Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Granada Rehabilitation & Wellness Center, Lp during CMS and state inspections, most recent first.
Incomplete Neurological Assessment After Head Injury: A resident with dementia, anxiety, depression, and mild cognitive impairment was struck on the right temple during an altercation with his roommate and had a lasting headache. The facility initiated Q4h neuro checks, but the chart contained no flowsheets or documentation showing a complete neuro assessment; the ADON stated entries such as “neuros wnl” or “neuros at baseline” were acceptable, and the DON said there was no neuro assessment policy or competency process.
Failure to Protect Resident from Physical Abuse: A resident with dementia, depression, anxiety, and unsteadiness on feet was struck on the head several times by a roommate after a verbal exchange over a TV program. Staff separated the residents after the assault, and the injured resident had an elevated BP and a headache that lasted until the next day; the ADM acknowledged the assault occurred.
Failure to notify the state mental health authority after significant mental health changes for two residents. One resident with CHF, malnutrition, and muscle weakness later developed depressed mood, disorganized and tangential thinking, and assaulted a roommate; another resident with metabolic encephalopathy and cognitive communication deficit was later diagnosed with adjustment disorder with anxiety. Neither record documented the required PASRR-related notification, and the MDS nurse and nursing staff did not notify the Medical Records Director of the changes.
Insufficient dietary staffing led to cleaning and sanitation tasks being deferred when staff assigned to sanitation were reassigned to cover vacant food prep roles. The CDM reported multiple staffing vacancies, including a cook on leave, a cook who resigned, and diet aides on leave, while observations found grease and food debris on the stove, stains on the backsplash, debris and residue on the oven, dust buildup behind the oven, and dust in the toaster vents.
Food storage, sanitation, and equipment maintenance were deficient in the kitchen. Two dietary staff wore hair restraints that did not fully cover their hair, expired food and drink were found in refrigeration, moldy strawberries and onions were observed, and multiple kitchen surfaces and equipment had grease, dust, residue, and debris buildup. Ice buildup was also noted on a freezer door gasket, and the MND stated the gasket needed replacement and that kitchen equipment was not routinely inspected.
An LPN failed to protect resident information during a med pass for three residents when the laptop was left partially open and the screen was not locked or logged out. Visitors were seen walking past while the resident chart remained visible, and the LPN confirmed the screen was not secured. The ADON stated resident privacy was expected to be protected by turning the med cart away from public view or using the lock screen.
Medication Storage and Labeling Deficiencies: An LPN found one unlabeled bottle of eye drops, two inhalers without open dates, and three loose pills in a medication cart, and later found an expired insulin pen in a medication fridge. The LPN and ADON stated medications should have resident labels and open dates, and expired medications should be removed; the facility policy also required pharmacy-labeled storage and removal of outdated meds.
Staff failed to follow EBP for multiple residents by not wearing gowns and gloves during high-contact care such as linen changes, transfers, and ambulation, despite posted precaution signs. A CNA, PT, OT, and SLP were observed providing care without PPE for residents with elevated WBCs, wounds, bacteremia, and MRSA. In addition, several rooms lacked clear precaution signage or accessible PPE, and an oxygen concentrator for a resident with respiratory failure and COPD was observed with visible dust and debris on the unit and filter.
A resident admitted with cellulitis and under conservatorship did not have documented evidence that admissions or social service staff asked the RP about an Advance Directive. The admissions agreement left the Advance Directive section blank, and the MRD stated no Advance Directive paperwork was available. The ADON and Interim DON said residents or their RPs were expected to be asked about Advance Directives and life-sustaining treatment wishes upon admission.
Failure to Provide Baseline Care Plan Summaries: Licensed nurses and social service staff failed to provide written baseline care plan summaries to two residents after admission. Both residents were their own RP, had baseline care plans signed by the ADON, SSD, and DOR, but neither signed the document or reported receiving a copy of the summary. One resident had osteoporosis, a R heel pressure ulcer, muscle weakness, and repeated falls; the other had polyosteoarthritis, hypoxemia, and muscle weakness.
A resident with BPH, diabetes, and an indwelling Foley for urinary retention had orders and a care plan requiring catheter care each shift and monitoring for pain and UTI symptoms, yet CNAs did not document catheter care and there was no evidence of catheter securement with a leg strap as required by facility policy and CDC-based practices. The resident, who was dependent for toileting and hygiene, was repeatedly documented as having no genital skin issues until an OT noted unsecured tubing, yellow drainage on clothing and the penis, and a split penile opening, prompting nursing assessment. LNs then documented a lacerated urethral meatus with purulent green-yellow exudate tracking down the catheter, and subsequent testing showed pseudomonas aeruginosa UTI associated with the indwelling catheter, while the MD indicated the tearing and infection had developed over time and should have been detected during ordered foley care.
The facility did not complete required baseline care plans (BCPs) within 48 hours of admission for two residents, including one with dementia and stage 2 PUs on both buttocks and another with dementia and muscle weakness. For the resident with PUs, the BCP and a skin care plan addressing the wounds were not completed until nearly a month after admission. During an interview and record review, the DON confirmed that facility policy requires BCPs within 48 hours and that this was not done for either resident, despite the policy stating that timely BCPs are needed to promote continuity of care, staff communication, resident safety, and to safeguard against adverse events.
A resident with COPD and moderate cognitive impairment was allowed to self-administer a nebulizer treatment without a physician order or a completed self-medication assessment, and more than 1 ml of medication remained in the nebulizer cup when the nurse stopped the treatment. The resident also reported not receiving a prescribed laxative, despite the EMAR showing it as administered. An LN initially asserted the laxative had been given but, after failing to find the expected used cup in the trash, acknowledged it had not been administered and that documentation had been completed contrary to facility policy requiring documentation only after actual administration.
A resident with CHF, hypertensive heart disease, and muscle weakness was involved in an altercation with a roommate, and nursing staff failed to follow abuse and COC procedures. Although a nurse noted the altercation and the plan to monitor the resident, there was no immediate documented assessment for injury or distress, no timely COC entry, and no contemporaneous documentation of MD or family notification. The DON later entered a backdated COC note and 72-hour behavior monitoring notes were completed 48–72 hours late, and the DON confirmed that required 72-hour checks and assessments were incomplete and below expected standards, despite prior staff training and written policies requiring prompt assessment, notification, care plan updates, and 72-hour monitoring.
The facility failed to report an allegation of verbal abuse within the required timeframe. A cognitively intact resident with developmental delay, rheumatoid arthritis, MDD, and anxiety reported that a CNA told her he wanted to clean her vagina, which made her uncomfortable with male CNAs providing this care. The ADM and DON stated the incident was reported internally the same evening it occurred and that CDPH was called, but they could not provide documentation of timely reporting. Review of the SOC 341 showed that CDPH, the Ombudsman, and law enforcement were notified the following day, contrary to facility policy requiring notification of law enforcement and submission of SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours of any abuse allegation.
Failure to Provide Ordered Drain Care: A resident with two abdominal surgical drains was admitted with orders to flush both drains and monitor output, but the facility did not document drain flushing, output monitoring, or a drain care plan. The DON acknowledged there was no nursing protocol for drain management and no evidence nurses obtained orders for it. At follow-up, the surgeon found the drains clogged and neglected, documented that nursing had not been flushing them, and the resident was later readmitted to the hospital with a closed-space infection that had eroded through the abdominal wall.
A licensed nurse gave a dose of a resident's prescribed propranolol to a staff member experiencing anxiety, in violation of facility policy and professional standards. The staff member did not take the medication and disposed of it, resulting in the loss of a resident's dose. The incident was confirmed through staff interviews and security camera footage.
A resident with multiple risk factors, including hemiplegia, dementia, and a history of falls, was not provided with a fall risk care plan upon admission despite being identified as high risk. The lack of a care plan led to an unwitnessed fall resulting in a rib fracture and significant pain, with staff and the DON confirming that required protocols were not followed until after the incident.
A facility failed to conduct a Level II PASARR for a resident who received new mental illness diagnoses of bipolar disorder and schizoaffective disorder. Despite the facility's policy requiring PASARR updates, staff interviews revealed a lack of awareness and action, with the only PASARR on file being from the resident's initial admission. The MDS Coordinator was responsible for ensuring updates, but this was not done, resulting in the deficiency.
A facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with multiple pressure ulcers. Despite the facility's policy requiring EBP for wound care, a nurse did not wear a gown, citing the wound's lack of exudate. Interviews revealed inconsistent understanding among staff about when EBP should be applied, contributing to the deficiency.
Incomplete Neurological Assessment After Head Injury
Penalty
Summary
The facility failed to ensure nursing services met professional standards for one resident after a head injury. Resident 2 had diagnoses including dementia, depression, anxiety, and unsteadiness on feet, and his MDS indicated mild cognitive impairment. Following a verbal and physical altercation with his roommate, he had a lasting headache after being struck on the right temple, and the facility initiated alert charting and ordered neurological checks every four hours due to complaints of headache. During interview and record review, the Assistant Director of Nursing stated the chart contained no flowsheets or documentation showing the components of a complete neurological assessment after the head injury. The ADON stated that documentation such as “neuros wnl” or “neuros at baseline” was acceptable and that the facility had no neurological assessment policy, procedure, or protocol. The DON stated nurses should know how to perform neurological checks and that no competencies were provided by the Director of Staff Development. Licensed nurses interviewed described neurological checks as including pupils, hand grip, vital signs, level of consciousness, pain, response, speech, and extremity movement, but these components were not documented in the resident’s record.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect one of six sampled residents from abuse when Resident 3 struck Resident 2 during a physical altercation in their shared room. Resident 2 had diagnoses including dementia, depression, anxiety, and unsteadiness on feet, and his MDS indicated mild cognitive impairment. Resident 3 had diagnoses including congestive heart failure, malnutrition, and muscle weakness, with his MDS showing mild problems with memory, orientation, and decision-making. A psychology progress note also described Resident 3 as having adjustment disorder with depressed mood related to medical conditions, functional limitations, increased need for assistance, and rehab placement. According to nursing progress notes, Resident 3 became upset because Resident 2 was watching a war movie on the television. After a verbal exchange, Resident 3 hit Resident 2 on the head several times, and staff then responded and separated the residents. Resident 2 was assessed after the incident and had no visible bruising or bleeding, but he had an elevated blood pressure reading of 159/101 and complained of a headache that lasted until the next day. He was given pain medication for discomfort. During interview, the Administrator acknowledged that the assault against Resident 2 occurred.
Failure to Notify State Mental Health Authority After Significant Mental Health Changes
Penalty
Summary
The facility failed to notify the state mental health authority for two sampled residents who had significant changes in mental health status. One resident was admitted with CHF, malnutrition, and muscle weakness, had a PASRR Level 1 screening showing no need for a Level 2 screening due to negative SMI, later developed mood symptoms and was diagnosed with adjustment disorder with depressed mood, then showed disorganized and tangential thought processes and became upset and physically attacked his roommate after a war movie was being watched in the shared room. The medical record did not document notification to the state mental health authority regarding this change in mental health status. A second resident was admitted with metabolic encephalopathy and cognitive communication deficit, had a PASRR Level 1 screening showing no need for a Level 2 screening due to negative SMI, and was later diagnosed with adjustment disorder with anxiety. The record did not document notification to the state mental health authority regarding this significant change in mental health status. During interview, the Medical Records Director stated she was responsible for ensuring PASRR processes were completed and that the MDS nurse and nursing staff were responsible for notifying her when residents experienced significant mental health changes requiring renewed PASRR referral, but she had not received notification regarding either resident.
Insufficient Dietary Staffing and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to provide a sufficient number of dietary staff to carry out food and nutrition service functions when staff responsible for cleaning and sanitation were reassigned to cover vacant food preparation roles. During a concurrent observation and interview with the Certified Dietary Manager in the kitchen, the stove had large amounts of grease and food debris built up around and beneath all burners, and the backsplash behind the grill was stained with grease. The Certified Dietary Manager stated she was an interim traveler CDM until the current CDM in training could resume classes to become certified, and that the CDM in training had been pulled to work as a cook until the position could be filled. During a later interview, the Certified Dietary Manager stated the dietary department was short staffed because the full-time cook was on leave, the morning cook resigned, a diet aide was out on leave, and the morning diet aide had just gone out on medical leave for 3 months. She stated these vacancies had affected tasks such as cleaning and sanitation, which were pushed to the bottom of the list of priorities. Additional observations in the kitchen showed the side of the oven had accumulated food debris, rust-colored stains, and white residue of unknown origin, the space between the back of the oven and the wall had significant dust buildup, and the toaster had a large amount of dust accumulated in the upper vents above the serving tray.
Food Storage, Sanitation, and Equipment Maintenance Deficiencies
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards in the kitchen and storage areas. During observation, two dietary staff members wore hair restraints that did not fully cover the back of their heads, leaving hair exposed. The Certified Dietary Manager stated she was unaware the hair nets were not fully covering the hair and explained that the staff members’ high bun hairstyles caused the restraints to pull up and expose hair. The facility policy required an effective hair restraint in kitchen and food storage areas, and the FDA Food Code required hair restraints to be worn to keep hair from contacting exposed food and clean equipment. Expired and unsafe food items were found in refrigeration and storage areas. A refrigerator contained shredded carrots with a use-by date of 4/18/26, parsley with a use-by date of 4/1/26, and a pitcher of punch marked with a use-by date of 4/19/26. The CDM stated these items should have been thrown out and that expired food and drink were considered unsafe to consume. In another observation, packaged strawberries in the refrigerator were covered with white mold, and a bin of onions in dry storage contained onions with gray/black mold. The CDM stated the moldy strawberries and onions should have been discarded. The facility’s food storage policy directed staff to check and sort fresh vegetables and use the oldest produce first, and the FDA Food Code required unsafe food to be discarded. Kitchen equipment and surrounding surfaces were not maintained in a clean and operable condition. The stovetop had greasy, hardened black residue around and in all burners, the backsplash was stained with grease, the side of the oven had white and rust-colored residue, and the toaster vents had dust accumulation. Dust and debris were also observed between the oven, stovetop, and wall, including clumps adhered to the wall, pipe, and floor. The CDM stated the stovetop was cleaned once per week and that staffing shortages had affected cleaning and sanitation tasks. Ice buildup was also observed on the freezer door gasket, and the Maintenance Director stated the gasket had gone bad and needed replacement; he also stated he did not routinely schedule inspections of kitchen equipment. The facility policies and the FDA Food Code required equipment and food-contact and nonfood-contact surfaces to be kept clean and in good repair.
Failure to Protect Resident Electronic Information During Medication Pass
Penalty
Summary
The licensed nurse failed to protect resident information during a medication pass for three residents when the laptop used for charting was not locked after medications were prepared. During observation, the nurse closed the laptop lid halfway and left the screen partially visible while visitors walked past the cart. The nurse later confirmed that she did not lock the computer screen or log out of the resident chart and stated that someone could see resident information if they lifted the laptop screen. The Assistant Director of Nursing stated that resident privacy was expected to be protected by turning the med cart away from public view or using the lock screen. The facility policy on electronic protected health information stated that resident medical records must be maintained to protect electronic protected health information from unauthorized use and access, and that monitors should face away from public view.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Licensed nurses failed to maintain proper medication storage and labeling in one of two medication carts and one of two medication storage room refrigerators. During a concurrent observation and interview with Licensed Nurse 2, one bottle of [brand name] contact lens drops was found without a resident identifier, two budesonide inhalers were found without open dates, and three loose pills were found in Side Two Top medication cart. LN 2 stated medications needed a resident label so they would not be given to the wrong resident, that medications needed open dates because some medications have time frames and could be expired, and that loose pills in the cart could lead to missed doses or could possibly be taken by staff. During a later observation and interview with LN 2, a long-acting insulin pen with an expiry date of [DATE] was found in the Side Two medication fridge. LN 2 stated expired medication may have a reduced or negative effect if given to a resident. The ADON stated she expected all medication to have open dates, all prescribed medications to have resident names, and expired medications to be removed. The facility policy stated medications dispensed by the pharmacy are stored in the container with the pharmacy label, outdated medications are immediately removed from inventory, and medication storage areas are kept clean and free of clutter.
Failure to Follow EBP and Maintain Oxygen Equipment
Penalty
Summary
Infection prevention and control practices were not implemented for residents on Enhanced Barrier Precautions (EBP) when staff entered resident rooms and performed high-contact care without wearing the required gown and gloves. Resident 25 was admitted with an unspecified elevated white blood count, and during an observation a CNA changed the bed linens in the resident’s room without PPE even though an EBP sign was posted outside the room indicating gloves and a gown were required for changing linens. Resident 40 was admitted with an elevated white blood count and an open wound of the right back wall of the thorax, and during observation a CNA transferred the resident to a wheelchair without wearing a gown or gloves despite EBP signage posted outside the room. Resident 40 was also observed with a PT and an OT assisting with ambulation and transferring the resident to a wheelchair without PPE, even though EBP signage was posted in front of the room and above the bed. In interview, the CNA stated PPE was used only when cleaning a resident and that the sign had just been noticed. The COTA stated barrier precautions meant gowning up, said the EBP sign had never been noticed, and stated no one had told her about it. The CNA who changed linens for Resident 25 stated PPE was not worn because the bed was already clean and there was no food or soilage. Resident 96 was admitted with bacteremia and MRSA, and during an observation the SLP and a CNA transferred the resident to bed without gowns while EBP signage was posted outside the room. Both staff confirmed they were not wearing gowns and stated that not wearing a gown could spread infection. The resident’s care plan indicated EBP was required related to a history of MRSA and that staff were expected to implement EBP to prevent the spread of infections. In addition, 12 rooms were observed for infection control signage and PPE storage, and one room had no precaution signage posted, two rooms had no PPE supplies outside the room, and 11 rooms had PPE supplies stored deep inside the room, with supplies in three of those rooms not easily noticeable. For Resident 46, who had respiratory failure with hypoxia and COPD and was ordered oxygen at 2 L via nasal cannula, an oxygen concentrator near the bed was observed with visible dust and debris on the outside and a filter containing visible dust, lint, and debris. Staff interviews identified differing expectations about who was responsible for cleaning the concentrator, and the maintenance director stated there was no documentation received for work completed by the third-party vendor.
Failure to Document Advance Directive Discussion at Admission
Penalty
Summary
The facility failed to ensure that Resident 20 was asked about an Advance Directive during the admission process. Resident 20 was admitted in February 2026 with a diagnosis of cellulitis of the buttocks and was documented as having a Public Guardian as the responsible party. The medical record showed Resident 20 was conserved on 3/19/25, but there was no documented evidence in the progress notes that admissions or social service staff discussed an Advance Directive with the resident's responsible party. The admissions agreement signed on 4/2/26 had the Advance Directive section left blank, and none of the questions in that section were reviewed or asked of the resident's responsible party. The Medical Records Director stated that Resident 20 did not have Advance Directive paperwork because he was in the process of getting conserved, while the ADON and Interim DON stated that all residents or their responsible parties were expected to be asked about Advance Directives and life-sustaining treatment wishes upon admission. The resident's responsible party later confirmed they were unaware Resident 20 did not have an Advance Directive and wanted Resident 20 to have one.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
Licensed nurses and social service staff failed to provide written summaries of the baseline care plans for two residents, Resident 8 and Resident 14, to communicate their initial goals of care within 48 hours of admission. Resident 8 was admitted in February 2026 with diagnoses of age-related osteoporosis, muscle weakness, a pressure ulcer of the right heel, and repeated falls, and the face sheet identified her as her own responsible party. Resident 14 was admitted in March 2026 with diagnoses of polyosteoarthritis, hypoxemia, and muscle weakness, and her face sheet also identified her as her own responsible party. Record review showed that both residents had baseline care plans signed by the ADON, SSD, and DOR, but neither resident signed the document. During interviews, Resident 14 stated she did not receive a copy of her baseline care plan summary, and Resident 8 stated she never received a copy of her baseline care plan summary. The ADON reviewed the facility policy and stated the facility must provide the resident and their representative with a summary of the baseline care plan that includes the initial goals of the resident, a summary of medications and dietary instructions, and any services and treatments provided.
Failure to Provide and Document Proper Catheter Care Resulting in Meatal Injury and CAUTI
Penalty
Summary
Staff failed to provide appropriate urinary catheter care and monitoring for a male resident with benign prostatic hyperplasia (BPH) and diabetes mellitus who had an indwelling urinary catheter for urinary retention. The resident’s care plan identified the catheter and included a goal to be free from catheter-related trauma, with expectations that staff monitor, document, and report pain or discomfort and signs and symptoms of UTI to the physician. Orders were in place for insertion of an indwelling catheter and for catheter care starting on 1/4/26, and the MAR showed LNs documented catheter care every shift from 1/13/26 through 1/19/26. Earlier skin assessments and shower sheets documented no genital skin concerns, and the resident was documented as dependent for toileting hygiene, lower body dressing, and personal hygiene. On 1/19/26, an OT noted drainage from the catheter site while assisting the resident with a transfer and observed that the catheter tubing was not secured to the resident’s thigh. The OT saw a large smear of yellowish drainage on the resident’s pants and the tip of the penis, and observed that the opening of the penis appeared split, which she reported immediately to nursing. Subsequent nursing assessment documented that the resident’s urethra was split down the middle, approximately 1/2 inch thick, with purulent green and yellow exudate inside the urethra and extending down the catheter tubing. The resident reported that the catheter hurt, that it had been like that “for a while,” and that he had pain in the area when moving or when catheter care was provided. A skin assessment later that day identified a new, facility-acquired laceration on the urethra of the penis, measuring approximately 1.5 cm by 0.5 cm, with erythema, edema, increased exudate, and sharp pain. A UA and C&S subsequently showed turbid urine, 3+ leukocyte esterase, positive blood, positive nitrites, and many bacteria, with pseudomonas aeruginosa identified as the causative organism. An ED exam documented pus around the meatus, enlarged testicles with swelling, erythema, and tenderness, and diagnosed a UTI associated with the indwelling urethral catheter. The DON stated that CNAs were responsible for catheter care, including cleaning around the meatus, and confirmed there was no documented evidence in the EMR that CNAs had provided catheter care for this resident. The DON also acknowledged there was no documentation of use of a leg strap or other securement device for the catheter, despite facility policy and CDC guidance requiring securement and daily meatal assessment and cleaning. The physician stated the meatal tearing likely occurred in small increments over time and that the infection should have been detected by nursing staff given that foley care was ordered every shift. Facility policies on indwelling catheters and pressure injury prevention required securement of catheters to the thigh and daily observation for signs of potential or active pressure injury related to medical tubes and catheters. CDC guidance referenced by the facility emphasized proper catheter securement to prevent urethral traction, daily meatal cleaning during bathing, and assessment of the meatus for redness, irritation, drainage, and encrustation. Despite these expectations, there was no evidence that catheter securement devices were used or documented for this resident, and no CNA documentation of catheter care was found. The failure of LNs and CNAs to provide and document appropriate catheter care, to secure the catheter, and to identify and report progressive meatal injury and infection resulted in a facility-acquired mucosal membrane injury to the urinary meatus and a severe UTI with pseudomonas aeruginosa associated with the indwelling catheter.
Failure to Complete Timely Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to complete baseline care plans (BCPs) within 48 hours of admission for two residents, contrary to its policy and regulatory expectations. Resident 1 was admitted on 1/7/2026 with dementia and documented stage 2 pressure ulcers on both sides of the buttocks. Although the BCP noted that the resident was admitted with stage 2 pressure ulcers, the BCP itself was not completed until 2/5/2026, nearly one month after admission. Additionally, Resident 1’s skin care plan/care plan for the pressure ulcers was not initiated until 2/5/2026, despite the presence of existing pressure ulcers at admission. Resident 2 was admitted on 2/2/2026 with dementia and muscle weakness, but the BCP for this resident was also not completed until 2/5/2026, exceeding the 48-hour requirement. During an interview and concurrent record review on 2/5/2026 at 11:17 a.m., the DON confirmed that facility policy required BCPs to be completed within 48 hours of admission and acknowledged that neither resident’s BCP met this timeframe. The DON also confirmed that the absence of a timely BCP and skin care plan could increase the risk of unsafe care, including risk for skin breakdown and wound worsening. A review of the facility’s Person-Centered Care Planning policy, revised 4/24/2025, indicated that the baseline care plan was to be developed and implemented within 48 hours of admission to promote continuity of care, communication among staff, resident safety, and safeguard against adverse events.
Failure to Ensure Safe Self-Administration and Accurate Medication Documentation
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident with COPD and moderate cognitive impairment. The resident, admitted in November 2025 and scoring 12 on the BIMS, was observed on the morning of 2/5/26 self-administering a nebulizer treatment alone in her room without staff present. The resident reported she had always given herself the nebulizer treatment. During an interview and observation, LN B confirmed the resident had administered the nebulizer treatment herself, acknowledged there was no physician order for self-administration, and that no self-medication administration assessment had been completed. LN B also verified that more than 1 ml of medication remained in the nebulizer cup when the treatment was stopped. The DON later confirmed there was no order or assessment authorizing the resident to self-administer medications, despite facility policy requiring both before self-administration. The facility also failed to ensure accurate medication documentation for the same resident. Review of the EMAR for 2/5/26 showed that polyethylene glycol had been documented as administered at 9:00 a.m. The resident stated she had not received her laxative, which she expected to be mixed with water in a disposable cup. When challenged by the resident to locate the used cup in the trash, LN B checked the trash can, found no cup, and then recalled she had not actually given the laxative. During a concurrent record review, LN B verified that the EMAR indicated the polyethylene glycol had been administered and acknowledged she had not followed facility policy, which required documenting medication administration on the EMAR only after the medication was actually given. The DON confirmed the facility policy required immediate documentation after administration and stated that documenting a medication as given when it was not could mislead clinical decisions and put resident safety at risk.
Failure to Implement Abuse Policy and Change of Condition Procedures After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention and management policy and its change of condition documentation procedures following an alleged altercation involving one resident. The resident was admitted with chronic systolic CHF, hypertensive heart disease, and generalized muscle weakness, and had no documented memory impairment. On 12/25/25, a health status note by a licensed nurse recorded that the resident was in an altercation with his roommate and would be on alert charting and monitored for changes or concerns. However, there was no documented immediate assessment of the resident for physical injuries or emotional distress, no timely change of condition (COC) entry, and no contemporaneous documentation of physician or family notification as required by facility policy and the facility’s COC lesson plan. The DON later entered a COC note effective 12/25/25 but written on 12/26/25, documenting that the MD was notified and recommended monitoring, and stated she wrote it because she realized it had not been done and was needed to trigger alerts. Progress notes reflecting behavior monitoring for 72 hours after the alleged abuse incident, with effective dates of 12/27/25 and 12/28/25, were documented 48–72 hours late on 12/30/25. The DON confirmed that the 72-hour checks were incomplete, the assessments were not written to the expected standard, and there were no documented assessments immediately after the altercation. This occurred despite the DSD’s statement that nurses had been trained to chart assessments, COC, and 72-hour checks immediately after a resident was identified as a victim of an abuse allegation, and despite written policies requiring immediate assessment, MD and responsible party notification, care plan updates, and 72-hour monitoring documentation.
Failure to Timely Report Alleged Verbal Abuse to Required Agencies
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving one resident was reported to the California Department of Public Health (CDPH) within the required timeframe. The resident had been admitted with diagnoses including developmental delay, rheumatoid arthritis, major depressive disorder, and anxiety disorder, and had a BIMS score of 13, indicating cognitively intact status. During an interview, the resident reported that a CNA said to her that he wanted to clean her vagina. The resident stated that this disturbed her, that she did not feel comfortable having male CNAs clean her, and that she wanted to keep her dignity. The Administrator and DON stated that the resident reported the event to the Nurse Supervisor on the evening of 12/6/25, and that the Nurse Supervisor then notified them. The DON stated she called the incident in to CDPH that same evening; however, the Administrator and DON were unable to provide documented evidence that the event was reported to CDPH on that date. A review of the SOC 341 form showed that CDPH, the Ombudsman, and law enforcement were notified of the alleged abuse on 12/7/25. The facility’s Abuse Prevention and Management policy required the administrator or designee to notify law enforcement by telephone immediately or as soon as possible, but no longer than two hours after an initial report, and to send a written SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours, for all allegations of abuse.
Failure to Provide Ordered Surgical Drain Care
Penalty
Summary
The facility failed to provide ordered care for a resident with two surgically placed abdominal drains after admission. Hospital records showed the resident had a drain on the right lateral flank and another on the right medial upper quadrant after surgery for a liver abscess and related intra-abdominal infection. The hospital discharge instructions directed nursing staff to flush both drains with 10 cc normal saline every 8 hours until the drains were discontinued, and later surgeon instructions changed the flushing frequency to once daily while also directing that the drain bellows remain compressed. The resident’s diagnoses on admission included liver abscess, peritoneal abscess, and encounter for change or removal of drains. The resident’s care plan did not include the surgical drains or interventions for drain care, and the facility’s records did not show documented drain output monitoring or evidence that the drains were being flushed between admission and the resident’s later surgical follow-up. The DON stated the facility did not have a nursing protocol for drain management, that nurses called the doctor for drain management orders, and that there was no documented evidence of such calls. The DON also acknowledged that nurses had not called the physician to obtain orders for management of the resident’s drains upon admission and that no care plan had been initiated for drain management. At follow-up visits, the surgeon documented that nursing at the facility had not been flushing the drains, that the medial drain appeared clogged with thick exudative output, and that the drain bag was nearly full and had not been emptied in several days. The surgeon wrote that it was clear the resident was not receiving appropriate wound care at the facility despite multiple instructions to flush the drains. The resident was later sent back to the hospital, where the admitting physician documented that failure to flush the drain repeatedly at the facility had resulted in a closed-space infection that had eroded through the abdominal wall and was in communication with an abdominal wound and the previous drain site.
Nurse Administers Resident Medication to Staff Member
Penalty
Summary
A licensed nurse failed to follow professional standards by removing a dose of propranolol, a prescription medication intended for a resident with hypertension, from the medication cart and offering it to an unlicensed staff member who reported experiencing anxiety. The staff member took the medication from the nurse but ultimately disposed of it in a hopper without ingesting it. The medication was specifically labeled for a resident who had an active physician's order for propranolol 40 mg three times daily for hypertension. The nurse had full access to the medication cart and did not have a physician's order to administer the medication to the staff member. Facility policy and the nurse's job description both require that medications be administered only as ordered by a physician and only to the intended resident. Interviews with staff confirmed that nurses are not permitted to give resident medications to staff, as these medications are not prescribed for them and could cause unknown side effects. The incident was observed on security cameras and verified through interviews with the involved staff, including the nurse who admitted to giving the medication to the staff member.
Failure to Initiate Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a fall risk care plan for a resident with multiple risk factors, including hemiplegia, morbid obesity, muscle weakness, dementia, and a history of falls. Upon admission, the resident was identified as high risk for falls due to recent hospitalization, incontinence, multiple diagnoses, and medication use. Despite this, no fall risk care plan was initiated at the time of admission or prior to a significant fall event. The resident experienced an unwitnessed fall, resulting in a closed rib fracture and significant pain. Documentation shows that the resident was found on the floor after calling for help, and subsequently required transfer to an acute care hospital for evaluation and treatment. The resident continued to experience pain after returning to the facility, necessitating stronger pain management interventions. Interviews with nursing staff and the DON confirmed that a fall risk care plan was not in place prior to the fall, despite facility policy requiring such plans to be developed upon admission for residents identified as high risk. The care plan was only initiated after the fall occurred, contrary to established procedures and expectations for resident safety.
Failure to Conduct Updated PASARR for New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was conducted for a resident who received new mental illness diagnoses. The resident, admitted on 05/05/2011, had a medical history including hemiplegia, hemiparesis, ataxia, protein-calorie malnutrition, and an unspecified mental disorder. The resident was later diagnosed with bipolar disorder on 11/20/2015 and schizoaffective disorder on 11/23/2018. However, the facility did not complete a PASARR evaluation following these new diagnoses, as required. Interviews with facility staff revealed a lack of awareness and action regarding the need for updated PASARR evaluations. The Social Services Director, who had been with the facility for several years, stated she had never conducted any PASARR-related activities. The Director of Nursing confirmed that the only PASARR on file for the resident was from the initial admission in 2011 and was unaware that a new PASARR should be completed with new mental illness diagnoses. The facility's policy indicated that the MDS Coordinator was responsible for ensuring PASARR updates, but this was not adhered to, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with multiple pressure ulcers and severe cognitive impairment. The resident, admitted with a diagnosis of a Stage 2 pressure ulcer in the sacral region, also had two unstageable pressure ulcers and two unstageable deep tissue injuries. During an observation of wound care, a Licensed Vocational Nurse (LVN) did not wear a gown, which is required under the facility's policy for EBP when performing wound care on residents at risk of transmission or acquisition of multi-drug resistant organisms (MDROs). Interviews with staff revealed inconsistencies in understanding and implementing EBP. The LVN believed EBP was not necessary due to the lack of exudate from the wound, while a Registered Nurse (RN) and the Director of Nursing stated that EBP should be applied for any wound care. The Infection Control Preventionists (ICPs) also indicated that EBP was not required for the resident's wound due to its dry state and healing progress. This discrepancy in staff education and understanding led to the failure to adhere to the facility's policy on EBP during wound care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eureka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eureka Rehabilitation & Wellness Center, Lp | 0.4 mi | ★★★★★ | 28 | 0 |
| Seaview Rehabilitation & Wellness Center, Lp | 4.6 mi | ★★★★★ | 12 | 0 |
| Fortuna Rehabilitation And Wellness Center, Lp | 13.2 mi | ★★★★★ | 33 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.