Inspection Reports for
Eureka Rehabilitation & Wellness Center
2353 23rd St, Eureka, CA 95501, United States, CA, 95501
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
195% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Deficiencies: 2
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing services at Eureka Rehabilitation & Wellness Center, LP.
Findings
The facility failed to provide nursing services meeting professional standards for three residents by not initiating or updating care plans after a resident-to-resident abuse incident and by failing to conduct and document the required 72-hour monitoring following a resident's fall. These failures posed potential risks of serious harm, health deterioration, and loss of quality of life.
Deficiencies (2)
Failure to initiate or update care plans following a resident-to-resident abuse incident involving Resident 1 and Resident 2.
Failure to conduct and document 72-hour monitoring after Resident 3's fall.
Report Facts
Residents sampled: 7
Residents affected: 3
BIMS score: 6
BIMS score: 3
BIMS score: 0
Missing monitoring hours: 48
Monitoring period: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Witnessed resident-to-resident abuse incident between Resident 1 and Resident 2 |
| Director of Nursing | Director of Nursing | Confirmed failure to create or update care plans and missing monitoring documentation |
| Director of Staff Development | Director of Staff Development | Confirmed failure to create or update care plans and missing monitoring documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to accurately assess a resident's fall risk and ensure a person-centered care plan, which led to a resident's fall and injury.
Complaint Details
The complaint investigation found that Resident 1 was incorrectly assessed as moderate risk for falls instead of high risk upon admission, which was substantiated by interviews and record reviews. The facility's fall prevention protocol was not followed for Resident 1.
Findings
The facility failed to properly assess Resident 1's fall risk upon admission, incorrectly categorizing her as moderate risk instead of high risk, which resulted in inadequate fall prevention measures. This failure contributed to Resident 1's fall on 5/24/25 causing a nondisplaced distal radius fracture.
Deficiencies (1)
Failed to accurately assess a resident's fall risk status and ensure a person-centered care plan for Resident 1, leading to a fall and injury.
Report Facts
Resident fall risk score: 6
Brief Interview for Mental Status (BIMS) score: 7
Date of fall: May 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Noted Resident 1's fall and reported she was not considered a fall risk prior to the fall |
| Physical Therapy Assistant | Physical Therapy Assistant | Stated Resident 1 needed moderate assistance and was overconfident in transferring without help |
| Regional Quality Management Consultant | Regional Quality Management Consultant | Confirmed incorrect fall risk assessment and that fall prevention protocol was not followed |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 19, 2025
Visit Reason
The inspection was conducted to assess compliance with PASRR screening requirements for mental disorders and to evaluate food storage and labeling practices in the facility.
Findings
The facility failed to ensure accurate PASRR Level I screening for one resident, missing diagnosed mental disorders, and failed to properly label and date food items in the dietary department, potentially affecting all residents.
Deficiencies (2)
Failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of diagnosed mental disorders for 1 of 6 sampled residents.
Failed to ensure food items were labeled and dated in accordance with professional standards, affecting all residents receiving meals.
Report Facts
Residents reviewed for PASRR requirements: 6
Residents affected by PASRR deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medial Records Director | Medical Records Director | Completed Resident #53's PASRR Level I Screening and interviewed regarding PASRR accuracy |
| MDS Nurse #4 | MDS Nurse | Interviewed regarding Resident #53's diagnosis and PASRR screening accuracy |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for PASRR review and food labeling |
| Administrator | Administrator | Interviewed regarding expectations for PASRR accuracy and food labeling |
| Dietary Manager | Dietary Manager | Interviewed and observed during kitchen tours regarding food labeling and dating |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities of daily living, pressure ulcer care, fall prevention, staffing adequacy, and nursing competencies.
Findings
The facility failed to provide scheduled showers and adequate skin care to Resident 1, resulting in pressure injuries and wound infection requiring hospitalization. Licensed nurses did not accurately document skin impairments or monitor for signs of UTI and sepsis, contributing to a fall and fracture. The facility was also found to be short staffed, impacting resident safety and care quality.
Deficiencies (5)
Failure to provide scheduled showers twice weekly to Resident 1, increasing risk of skin breakdown and infection.
Failure to provide appropriate pressure ulcer care, resulting in Resident 1 developing Stage 3 and Stage 4 pressure injuries and wound infection requiring hospitalization.
Failure to recognize signs and symptoms of UTI and sepsis in Resident 1, leading to a fall and femoral fracture.
Failure to ensure adequate nursing staff to meet resident needs, resulting in delayed response to call lights and resident complaints of feeling unsafe.
Licensed nurses failed to accurately document skin impairments and monitor Resident 1 for UTI and sepsis.
Report Facts
Scheduled showers missed: 14
Braden Scale scores: 15
Braden Scale scores: 13
Braden Scale scores: 12
Direct Care Service Hours Per Patient Day (DHPPD): 2.68
Direct Care Service Hours Per Patient Day (DHPPD): 2.63
Direct Care Service Hours Per Patient Day (DHPPD): 3.3
Direct Care Service Hours Per Patient Day (DHPPD): 3.43
Direct Care Service Hours Per Patient Day (DHPPD): 3.08
Direct Care Service Hours Per Patient Day (DHPPD): 3.35
Direct Care Service Hours Per Patient Day (DHPPD): 2.93
Direct Care Service Hours Per Patient Day (DHPPD): 2.99
Fall Risk Evaluation: 15
Skin tear size: 6.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Stated importance of showers and turning to prevent skin breakdown and accurate wound documentation. |
| Licensed Nurse F | Licensed Nurse | Discussed shower frequency, turning, and wound care importance. |
| Director of Nursing | Director of Nursing (DON) | Verified wound assessments, treatment delays, and staffing concerns. |
| Certified Nursing Assistant I | Certified Nursing Assistant | Stated importance of scheduled showers and turning to prevent skin breakdown. |
| Licensed Nurse E | Licensed Nurse | Discussed UTI, sepsis, and fall risk. |
| Certified Nursing Assistant A | Certified Nursing Assistant and Staffing Coordinator | Discussed staffing decisions and short staffing impact. |
| Certified Nursing Assistant C | Certified Nursing Assistant | Reported short staffing and safety risks. |
| Certified Nursing Assistant G | Certified Nursing Assistant | Reported short staffing and safety risks. |
| Infection Preventionist | Infection Preventionist (IP) | Discussed risks of missed showers, wound documentation, UTI, and sepsis. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 13, 2023
Visit Reason
The inspection was conducted due to an allegation of abuse involving Resident 1, specifically regarding failure to timely report suspected abuse as required by facility policy and state law.
Complaint Details
The complaint involved allegations of rough handling by staff toward Resident 1, reported on 10/6/23. The Ombudsman had been working with the facility since July regarding complaints. The facility did not notify appropriate agencies such as the California Department of Public Health, local law enforcement, and Ombudsman within the required timeframe. The Administrator confirmed the allegations were reported and investigated on 10/4/23. An incident involving three CNAs was reviewed in an Interdisciplinary Team Meeting on 08/08/23 but was not presented as an abuse allegation.
Findings
The facility failed to report an allegation of abuse involving Resident 1 within the required timeframe to appropriate agencies, potentially allowing the alleged abuse to continue and preventing proper investigation. The abuse allegation involved rough handling by staff, which was reported and investigated on 10/4/23, but prior incidents were not properly documented or reported as abuse.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
BIMS score: 13
Number of rough handling incidences reported: 5
Timeframe for abuse reporting: 2
Inspection Report
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with privacy requirements related to resident bedrooms, specifically focusing on the functionality of privacy curtains around resident beds.
Findings
The facility failed to ensure that three of 17 sampled resident beds provided full visual privacy due to privacy curtains that did not operate properly, with curtains getting stuck or falling off the rails, which was identified as a pervasive problem.
Deficiencies (1)
Failed to ensure three of 17 sampled resident beds provided full visual privacy due to privacy curtains not operating properly.
Report Facts
Residents sampled: 17
Beds with privacy curtain issues: 3
Beds observed: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistants (CNAs) | CNAs A, B, and D observed having difficulty deploying privacy curtains | |
| Director of Maintenance | Observed privacy curtain issues with beds | |
| Resident Council President | Resident 2 stated privacy curtain issues were pervasive |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident being left in a soiled brief for a prolonged period, causing distress and discomfort.
Complaint Details
The complaint was substantiated; Resident 1 was left in a soiled brief overnight on the night shift, causing discomfort and distress. Staffing shortages and delayed response to call bells were noted.
Findings
The facility failed to ensure dignity and timely care for Resident 1, who was left in a soiled brief overnight. Interviews with residents and staff confirmed staffing shortages and inconsistent care, with residents sometimes left unattended for extended periods. The facility policy requires checking residents wearing briefs every 2 hours, which was not consistently followed.
Deficiencies (1)
Failure to ensure dignity and timely care for a resident left in a soiled brief for a prolonged period.
Report Facts
Brief Interview for Mental Status (BIMS) score: 13
Date of clinical record review: Apr 26, 2023
Date of observation and interviews: May 11, 2023
Date of observation and interview: May 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-B | Certified Nursing Assistant | Assisted Resident 1 in the morning after finding her in a soiled brief and provided information about care practices and resident condition. |
| CNA-A | Certified Nursing Assistant | Interviewed regarding staffing and care practices; stated no observed mistreatment. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement policies and procedures for reporting injuries of unknown source, specifically concerning one resident with an unexplained femur fracture.
Complaint Details
The complaint investigation focused on the failure to report an injury of unknown source involving Resident 1's left femur fracture. The facility did not notify local law enforcement despite policy requirements. Staff were unaware of the policy and reporting protocols. The incident was reported to the state and Ombudsman but not to local law enforcement.
Findings
The facility failed to ensure staff awareness and adherence to policies for reporting injuries of unknown source. Staff interviewed were unaware of the policy, reporting requirements, and protocols, and the facility did not notify local law enforcement of the injury as required. The injury's cause was undetermined, and the facility reported the incident to the state and Ombudsman but not to local law enforcement.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to injury of unknown source.
Report Facts
Residents affected: 3
Date of injury: Mar 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Staff A | Interviewed and stated unawareness of facility policy and reporting protocol for injury of unknown source. | |
| Licensed Staff B | Interviewed and stated unawareness of facility policy and reporting parameters for injury of unknown source. | |
| Unlicensed Staff C | Interviewed and stated unawareness of facility policy and reporting requirements for injury of unknown source. | |
| Licensed Staff D | Assessed Resident 1 on 03/31/23 and noted pain and swelling leading to fracture diagnosis. | |
| Licensed Staff E | Interviewed by DON; reported no fall incidents on 03/31/23. | |
| Unlicensed Staff F | Interviewed and verified Resident 1 had no incidents or falls during night shift on 03/31/23; also unaware of injury reporting policy. | |
| Administrator | Verified injury was not reported to local law enforcement and stated facility policy did not require such reporting. | |
| Director of Nursing | DON | Verified injury details, interviews, and reporting to state and Ombudsman but not local law enforcement. |
Inspection Report
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's pharmaceutical services and compliance with medication administration requirements.
Findings
The facility failed to provide pharmaceutical services to meet the needs of one resident when the medication Eliquis ran out, resulting in the resident missing two consecutive doses and compromising the efficacy of the medication regimen.
Deficiencies (1)
Failure to timely re-order Eliquis for Resident 1, resulting in missed doses.
Report Facts
Medication doses missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Reported Resident 1 missed doses due to medication running out |
| Director of Nursing | Director of Nursing | Observed medication cart and confirmed Eliquis was not available |
Inspection Report
Deficiencies: 3
Date: Mar 29, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards, focusing on personal hygiene assistance, behavioral health care, and medication management for residents.
Findings
The facility failed to provide necessary showering and personal hygiene services to four sampled residents, resulting in potential risks of skin issues. Additionally, the facility failed to provide psychiatric consultation and appropriate behavioral health care for a resident displaying aggressive behavior, and failed to ensure gradual dose reductions and monitoring for antipsychotic medication use.
Deficiencies (3)
Failure to provide necessary services to maintain good grooming and personal hygiene for four sampled residents who did not receive showers on their scheduled days.
Failure to provide psychiatric consultation for a resident displaying aggressive behavior, resulting in repeated physical harm to others and refusals of care.
Failure to ensure one resident was free from unnecessary medications due to lack of attempted gradual dose reduction of antipsychotic medication and lack of monitoring of aggressive behavior.
Report Facts
BIMS score: 9
BIMS score: 1
BIMS score: 8
BIMS score: 7
Antipsychotic medication dosage: 15
Shower counts: 1
Shower counts: 2
Shower refusals: 3
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 2, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with residents' rights to a dignified existence, self-determination, communication, and access to services, focusing on timely assistance to residents.
Findings
The facility failed to ensure timely assistance to residents, resulting in three residents sitting in soiled conditions and feeling uncared for. Interviews and record reviews revealed inconsistent CNA response times and inadequate care, negatively impacting residents' dignity and self-esteem.
Deficiencies (1)
Failure to ensure residents have a right to a dignified existence and access to services in a timely manner, resulting in residents sitting in wet or soiled conditions and feeling uncared for.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Interviewed regarding response times and care practices for residents with incontinence. |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 1, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, staff hiring practices, and quality of life measures including personal property protection, background checks, and shower frequency.
Findings
The facility failed to maintain an accurate personal property inventory for one resident, conducted a criminal background check with a misspelled employee name, and did not provide two showers per week as per policy to two residents, potentially impacting resident safety, staff screening accuracy, and resident well-being.
Deficiencies (3)
Failed to ensure Resident 1's personal property inventory list reflected all clothes stored by the facility.
Failed to ensure criminal background check was accurate due to misspelling of CNA A's name.
Failed to provide or offer showers in the number and frequency desired by Residents 2 and 3.
Report Facts
Items of clothing on inventory list: 30
Items of clothing found in storage: 40
Showers received by Resident 2: 3
Showers received by Resident 3: 3
Shower refusals by Resident 2: 1
Shower refusals by Resident 3: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in finding related to inaccurate criminal background check due to misspelled name |
| Social Services Director | Interviewed regarding Resident 1's personal property inventory | |
| Administrator | Interviewed regarding pre-employment criminal background checks | |
| Director of Nursing | Interviewed regarding shower policy and shower records for Residents 2 and 3 |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Jun 10, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigations into allegations of abuse, resident care, infection control, medication management, and compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to involve responsible parties in care planning, failure to notify responsible parties and physicians of significant changes in residents' conditions, failure to prevent and report abuse, incomplete and inaccurate resident assessments and care plans, inadequate infection control practices, improper medication management, and failure to provide adequate resident hygiene and nutrition.
Deficiencies (19)
Failure to involve the responsible party in the care planning process for Resident 173, resulting in weight loss and lack of communication.
Failure to notify responsible parties and physicians of significant changes in condition for Residents 22, 42, and 173.
Physical abuse of Resident 18 by a Certified Nursing Assistant, substantiated and resulted in termination of the CNA.
Failure to report the results of the abuse investigation of Resident 18 to the California Department of Public Health within five working days.
Inaccurate assessments for Residents 17 and 19, including failure to document venous ulcers and behavioral symptoms.
Failure to develop a baseline care plan within 48 hours for Resident 173 and failure to provide a copy to the responsible party.
Incomplete care plan for Resident 19 regarding use of antipsychotic medication, lacking target behavior and measurable goals.
Failure to complete admission progress notes and accurate skin assessments for Resident 173, including missing documentation of a bruise after a fall.
Failure to provide scheduled showers to Residents 22 and 42, with no documentation of refusals or notifications to responsible parties and physicians.
Failure to act on pharmacist's recommendations to add monitoring for behavior and side effects of psychotropic medications for Residents 67, 19, and 38.
Failure to ensure all drugs and biologicals were labeled with opened and expiration dates and removal of expired medications.
Failure to follow the lunch menu on 6/6/22 by not providing margarine with dinner rolls for all residents.
Failure to prepare food to conserve flavor and palatability for Residents 62, 16, 123, and 19, resulting in complaints of bland and unappetizing food.
Failure to offer or ensure availability of alternate food options to Residents 20, 123, 124, 67, 125, 17, and 19, and failure to provide alternate food lists to some residents.
Failure of the Quality Assurance and Performance Improvement (QAPI) committee to identify and improve on deficiencies related to notifications to responsible parties and monitoring of psychotropic medications.
Failure to follow infection control practices including sanitizing handheld thermometers and pens between uses, lack of hand sanitizers in Memory Lane unit rooms, failure to provide hand hygiene to residents before meals, and presence of broken/missing floor tiles in resident rooms and laundry room.
Failure to promote appropriate use of antibiotics for Resident 35 by initiating antibiotic treatment without meeting McGreer's criteria or reviewing urinalysis and culture results.
Failure to perform daily quality control checks on blood glucose monitors and use of expired Accucheck solution.
Failure to maintain a system to ensure all staff were trained in abuse prevention and reporting, with gaps in training attendance and no tracking system.
Report Facts
Days no quality control check: 46
Staff attendance: 7
Staff attendance: 29
Staff attendance: 34
Staff attendance: 37
Weight loss percentage: 7.2
Venous ulcers: 2
Shower frequency: 8
Shower count: 2
Shower count: 1
Shower count: 4
Shower count: 5
Shower count: 2
Medication dose: 150
Medication dose: 60
Medication dose: 100
Medication dose: 10
Alternate food request time: 11
Alternate food request time: 16
Missing tiles: 2
Missing tiles: 1
Staff attendance: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RP 2 | Responsible Party | Named in care planning and communication deficiencies related to Resident 173 |
| Physician A | Physician | Named in communication and notification deficiencies related to Resident 173 |
| Registered Dietitian (RD) | Registered Dietitian | Named in weight loss and care planning deficiencies |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including care planning, notification, medication monitoring, and infection control |
| Social Services Director (SSD) | Social Services Director | Named in care conference scheduling and notification deficiencies |
| Certified Nursing Assistant (CNA) P | Certified Nursing Assistant | Named in physical abuse incident involving Resident 18 |
| Administrator | Administrator | Named in abuse investigation reporting and staff training deficiencies |
| Licensed Nurse J | Licensed Nurse | Named in wound care and assessment deficiencies for Resident 17 |
| Licensed Nurse H | Licensed Nurse | Named in behavioral monitoring and resident care deficiencies for Resident 19 |
| Licensed Nurse F | Licensed Nurse | Named in bruise documentation deficiencies for Resident 173 |
| Licensed Nurse G | Licensed Nurse | Named in documentation deficiencies for Resident 173 |
| Director of Staff Development (DSD) | Interim Director of Staff Development | Named in staff training deficiencies |
| Infection Preventionist/Director of Staff Development (IP/DSD) | Infection Preventionist/Director of Staff Development | Named in infection control deficiencies |
| Regional Dietary Manager (RDM) | Regional Dietary Manager | Named in food service and alternate menu deficiencies |
| Dietary Services Manager (DSM) | Dietary Services Manager | Named in food service and alternate menu deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 18
Date: Feb 14, 2020
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and investigate resident complaints including loss of personal clothing, environmental conditions, medication administration, and food service.
Findings
The facility was found deficient in multiple areas including loss and misplacement of residents' clothes, failure to develop timely care plans, inadequate staff performance reviews, medication administration discrepancies, unsafe medication storage, food safety and sanitation issues, inadequate infection control practices, unsafe environment conditions, and pest control deficiencies. Immediate jeopardy was identified related to unsafe food storage temperatures and poor sanitation of the ice machine and drain pipes.
Deficiencies (18)
Loss or misplacement of residents' clothes affecting multiple residents.
Failure to develop a baseline fall care plan within 48 hours of admission for Resident 60.
Failure to complete annual performance reviews for CNA 27 for 36 months.
Discrepancies in dispensation and administration of controlled drugs leading to unaccounted medications.
Opened bottle of irrigation solution found in medication room without proper labeling.
Failure to maintain food safety and sanitation in kitchen and nursing unit food pantries, including improper food labeling, dirty equipment, and inadequate staff training.
Failure to provide food that meets resident preferences and therapeutic diet requirements, including serving unapproved alternate menu items and failure to follow menu.
Failure to provide suitable nourishing meals at requested alternate times for Resident 47, resulting in discarded meals and inadequate nutrition.
Unsafe food storage temperatures in utility room refrigerators with turkey sandwiches held above 41°F for over 6 hours, leading to immediate jeopardy.
Ice machine and drain pipes were dirty and contained sludge; facility lacked an appropriate water management program.
Equipment and utensils in kitchen were dirty, in poor condition, and not properly maintained.
Facility failed to dispose of garbage properly; outside trash container was open with trash on ground attracting rodents.
Incomplete and inaccurate medication administration records for Resident 28.
Delayed implementation of quality improvement plan to address loss of resident clothes; QAPI committee lacked records for five months.
Facility failed to maintain infection prevention and control program including poor hand hygiene by housekeeping, improper disinfection of glucometer, and unclean ice machine.
Insufficient lighting in kitchen with multiple ceiling lights out or flickering, creating unsafe working conditions.
Unsafe environment with dirty toilets left unclean for a whole day and unsecured electrical cords in resident rooms.
Facility failed to maintain pest control program; presence of ants, flies, and rodents; broken window screens; improper garbage disposal.
Report Facts
Lost resident clothing events: 48
Missing controlled drug units: 16
Refrigerator temperatures above 41°F: 3
QAPI meeting record gap: 5
Pest control inspection gap: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 27 | Certified Nursing Assistant | Failed to have annual performance reviews for 36 months |
| Director of Nursing | Director of Nursing | Acknowledged medication administration discrepancies and incomplete MAR |
| Certified Dietary Manager | Certified Dietary Manager | Acknowledged food safety and sanitation deficiencies in kitchen |
| Maintenance Supervisor | Maintenance Supervisor | Confirmed ice machine and drain pipe sanitation issues |
| Registered Dietitian 1 | Registered Dietitian | Conducted kitchen audits and identified sanitation and safety issues |
| Housekeeping Staff 1 | Housekeeping Staff | Observed not washing hands between rooms and improper glove use |
| Housekeeping Staff 2 | Housekeeping Staff | Observed not washing hands between rooms and improper glove use |
| Administrator | Administrator | Acknowledged QAPI delays and facility deficiencies |
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