same sample (CNA 3 and CNA 7). Cross reference F947. This failure placed facility's residents at risk for receiving substandard quality of care, which could have resulted in harm. During a concurrent interview and record review on 1/28/26 at 2:02 p.m. with the Director of Staff Development (DSD), CNA 4's employee training file was reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon the Consultant Pharmacist's (CP) recommendations in a timely manner for Residents 1, 3, 6, 14, 16, 17, 18, 19, 24, 57, 76, 83, and 85, out of a census of 87 residents. This failure had the potential to result in medication-related problems or errors, such as prolonged use, excessive doses or unmonitored usage, due to the irregularities identified and reported by the CP.1. A review of Resident 1's admission record indicated Resident 1 was admitted on 9/2025 with a diagnosis of Benign Prostatic Hyperplasia (BPH- enlarged prostate). A review of Resident 1's order summary report dated 1/29/26 indicated Resident 1 had a physician's order for tamsulosin HCI (medication to treat an enlarged prostate gland) oral capsule 0.4 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored safety and within accepted professional standards of practice for a census of 87 residents when:Loose pills were found in a medication cart,Medications were found without open dates, and;Used insulin pens were found comingled in the same drawer. These findings had the potential to result in medication errors, decreased medication therapy, and harm to the residents of the facility. During a concurrent interview and C wing medication cart inspection on 1/28/26 at 1:14 p.m., with the Director of Nursing (DON), the DON confirmed the following: 10 loose pills were found in the medication cart. The DON stated loose pills could potentially be given mistakenly to residents or be taken by staff. Six medications were found without open dates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was properly contained for a census of 87 residents when one out of two dumpsters were observed with open lids, was overflowing with trash, and the area around it was littered with garbage. This failure had the potential to expose the facility environment to odors, insects, pests, and disease, which could have caused harm to the residents. During a concurrent observation and interview on 1/26/26 at 10:40 a.m. with the Dietary Supervisor (DS), one of the two facility dumpsters was left open with plastic bags filled with garbage piled above the top of the dumpster. The dumpster was observed without the lids on to provide closure to the dumpster. One bag of garbage and a box was on the ground next to the dumpster. The DS confirmed the dumpster was overflowing and was too full to close the lids. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and functional environment for one of 21 sampled residents (Resident 70) when Resident 70's light was not in working condition. This failure had the potential to increase Resident 70's risk for accidents, feelings of frustration and lack of independence. A review of Resident 70's admission record indicated she was admitted to the facility in July, 2025, with medical diagnosis which included spinal stenosis (a narrowing of the spinal canal which puts pressure on the spinal cord and nerves), strabismus (eyes are misaligned and do not point in the same direction) and vascular dementia (when damaged blood vessels reduce blood flow and oxygen to the brain, impairing thinking, memory, and function). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services that met professional standards of quality for three residents (Resident 1, Resident 2, Resident 3) out of a sampled seven residents when licensed nurses did not:1. Initiate a care plan that included a recent occurrence of resident-to-resident abuse for Resident 1 and Resident 2; and,2. Conduct 72-hour monitoring following Resident 3's fall. These failures had the potential to place Resident 1, Resident 2, and Resident 3 at risk for serious harm, health deterioration and a loss of quality of life.1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with Alzheimer's Disease (a disease characterized by progressive decline in mental abilities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess a resident's fall risk status and ensure a care plan was person-centered for one resident (Resident 1) of four sampled residents when Resident 1 was admitted to the facility with a history of falls These failures decreased the facility's ability to supervise and prevent Resident 1's fall on 5/24/25 which resulted in a right nondisplaced (not shifted out of place) distal radius (bone that is near the wrist of your lower arm) fracture (a break) to the right arm, limiting use of her dominant hand.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items were labeled and dated. This had the potential to affect all residents receiving meals from the dietary department.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of diagnosed mental disorders for 1 (Resident #53) of 6 sampled residents reviewed for PASRR requirements.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure one of two sampled residents (Resident 1): 1. Received showers as scheduled every Sunday and Wednesday. 2. A treatment was requested and initiated once Resident 1 was noted with moisture associated skin damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool) when he was admitted on [DATE]. 3. Treatments for pressure injury (PI, injury to skin and underlying tissue resulting from prolonged pressure on the skin) were consistently and regularly rendered per physician ' s order. 4. Resident 1 was being turned and repositioned (T&R, the movement of patients from one position to another to alleviate or redistribute any pressure) every 2 hours and more often as needed. 5. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure there were adequate staff when: 1. Four out of four residents (Residents 2, 3, 4 and 5) complained the facility was short staffed. 2. Six out of six staff reported the facility was short staffed. 3. Based on the census (official periodic count of a population) and Direct Care Service Hours Per Patient Day (DHPPD, the minimum number of actual nursing hours performed by nursing staff per patient day), the facility did not meet the actual DHPPD for 8 out of 10 days from 4/21/24 up to 4/30/24 on these dates: 4/21/24 at 2.68, 4/22/24 at 2.63, 4/23/24 at 3.30, 4/25/24 at 3.43, 4/26/24 at 3.08, 4/27/24 at 3.35, 4/28/24 at 2.93, 4/29/24 at 2.99. These failures resulted in 1A. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure licensed nurses have the competencies necessary in providing care for the residents when: 1. Licensed Nurses (LNs) were not accurately documenting the skin impairment and its location for one out of two sampled residents (Resident 1). 2. LNs failed to recognize signs and symptoms of Urinary Tract Infection (UTI, a bacterial infection of the bladder and associated structures) and Sepsis (your body's extreme reaction to an infection) for one out of 2 sampled residents (Resident 1). These failures: 1A. resulted to inaccurate documentation as to the exact location and status of Resident 1 ' s pressure injury (PI, breakdown of skin integrity due to pressure). 2B. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) received his showers twice a week as scheduled every Sundays and Wednesday. This failure reduced the facility ' s potential to mitigate Resident 1 ' s skin breakdown and reduced the potential for skin infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1.recognize signs and symptoms of Urinary Tract Infection (UTI, a bacterial infection of the bladder and associated structures) and Sepsis (your body's extreme reaction to an infection) for one out of 2 sampled residents (Resident 1). This failure resulted to Resident 1 to fall on 4/25/24 which caused: A.skin tear(traumatic wounds that may result from a variety of mechanical forces such as shearing - a horizontal force that causes the bony prominence to move across the tissue as the skin is held in place, or frictional forces- the rubbing of one body against another , including blunt trauma, falls, poor handling, equipment injury) on his right elbow measuring 6.4 centimeters (cm, a measure of length) and; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse, in accordance with facility policy and procedure and with state law, for one resident (Resident 1), when the facility did not notify the appropriate agencies such as California Department of Public Health (CDPH), Local law enforcement, and Ombudsman of a potential allegation of abuse, within the required timeframe. This failure had the potential for the alleged abuse to continue and did not allow the appropriate agencies to investigate the allegations.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow the lunch menu on 6/6/22 when margarine was not provided with dinner rolls for all residents in the facility. This failure could lead to a decline in the nutritional status of residents in the facility.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to prepare food to conserve flavor and palatability (tastiness) for four of 31 residents (Resident 62, Resident 16, Resident 123, and Resident 19) observed during lunch from 6/6/22 to 6/8/22. This failure could lead to weight loss among residents not consuming their food.

Inspectors wroteBased on interview and record review, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to identify and improve on three deficient practices found during the recertification survey process. This failure resulted in lack of symptoms monitoring for psychotropic medications, responsible parties (RP) were not notified that residents were refusing their showers, and responsible parties were not notified of changes in residents' condition.

Inspectors wroteBased on interview and record review, the interim director of staff development (DSD) failed to maintain a system to ensure all staff with access to vulnerable residents were trained in abuse prevention and reporting. This failure could potentially result in harm to residents.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide two out of 19 sampled residents (Resident 22 and Resident 42) scheduled weekly showers who depended on staff to assist. This failure to provide the necessary care resulted in residents looking unkempt and had the potential for residents having body odor, dry broken skin and infection.

Inspectors wroteBased on interview and records review, the facility failed to act on the facility pharmacist's recommendation to add monitors for manifested behavior and side effects of a psychotropic (substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for three of five residents sampled for unnecessary medication review (Resident 67, 19, and 38). This failure had the potential to lead to the facility staff not knowing if the medication was effective in reducing symptoms of depression, psychosis, or producing undesirable side effects that would then necessitate a discontinuation or a change in medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and the facility policy. This failure put residents at risk of receiving medications that were expired and potentially ineffective and unsafe for use.

Inspectors wroteBased on observation, interview and records review, the facility failed to offer or ensure availability of food of similar nutritive value to three randomly selected residents (Resident 20, Resident 123, and Resident 124) and four of 19 sampled residents (Resident 67, Resident 125, Resident 17, and Resident 19) when Resident 20, Resident 19, and Resident 17 were not offered food from the alternate menu, and Resident 124, Resident 67, Resident 123, and Resident 125 were not provided the list of alternate food menu they can choose from. This failure had the potential to result to inadequate intake and nutrition for residents in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow infection control practices when 1. Handheld thermometer and pens where not sanitized in between use for screening staff/visitors. 2. There were no hand sanitizers readily accessible for staff to use in 14 out of 14 rooms in Memory Lane unit 3. Hand hygiene (a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub) were not provided for nine out of 19 sampled residents ( Residents 14, 22, 25, 27, 29, 43, 55, 57 and 61) prior to meals. 4. There were missing/broken tiles in two out of 14 rooms in Memory Lane unit ( room [ROOM NUMBER] and #20 ) and laundry room. This failure had the potential to 1. transmit infection to resident from staff and or visitors 2. prohibits adequate cleaning and sanitizing of floors.

Inspectors wroteBased on observation, interview and record review the facility failed to follow it's policy and procedure and manufacture's recommendations to maintain patient care equipment when quality controls for blood glucose monitors were not performed daily per facility policy. This failure has the potential to give incorrect blood sugar readings for residents which staff rely on to give appropriate medication to the residents. On [DATE] at 4:00 p.m. during an inspection of the medicine cart on Unit A with the Director of Nursing (DON), the Accucheck solution was found to be expired, dated [DATE]. The DON took the Accucheck solution out of the cart and replaced it with a new solution. She stated, This should have been replaced. [...]

Inspectors wroteBased on interview and record review, the facility failed to involve the responsible party in the care planning process of one of two sampled residents, Resident 173. This potentially resulted in Resident 173 losing weight when the staff caring for her did not know what foods she liked, what texture she needed, or her level of assistance needed with eating.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to notify the Responsible Party (the person designated to make healthcare decisions for someone who has lost capacity to make decisions for themselves; in some cases the RP is an agency, like the Public Guardian) and the physician in three out of 19 sampled residents (Resident 22, Resident 42 and Resident 173) of significant changes in their health status. This failure had the potential to result in a delay in treatment, RP's not being involved in the resident's care and RP's feeling upset and very frustrated.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 74 residents (Resident 18) was free from physical abuse when a staff hit Resident 18 in the chest. This failure resulted in Resident 18 being subject to physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to report the results of its investigation of one allegation of abuse to the California Department of Public Health (the Department) within five working days of the incident. This failure prevented the Department from being informed of the facility's investigation of the abuse allegation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete accurate assessments for two of 14 sampled residents, Resident 17 and Resident 19. This failure could potentially result in incomplete care plans for Resident 17 and Resident 19.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours for one of two sampled residents, Resident 173, who had a history of falls, and failed to provide a copy of Resident 173's baseline care plan to Resident 173's representative. This failure could have potentially resulted in Resident 173 falling when there was no plan in place for staff to keep her safe from falls, and resulted in Resident 173's responsible party, RP 2, feeling upset and very frustrated when she never had the opportunity to discuss Resident 173's care needs with staff and did not know the plan for Resident 173's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for use of an antipsychotic medication when one of five residents sampled for unneccessary medications, Resident 19, did not include the target behavior for the medication or any goals related to the target behavior. This failure resulted in an incomplete plan of care for the use of a drug known to cause increased risk of death in elderly people.

Inspectors wroteBased on interview and record review, the facility staff did not complete admission progress notes or document accurate skin assessments for one of two sampled residents, Resident 173. This resulted in an incomplete medical record for Resident 173.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to promote appropriate use of antibiotics (a medication used to treat bacterial infections) when one out of 19 sampled residents (Resident 35) was prescribed an antibiotic without initiating the McGreer's criteria ( used to retrospectively count true infections) for Urinary Tract Infection (UTI- an infection in any part of the urinary system) and without waiting for Urinalysis (UA, a test of urine used to detect and manage a wide range of disorders), Culture and Sensitivity result (C&S, a culture is a test to find germs, a sensitivity test checks which type of antibiotic will work best to treat an infection.) This failure had the potential to cause antibiotic resistance, severe infections and complications.