Inspection Reports for
Eureka Rehabilitation & Wellness Center

The facility failed to provide nursing services meeting professional standards for three residents by not initiating or updating care plans after resident-to-resident abuse incidents and by not completing required 72-hour monitoring after a resident's fall. These failures posed risks of serious harm, health deterioration, and loss of quality of life.

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.

The complaint investigation found that Resident 1 was incorrectly assessed as a moderate fall risk instead of high risk upon admission, which was substantiated by interviews and record reviews. The facility's fall prevention protocol was not followed, contributing to Resident 1's fall and injury.

The facility failed to properly assess Resident 1's fall risk upon admission, incorrectly categorizing the resident as moderate risk instead of high risk. This failure led to inadequate care planning and contributed to Resident 1's fall on 5/24/25, resulting in a nondisplaced distal radial fracture.

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.

The complaint investigation focused on Resident 1's failure to receive scheduled showers, inadequate pressure ulcer care, failure to monitor and treat UTI and sepsis, resulting in a fall and fracture. Staffing shortages and inadequate nurse competencies were also investigated.

The facility failed to provide scheduled showers to Resident 1, resulting in skin breakdown and pressure injuries, including a Stage 4 pressure injury with infection requiring hospitalization. Licensed nurses failed to accurately document wounds and monitor for UTI and sepsis, leading to a fall and femoral fracture. The facility was also found to be short staffed, impacting resident care and safety.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The facility failed to provide pharmaceutical services to meet resident needs for one resident when the medication Eliquis was not available, resulting in two missed doses. This failure was due to either not re-ordering the medication or pharmacy delivery delays.

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.

The investigation was complaint-driven, focusing on allegations that the facility did not provide scheduled showers to residents and failed to provide psychiatric consultation and proper medication management for a resident exhibiting aggressive behavior. The complaints were substantiated based on observations, interviews, and record reviews.

The facility failed to provide scheduled showers to four sampled residents, risking skin issues and infections. Additionally, the facility failed to provide psychiatric consultation and proper monitoring of antipsychotic medication for a resident with aggressive behavior, resulting in repeated harm to others and lack of appropriate medication dose reduction.

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.

The complaint investigation substantiated that residents experienced delays in assistance, with one resident waiting two hours to be cleaned before breakfast and others sitting in soiled conditions for long periods. Staff interviews confirmed inconsistent response times and occasional staff frustration.

The facility failed to ensure residents' rights to a dignified existence and timely assistance. Three residents were found to have waited extended periods in soiled conditions, negatively impacting their dignity and well-being.

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.

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.

The facility had multiple deficiencies including failure to maintain a safe, clean, and homelike environment; loss and misplacement of residents' clothes; inadequate baseline care planning; incomplete nurse aide performance reviews; medication administration discrepancies; unsafe medication storage; food safety and sanitation issues; inadequate infection control; unsafe environment hazards; and pest control deficiencies.