5 Reports
Inspection Report — Nov 5, 2024
Complaint Investigation CMS
Date: Nov 5, 2024
Visit Reason
The inspection was conducted due to allegations of resident-to-resident sexual abuse and employee-to-resident abuse involving multiple residents, including a sexual assault incident on 09/30/24 and bruising of unknown origin on another resident.
Complaint Details
The complaint investigation involved allegations of resident-to-resident sexual abuse by Resident R2 against Resident R1 on 09/30/24 and employee-to-resident abuse involving bruises on Resident R10. The sexual abuse allegation was substantiated and placed the facility in immediate jeopardy. The bruising allegations were not properly investigated or reported, placing residents at risk.
Findings
The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, including resident-to-resident sexual abuse and employee-to-resident abuse. Resident R2, with a history of hypersexual behaviors, grabbed R1's breast without consent, and the facility did not adequately investigate or intervene. Additionally, bruises of unknown origin were documented on Resident R10, but the facility failed to investigate or report these as potential abuse.
Deficiencies (2)
F0600: The facility failed to protect residents from all types of abuse, including sexual abuse, neglecting to respond appropriately to resident-to-resident sexual abuse by R2 on 09/30/24 and failing to investigate employee-to-resident abuse allegations involving R10's bruises.
F0610: The facility failed to respond appropriately to all alleged violations, including failure to protect residents from sexual abuse by R2 and failure to implement adequate interventions and care plan updates after the incident on 09/30/24.
Report Facts
Residents sampled: 5
Residents reviewed for abuse: 2
BIMS score: 14
BIMS score: 3
Bruises documented: 15
One-on-one supervision duration: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Reported on interventions and supervision related to R2's behavior and abuse allegations. | |
| Administrative Nurse B | Involved in notification of immediate jeopardy and follow-up interviews. | |
| Administrative Nurse C | Involved in notification of immediate jeopardy and follow-up interviews. | |
| Certified Nurse Aide G | CNA | Witnessed R2 grabbing R1's breast and reported abuse concerns. |
| Certified Nurse Aide H | CNA | Reported on R2's behaviors and care plan documentation. |
| Licensed Nurse F | LN | Nurse on duty during the incident involving R2 touching R1 and provided education to R2. |
| Social Service Designee K | SSD | Interviewed residents and involved in care planning related to abuse incident. |
| Nurse Consultant L | Provided opinion on the sexual abuse incident and care plan updates. | |
| Therapy Staff N | Reported knowledge of abuse education and types of abuse. | |
| Certified Nurse Aide P | CNA | Reported abuse incident involving Resident R10 and CNA Q. |
| Licensed Nurse O | LN | Assessed Resident R10 after abuse allegations and documented findings. |
Inspection Report — Jul 11, 2024
Routine CMS
Date: Jul 11, 2024
Visit Reason
Routine inspection of Eureka Nursing Center to assess compliance with health, safety, and care standards.
Findings
The facility failed to maintain a sanitary, safe, and homelike environment, had inaccurate resident assessments, incomplete care plans, inadequate nursing coverage, unsafe resident transfers, and food safety violations.
Deficiencies (11)
F 0584: The facility failed to ensure a sanitary, safe, and homelike environment due to cracked and worn fall mats and pervasive urine odor in the special care unit affecting 11 residents.
F 0641: The facility failed to accurately complete the Minimum Data Set (MDS) for residents related to antiplatelet medication use and contractures, risking uncommunicated care needs.
F 0656: The facility failed to develop a comprehensive person-centered care plan for Resident 47 within 21 days of admission, risking uncommunicated needs.
F 0657: The facility failed to review and revise Resident 30's care plan to include the use of a controlled ankle movement (CAM) boot as ordered by the physician.
F 0684: The facility failed to apply sheepskin padding to Resident 34's wheelchair arm rests, increasing risk for skin injuries.
F 0689: The facility failed to ensure resident safety during two transfers of Resident 30, resulting in a fractured tibia and a laceration requiring sutures.
F 0699: The facility failed to develop and implement trauma-informed care approaches for Resident 47 with a history of personal trauma.
F 0727: The facility failed to have Registered Nurse coverage for at least eight continuous hours on 29 days as required, risking unsupervised nursing care.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including improper food storage and unsanitary kitchen equipment.
F 0851: The facility failed to accurately submit complete and accurate direct care staffing information to CMS, misreporting licensed nurse coverage on 16 dates.
F 0921: The facility failed to provide a sanitary environment by storing an unlined trash can in the soiled utility room of the 400-hall.
Report Facts
Residents affected: 11
Residents affected: 13
Deficiency days: 29
Dates with inaccurate licensed nurse coverage reporting: 16
Length of laceration: 7.5
Width of laceration: 6.3
Depth of laceration: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Confirmed fall mat issues, resident laceration, and care plan concerns |
| Administrative Nurse F | Administrative Nurse | Confirmed MDS documentation errors and care plan delays |
| Maintenance Director U | Maintenance Director | Reported urine odor issues and trash can concerns |
| Certified Nurse Aide M | Certified Nurse Aide | Reported lack of sheepskin padding on wheelchair arm rests |
| Administrative Nurse D | Administrative Nurse | Confirmed expectations for CAM boot application |
| Administrative Staff A | Administrative Staff | Confirmed RN coverage deficiencies and PBJ reporting inaccuracies |
| Social Service Staff X | Social Service Staff | Provided trauma history information for Resident 47 |
Inspection Report — Jul 11, 2024
CMS
Date: Jul 11, 2024
Visit Reason
The inspection was conducted to assess compliance with nursing staffing requirements and the accuracy of electronic staffing data submissions to CMS.
Findings
The facility failed to ensure eight consecutive hours of Registered Nurse coverage on 29 days and failed to accurately submit complete and accurate direct care staffing information to CMS for 16 dates between April 1, 2023 and March 31, 2024.
Deficiencies (2)
F 0727: The facility failed to have Registered Nurse coverage for at least eight continuous hours on 29 days as required, placing residents at risk for unsupervised nursing care.
F 0851: The facility failed to electronically submit complete and accurate direct care staffing information to CMS, inaccurately reporting 24-hour Licensed Nurse coverage on 16 dates between April 1, 2023 and March 31, 2024.
Report Facts
Days without 8 consecutive hours RN coverage: 29
Dates with inaccurate Licensed Nurse coverage reporting: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Confirmed lack of RN coverage and stated inaccuracies in PBJ staffing data. |
Inspection Report — Nov 21, 2022
Annual Inspection CMS
Date: Nov 21, 2022
Visit Reason
Annual inspection of Eureka Nursing Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility failed to provide a lawfully recognized Out of Hospital Do Not Resuscitate form for a resident, failed to revise care plans for elopement risk and wheelchair seatbelt use, failed to secure chemicals safely, failed to provide appropriate catheter care, failed to store respiratory equipment properly, failed to ensure appropriate use and monitoring of psychotropic medications, failed to monitor blood pressure parameters for hypertensive medication, failed to maintain sanitary dietary standards, and failed to follow infection control practices.
Deficiencies (10)
F578: The facility failed to provide a lawfully recognized Out of Hospital Do Not Resuscitate form for Resident 13, risking non-honor of her DNR choice.
F657: The facility failed to revise care plan interventions to include Resident 1's wheelchair seatbelt and Resident 12's elopement risk, placing residents at risk for ineffective treatment and safety hazards.
F689: The facility failed to identify Resident 12 as an elopement risk and failed to store bleach wipes safely, placing residents at risk for elopement and chemical exposure.
F690: The facility failed to assess for an individualized toileting program for Resident 20 after catheter removal and failed to provide appropriate catheter care for Resident 18, risking urinary tract infections and incontinence.
F695: The facility failed to store oxygen tubing, nasal cannula, and nebulizer equipment in a sanitary manner for Resident 100, increasing risk of respiratory infection.
F756: The facility failed to ensure the Consultant Pharmacist identified and reported inappropriate diagnoses for antipsychotic medication use for Residents 13 and 25, risking unnecessary medication use and side effects.
F757: The facility failed to monitor physician-ordered parameters for Resident 14's hypertensive medication, risking unnecessary medication administration and harmful side effects.
F758: The facility failed to ensure appropriate diagnosis and use of antipsychotic medication Seroquel for Residents 13 and 25, risking unnecessary medication use and side effects.
F812: The facility failed to maintain sanitary dietary standards related to equipment cleaning during food preparation, risking foodborne illness and cross-contamination.
F880: The facility failed to ensure staff practiced hand hygiene and maintain catheter bag sanitation during care for Resident 18, increasing risk of infection and disease transmission.
Report Facts
Sample size: 13
Deficiency count: 10
Seroquel dosage: 50
Seroquel dosage: 12.5
Amlodipine dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA S | Certified Medication Aide | Mentioned in relation to Resident 13 and 25 medication monitoring and respiratory equipment storage |
| LN G | Licensed Nurse | Mentioned in relation to Resident 13, 14, and 25 medication monitoring and respiratory equipment |
| Administrative Staff A | Mentioned in relation to medication regimen review and infection control | |
| Administrative Nurse D | Mentioned in relation to elopement interventions, medication monitoring, respiratory equipment, and infection control | |
| Dietary Staff CC | Dietary Staff | Mentioned in relation to food preparation and equipment cleaning |
| Dietary Staff BB | Dietary Staff | Mentioned in relation to food preparation and hygiene |
| CNA N | Certified Nurses Aid | Mentioned in relation to catheter care and hand hygiene failure |
| CNA O | Certified Nurses Aid | Mentioned in relation to catheter care |
Inspection Report — Mar 23, 2021
Routine CMS
Date: Mar 23, 2021
Visit Reason
Routine inspection of Eureka Nursing Center to assess compliance with care standards including activities of daily living, pressure ulcer care, toileting, behavioral health, and food sanitation.
Findings
The facility failed to provide adequate assistance for dependent residents in facial shaving, pressure ulcer prevention, toileting, and behavioral health interventions. Additionally, the facility failed to maintain sanitary food preparation and storage practices.
Deficiencies (5)
F 0677: The facility failed to provide adequate assistance for shaving of dependent residents' facial hair as care planned.
F 0686: The facility failed to provide appropriate care and services to prevent the development of an unstageable pressure ulcer for one resident.
F 0690: The facility failed to provide toileting opportunities as care planned to maintain normal bladder function for dependent residents.
F 0740: The facility failed to develop interventions to manage a resident's frequent yelling out behavior.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner, including improper sanitizer levels and uncovered or unlabeled food items.
Report Facts
Residents sampled: 14
Sanitizer ppm: 50
Pressure ulcer measurement: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nurse Assistant | Mentioned in relation to shaving and toileting deficiencies |
| Administrative Nurse F | Administrative Nurse | Provided statements regarding care expectations for shaving, toileting, and behavioral interventions |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding shaving, toileting, and care plan monitoring |
| CNA Q | Certified Nurse Assistant | Mentioned in behavioral health deficiency related to resident yelling out |
| Dietary staff CC | Dietary Staff | Interviewed regarding kitchen sanitation and sanitizer levels |
| Dietary staff BB | Dietary Staff | Interviewed regarding sanitizer use and kitchen sanitation |
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