Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eureka Nursing Center during CMS and state inspections, most recent first.
Unsanitary food prep and storage conditions were observed in the resident kitchenette and kitchen. Food debris and dried-on fluids were found on a worktable shelf, a cart with clean plates, a shelf with clean pots, a trash can near the steam table, a thickener container, and inside two reach-in freezers. The dietary cleaning schedule did not include cleaning the inside of the freezers, and an SD confirmed the areas needed more regular cleaning.
Failure to Preserve Resident Dignity During Meal Assistance: A resident with thickened juice was observed unable to drink from her cup and using her finger to scoop the juice out. Dietary staff commented that she "likes to make a mess" and wiped the table instead of assisting or offering a spoon. After the surveyor asked about a spoon, staff provided one and the resident was able to eat the juice.
A resident did not receive an ABN and NOMNC when skilled services ended. Record review showed the facility could not produce the NOMNC for the end of the resident’s Medicare-covered skilled stay, and an admin staff member confirmed it had not been located. The facility policy stated that a NOMNC must be issued when Medicare-covered services are ending, whether or not the resident is leaving the facility.
Staff failed to maintain privacy for two residents during in-room care. One resident with osteoarthritis and impaired cognition was left mostly naked while a CMA and an LN provided care, and another CMA left and re-entered the room without covering the resident; the room also lacked a privacy curtain. A second resident with dementia and severe cognitive impairment received peri-care with the window blinds open the entire time, and staff confirmed the blinds were not closed before care.
Unjustified Antipsychotic Use: Two residents received routine antipsychotic medications without documented appropriate indications. One resident had intact cognition and no documented psychosis or behaviors, yet was given quetiapine for hostility without physician rationale, GDR documentation, or evidence of failed nonpharmacologic interventions. Another resident with intact cognition received Zyprexa for dementia without behavioral disturbance, but the record lacked an appropriate indication and risk-versus-benefit documentation.
Failure to provide a baseline care plan for a resident after admission. The resident had EMR-documented diagnoses including thyrotoxicosis, CKD, anemia, HF, and a displaced supracondylar fracture of the right femur. The EMR lacked evidence of a baseline care plan, and an admin staff member confirmed the facility did not have one despite the required 24-48 hour timeframe for completion.
Failure to Develop Comprehensive Person-Centered Care Plan: A resident admitted with a complex femur fracture and multiple comorbidities, including CKD, anemia, HF, and thyrotoxicosis, had significant ADL dependence, urinary incontinence, pain needs, and wounds. Although the MDS CAAs identified functional status, incontinence, falls, nutrition, pressure ulcers, and pain, the facility had no comprehensive care plan in place; only a nutritional care plan was documented.
A resident with osteoarthritis, moderately impaired cognition, and dependence on staff for showering did not receive adequate ADL care. The care plan directed two staff for showers, but the EMR showed only four showers over 27 days with no further showering or refusal documentation. The resident was observed with dirty, greasy hair and stated he was not getting enough showers, while staff said residents were to be showered at least twice weekly.
Failure to evaluate and update fall interventions after repeated falls: A resident with dementia, severe cognitive impairment, and dependence for toileting, transfers, mobility, and showers had multiple falls with injuries, including a head laceration requiring sutures, a skin tear, bruising, and hematoma. After each event, staff documented changes such as altered toileting times, shower timing, and wheelchair positioning, but the care plan did not show that the interventions were implemented, and staff stated the care plan had not been updated with current interventions.
Unnecessary Medication and Inadequate Monitoring of Antihypertensive Therapy: A resident remained on prophylactic cephalexin for UTI prevention despite negative urine studies and no practitioner documentation supporting ongoing antibiotic use. Another resident received daily amlodipine for hypertensive CKD, but the record lacked routine BP documentation to show the medication was being monitored for effectiveness; staff stated they were unsure why BP checks were not being done regularly.
Failure to post nursing staff hours. Surveyors observed that the facility did not have posted census and direct care nursing staff hours accessible to residents and visitors. An Administrative Nurse stated the posting was usually done by the administrator and had not been posted because the administrator was absent, despite the facility policy requiring staffing information to be readily available in a readable format at all times.
A long-term care facility failed to protect residents from abuse, as evidenced by a resident-to-resident sexual abuse incident and inadequate investigation of employee-to-resident abuse allegations. A resident with a history of hypersexual behavior inappropriately touched another resident, and the facility's response was insufficient. Additionally, another resident was found with multiple bruises, but the facility did not conduct a thorough investigation or report the findings, placing residents at risk for further harm.
A resident with a history of hypersexual behaviors in a LTC facility grabbed another resident's breast without consent. Despite the resident's known history of inappropriate actions, the facility failed to implement adequate interventions or update the care plan to prevent such incidents. Staff interviews revealed a lack of awareness and documentation regarding the resident's behaviors, highlighting deficiencies in the facility's abuse prevention policies.
A resident with multiple medical conditions, including a right above-knee amputation, experienced two unsafe transfers at the facility. In the first incident, a shower chair's wheel broke, causing the resident to fall and fracture his tibia. In the second incident, the resident was transferred into an electric wheelchair with exposed metal, resulting in a laceration that required sutures. The facility failed to update the care plan to include a CAM boot and did not maintain the shower chair properly.
The facility failed to maintain sanitary conditions in food storage and preparation, potentially risking foodborne illnesses. Observations revealed undated food items, an open garbage can near food prep areas, and kitchen equipment with scratches and debris. Dietary staff confirmed these issues, and the facility lacked a food storage policy.
The facility did not maintain the required RN coverage for at least eight continuous hours on 29 days between August 2023 and January 2024, as confirmed by the Payroll Based Journal and Daily Staff Postings. With a census of 48 residents, this lack of coverage placed residents at risk for unsupervised nursing care. Administrative Staff A confirmed the absence of RN coverage on the specified days.
The facility failed to submit accurate staffing data to CMS, missing 24-hour Licensed Nurse coverage on 16 dates. This was confirmed by Administrative Staff A, who admitted inaccuracies in the Payroll Base Journal (PBJ) data for specific weekends in April, May, and June 2023.
The facility failed to provide a clean and sanitary environment for residents in the special care unit due to a persistent urine odor, despite multiple interventions. Additionally, two residents had cracked and worn fall mats, making sanitation difficult and reducing their effectiveness. The facility lacked policies for urine odor elimination and fall mat maintenance.
The facility failed to accurately complete the MDS for three residents, resulting in uncommunicated care needs. Errors included misdocumenting antiplatelet medication as anticoagulant for two residents and failing to document contractures for another. These discrepancies were confirmed by the Administrative Nurse, who noted the lack of a facility policy for MDS completion.
A facility failed to develop a comprehensive person-centered care plan for a resident with Alzheimer's, anxiety, and dementia within the required timeframe. The resident, with a BIMS score indicating moderately impaired cognition, did not have a care plan completed within 21 days of admission, contrary to the facility's policy. Observations noted the resident's anxiety and lack of documented interventions, highlighting unmet needs.
A resident with multiple health conditions, including a right above-knee amputation, was not provided with a revised care plan to include the use of a CAM boot as ordered by a physician. This oversight led to a laceration on the resident's leg during a transfer without the boot, due to contact with exposed metal on the wheelchair. The facility's policy required care plan updates for changes in condition, which was not followed.
A facility failed to apply sheepskin padding to a resident's wheelchair arm rests as required by the care plan, despite the resident's history of arthritis and a recent skin tear. Observations confirmed the absence of the padding, and staff verified it had never been applied. This oversight potentially increased the risk of further skin injuries.
A resident with a history of trauma, including childhood sexual abuse and domestic violence, did not receive trauma-informed and person-centered care. The care plan lacked interventions for past trauma, and staff were unaware of the resident's trauma history or PTSD training. The facility's policy on Trauma Informed Care was not followed, leading to inadequate care for the resident's mental and psychosocial well-being.
The facility was found to have a deficiency in maintaining a sanitary environment in the soiled utility room on the 400-hall. A trash can was observed without a liner and lid, contrary to the facility's standard practice. The Maintenance Director confirmed the requirement for liners and lids, but the facility lacked a policy on this matter.
Unsanitary Food Preparation and Storage Areas
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions in the resident kitchenette and kitchen areas. During observation, the bottom shelf of the worktable holding the food processor had a build-up of food debris and dried-on fluids, a cart holding clean serving plates contained food debris, a stainless steel shelf holding clean serving pots had a build-up of food debris, a plastic trash can next to the steam table had dried-on food and fluids on the lid and sides, a large white plastic container used to store thickener had a clear sticky substance on top, and two reach-in freezers in the dry storage room had food debris scattered on the bottom. Review of the Weekly Cleaning schedule showed dietary staff were to clean the bottom of prep tables weekly on Mondays, but the schedule did not include a day for cleaning the inside of the reach-in freezers. Dietary Staff BB confirmed the areas of concern needed to be cleaned more regularly. The facility policy for Dietary Cleaning Procedures stated that food shall be stored, prepared, and distributed under sanitary conditions to ensure proper food handling practices to prevent the outbreak of foodborne illnesses.
Failure to Preserve Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity for one resident, R42, when staff did not identify that she needed assistance with her thickened juice during a meal observation. On 04/14/26 at 09:20 AM, R42 attempted to drink the thickened juice from her cup but was unable to do so, then used her right index finger to scoop the juice out and eat it. Dietary Staff CC observed the resident, told the surveyor that she "likes to make a mess," and wiped the table instead of assisting the resident or offering a spoon. After the surveyor asked whether the resident might do better with a spoon, Dietary Staff CC stated, "Ya, I guess I can get her a spoon," and then provided one, after which R42 was able to spoon the thickened juice and eat it. On 04/15/26 at 12:25 PM, Administrative Nurse D stated that R42 should have been assisted and given a spoon so she would not have had to use her finger. The facility's Promoting/Maintaining Resident Dignity policy stated that residents are to be treated with respect and dignity and that care should maintain and enhance quality of life by recognizing each resident's individuality.
Missing NOMNC When Skilled Services Ended
Penalty
Summary
The facility failed to provide Resident 54, or the resident’s representative, with a Skilled Nursing Facility Advanced Beneficiary Notice (ABN) and a Notice of Medicare Non-Coverage (NOMNC) when the resident’s skilled services ended. Record review showed that Resident 54’s skilled stay began on 01/04/26 and ended on 02/16/26. On 04/14/26 at 09:12 AM, ABN and NOMNC notices were requested for Resident 54, along with two other residents, but the facility was unable to provide Resident 54’s NOMNC related to the end of skilled services. At 11:55 AM the same day, Administrative Staff A confirmed that she had not located the NOMNC for the end of Resident 54’s skilled services. The facility’s undated Advanced Beneficiary Notices policy stated that a NOMNC, Form CMS-10123, shall be issued to the resident or representative when Medicare-covered services are ending, whether or not the resident is leaving the facility.
Failure to Maintain Resident Privacy During In-Room Care
Penalty
Summary
The facility failed to provide privacy for two residents while staff performed cares in their rooms. One resident had osteoarthritis, a BIMS score of 10 indicating moderately impaired cognition, and was dependent on staff for bed mobility and assistance with ADLs. During care, the resident was left naked from the mid chest to the feet while a CMA and an LN provided care, and another CMA exited and re-entered the room to gather supplies without covering the resident. The room also lacked a privacy curtain, and staff confirmed the resident had not been covered while care was being provided. A second resident had dementia, a BIMS score of 6 indicating severe cognitive impairment, and was dependent on staff for bed mobility and turning/repositioning. During peri-care in the resident’s room, the bed was positioned directly in front of the window with the blinds open for the duration of the care. Staff confirmed the blinds were not closed before resident care. The facility policy for Promoting/Maintaining Resident Dignity stated that resident privacy shall be maintained at all times.
Unjustified Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents were free from antipsychotic medication use without an appropriate indication. For one resident, the electronic record documented diagnoses including insomnia, amnesia, hostility, anxiety disorder, chronic kidney disease, chronic anemia secondary to blood loss, and low back pain. The quarterly MDS showed intact cognition with no delirium, psychosis, or behaviors, yet the resident received an antipsychotic on a routine basis without a gradual dose reduction and without physician documentation that a GDR was clinically contraindicated. For that resident, the psychotropic drug use CAA was triggered because of psychotropic medication use and noted depression and ongoing psychotropic use. The care plan referenced a history of short-term memory issues and behaviors such as rejection of care and verbal aggression, and it directed staff to monitor for side effects and adverse reactions of antipsychotic and psychoactive medications. The physician order directed quetiapine 25 mg in the evening for hostility, but the pharmacy consultant note lacked a rationale for continued quetiapine use for the unapproved indication of hostility. The chart also lacked physician documentation of the rationale and risks versus benefits for quetiapine and lacked documentation of nonpharmacological interventions attempted and unsuccessful before the antipsychotic was started. Staff interviews described the resident as kind, helpful, and not exhibiting hostility or behaviors. For the second resident, the EMR documented dementia without behavioral disturbance and major depressive disorder. The annual MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident rejected care daily and received antipsychotic and antidepressant medication routinely. The care plan included interventions for behaviors such as agitation, inappropriate toileting, and sexually inappropriate comments, and the active order listed Zyprexa 2.5 mg in the evening for dementia without behavioral disturbances. The EMR lacked documentation of an appropriate indication and a risk-versus-benefit rationale for continued Zyprexa use, and an administrative nurse stated that the diagnosis of dementia was not approved by CMS and that the physician had not provided a different diagnosis or risk-versus-benefit documentation for the medication.
Failure to Provide Baseline Care Plan After Admission
Penalty
Summary
The facility failed to provide a baseline care plan for Resident 49 within the required timeframe after admission. Resident 49's EMR documented diagnoses of thyrotoxicosis, chronic kidney disease, anemia, heart failure, and a displaced supracondylar fracture with intercondylar extension of the lower end of the right femur. The Entry Tracking MDS documented that the resident had entered the facility, and a later MDS documented a modification of discharge with return anticipated/end of a Medicare Part A stay. The resident's EMR lacked evidence of a baseline care plan, and when asked for it, Administrative Staff A stated on 04/14/25 at 11:41 AM that the facility lacked a baseline care plan and expected staff to have completed one in the required timeframe. The facility's Resident Centered Care Plan Process stated that a baseline care plan will be developed within 24-48 hours after admission and include individualized interventions based on the resident's assessed needs and condition at admission, along with the minimum healthcare information necessary to properly care for the resident.
Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan for a resident whose stay began with admission for a right femur fracture and major surgery requiring SNF care. The resident’s EMR documented thyrotoxicosis, chronic kidney disease, anemia, heart failure, and a displaced supracondylar fracture with intercondylar extension of the lower end of the right femur. The admission MDS documented intact cognition, need for partial/moderate assistance with personal hygiene and upper body dressing, substantial/maximal assistance with bed mobility and transfers, and dependence for toileting hygiene, lower body dressing, and putting on and taking off footwear. The resident was frequently incontinent of urine and received scheduled pain medication, PRN pain medication, and non-medication pain interventions. The MDS also documented a history of falls with fracture before admission, surgical wound and pressure ulcer/injury upon admission, and receipt of OT and PT with a goal of discharge to the community. The CAAs triggered by the MDS identified functional abilities, urinary incontinence, falls, nutritional status, pressure ulcers, and pain, and documented that a comprehensive care plan would be initiated. The EMR contained only a nutritional care plan addressing decreased appetite, lack of mobility, and wounds, with directions to monitor weights and provide diet and supplements as ordered. On request for the comprehensive care plan, Administrative Staff A stated the facility lacked a comprehensive care plan and expected staff to have completed one within the required timeframe. The facility’s Resident Centered Care Plan Process stated that within seven days of completion of the initial comprehensive MDS, the interdisciplinary team would develop a comprehensive care plan with measurable objectives and timetables to meet the resident’s identified clinical, nursing, mental, cultural, and psychosocial needs.
Inadequate Showering Assistance
Penalty
Summary
The facility failed to provide adequate ADL care to a resident who was unable to complete showering independently. The resident had osteoarthritis, a BIMS score of 10 indicating moderately impaired cognition, and was documented on the re-admission MDS as dependent on staff for showering. The CAA stated the resident required staff assistance with ADLs due to generalized weakness, and the care plan directed staff to provide assistance of two staff for showering. From 03/16/26 through 04/12/26, the EMR showed the resident was showered only four times over a 27-day period, with no additional documentation of showering or refusal of care. During observation, the resident was seen in his wheelchair with dirty, greasy hair on 04/13/26 and again on 04/14/26. The resident stated he did not get enough showers and wanted to be showered two or three times per week. Staff stated residents were to be showered at least twice weekly, and one nurse stated refusals would be documented in the EMR; however, the record lacked such documentation for the missed showers.
Failure to Evaluate and Update Fall Interventions After Repeated Falls
Penalty
Summary
The facility failed to evaluate the effectiveness of fall interventions for a resident with dementia, hypertension, and type 2 DM with neuropathy who had severely impaired cognition, required substantial staff assistance for toileting, hygiene, showers, dressing, mobility, and transfers, and was non-ambulatory. The resident was identified as being at risk for falls on multiple fall risk assessments, and the care plan included toileting prompts, hourly checks while in bed, and later toileting times added after falls occurred. The resident experienced multiple falls with injuries, including a fall on 06/19/25 when she was found lying prone on the floor in front of the bathroom with urine on the floor and sustained an abrasion and hematoma; a fall on 07/30/25 when she was found seated on the floor in her room with her leg under the bed and was incontinent of urine and bowel; a fall on 12/25/25 when she was found on the floor behind the door with bleeding from her forehead and bruising and scratches to her knee, requiring emergency room evaluation and sutures; a fall on 03/03/26 in the shower room when she fell from the shower chair and sustained a skin tear to her forearm; and a fall on 03/08/26 when she was found on her knees beside her bed while dressed in a gown and barefoot. After each fall, immediate interventions were documented, such as changing toileting times, providing a shower upon awakening or whirlpool, and positioning the wheelchair at the bedside in a locked and ready position. However, the care plan lacked documentation that these interventions were actually put into place after the falls. Administrative staff stated the care plan had not been printed for staff access and had not been updated with current interventions, and one nurse stated she was unaware that the last three fall interventions were not on the care plan.
Unnecessary Medication and Inadequate Monitoring of Antihypertensive Therapy
Penalty
Summary
The facility failed to ensure that R16 was free from unnecessary medication. R16’s EMR documented diagnoses including hypertensive heart disease with heart failure, depression, anemia, anxiety disorder, and dementia. The quarterly MDS documented moderately impaired cognition, wandering behavior, and that R16 was independent with functional abilities and mobility, with occasional urinary incontinence. The care plan noted a history of UTIs and directed staff to monitor for signs and symptoms of UTI, including changes in urine, pain, altered mental status, and changes in behavior or eating patterns. R16 remained on cephalexin 500 mg every morning for UTI prophylaxis under a physician order dated 04/30/24. Urinalysis and culture results on 07/11/25 and 12/08/25 showed no growth at 48 hours, and a urinalysis on 01/18/26 indicated no culture was indicated. The EMR lacked documentation from the practitioner regarding the ongoing use of the antibiotic. On 04/15/26, R16 was observed sitting in her room in a recliner with a walker in front of her and reported feeling well. A CNA stated that R16 became more confused when she had a UTI and that she was independent with toileting tasks, while an administrative nurse verified that R16 was on prophylactic antibiotics with no laboratory values to support infection or antibiotic use. The facility also failed to adequately monitor R35’s amlodipine. R35’s EMR documented dementia and hypertensive chronic kidney disease, and the annual MDS showed long- and short-term memory problems with severely impaired decision-making skills and dependence on staff for toileting, hygiene, mobility, and transfers. The care plan and active orders directed blood pressure monitoring and administration of amlodipine 2.5 mg for hypertensive chronic kidney disease, with parameters for notifying the physician if blood pressure or pulse were outside specified ranges. However, the vital signs record for February and April 2026 lacked blood pressure readings, and March 2026 documented only one blood pressure reading after a fall. The EMR showed amlodipine was administered daily without documentation that blood pressure was taken, and staff stated they were not sure why blood pressures were not being obtained regularly, while another nurse stated blood pressure should be checked at least monthly.
Failure to Post Nursing Staff Hours
Penalty
Summary
The facility failed to display accurate posted nursing staff hours that were accessible to residents and visitors. During the survey period, observation showed the facility did not have posted census and direct care nursing staff hours. On 04/14/26 at 1:47 PM, Administrative Nurse D stated that the nursing hour posting had been posted at the entry of the nursing facility, but the administrator had been posting the information and, due to the administrator's absence, the information had not been posted. Administrative Nurse D also stated she had instructions to provide the information in the usual place upon entry into the facility. The facility's undated Nurse Staffing Posting Information policy stated that nurse staffing information was to be readily available in a readable format to residents, staff, and visitors at any given time.
Failure to Prevent and Respond to Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of a resident-to-resident sexual abuse incident. Resident 2, who had a history of hypersexual behaviors, grabbed Resident 1's breast without consent. Despite Resident 2's documented history of inappropriate sexual behavior towards staff, the facility did not have adequate interventions in place to prevent such incidents. The care plan for Resident 2 lacked specific interventions related to sexual abuse, and the facility's response to the incident was insufficient, as it did not include a thorough investigation or appropriate updates to the care plan. Additionally, the facility failed to investigate and report potential employee-to-resident abuse involving Resident 10, who was found with multiple bruises of unknown origin. Despite the presence of bruises documented during skin assessments, the facility did not conduct a thorough investigation or report the findings to the state agency or local police. The lack of investigation into the bruises and the failure to identify them as potential abuse placed Resident 10 at risk for further harm. The facility's inaction in both cases demonstrates a failure to ensure the safety and well-being of its residents. The lack of appropriate interventions, failure to update care plans, and inadequate response to allegations of abuse highlight significant deficiencies in the facility's handling of abuse prevention and response.
Removal Plan
- R2 was placed on a one on one and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges.
- To ensure the psychosocial well-being of R1, a follow-up interview was conducted. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically when a resident with a history of hypersexual behaviors, including groping and making inappropriate comments, grabbed another resident's breast without consent. This incident occurred despite the resident's known history of such behaviors, which included previous inappropriate actions towards staff and other residents. The facility did not have adequate interventions in place to prevent this behavior, and the care plan for the resident lacked any documentation or interventions related to the sexual abuse incident. The resident involved in the incident had a diagnosis of vascular dementia and was noted to have intact cognition with a BIMS score of 14. Despite this, the resident exhibited impulsivity and behaviors that could lead to unsafe situations. The care plan included instructions for staff to provide redirection and reorientation, but it did not address the specific risk of sexual abuse towards other residents. The facility's records showed multiple instances of inappropriate behavior by the resident, yet there was no comprehensive plan to address these behaviors or protect other residents. Interviews with staff revealed that there was a lack of awareness and documentation regarding the resident's inappropriate behaviors towards other residents. Some staff members were unaware of the incident, and others confirmed that the care plan did not include interventions for sexual abuse. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to update the care plan and take appropriate measures to prevent further incidents.
Removal Plan
- R2 was placed on a one on one and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges.
- To ensure the psychosocial well-being of R1, a follow-up interview was conducted. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints.
Resident Safety Compromised During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident during two separate transfer incidents. The first incident occurred when staff used a shower chair to transport the resident, resulting in the chair's wheel breaking and the resident falling forward, sustaining a fractured tibia. The resident's medical history included chronic obstructive pulmonary disease, diabetes, polyneuropathy, and a right above-knee amputation, which made him dependent on staff for transfers and increased his risk for difficult transfers. In the second incident, the facility staff did not ensure a safe transfer of the resident into his electric wheelchair, which had exposed metal, while using a mechanical lift. This resulted in a laceration on the resident's anterior lower leg that required sutures. The resident's care plan was not updated to include the use of a controlled ankle movement boot, which was ordered by a physician for protection after the removal of a cast. The facility's policies and procedures were not adequately followed, as evidenced by the lack of maintenance documentation for the shower chair prior to the incident and the failure to apply the CAM boot before transferring the resident. Interviews with staff revealed that the resident's wheelchair lacked proper padding, contributing to the injury during the transfer. The facility's policy for resident showers and accident prevention was not effectively implemented, leading to these safety deficiencies.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to foodborne illnesses among residents. During an observation, a sealed 10-pound bag of macaroni was found without an opened date in the dry goods pantry. Additionally, a half meat sandwich in a zip lock bag lacked a date, and a sealed zip lock bag contained four half-emptied squeeze bags of icing dated several months prior, with no expiration dates noted. Dietary Staff BB confirmed these concerns during an interview. Furthermore, an open garbage can full of garbage was observed near the food preparation station, which Dietary Staff B acknowledged should have been closed at all times. During an environmental tour, several unsanitary conditions were noted in the kitchen. The top oven had areas of bubbled burned food debris, and two large fry pans had multiple scratches on their cooking surfaces. A large white cutting board was found with multiple scratches and gouges on both sides, and two white rubber spatulas had cracks and chips on their outer surfaces. Dietary Staff BB confirmed these issues during an interview. The facility also failed to provide a policy on food storage, further contributing to the unsanitary conditions observed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for at least eight continuous hours on 29 specific days between August 2023 and January 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) and Daily Staff Postings, which confirmed the absence of RN coverage on the specified dates. The facility reported a census of 48 residents, and the lack of RN coverage placed these residents at risk for unsupervised nursing care and services. Administrative Staff A confirmed the absence of RN coverage on the days indicated in the PBJ report. The facility utilized the Facility Assessment to determine the required RN coverage but failed to ensure compliance with the eight-hour requirement.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour Licensed Nurse (LN) coverage for 16 specific dates between April 1, 2023, and March 31, 2024. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 3 of 2023, which revealed gaps in LN coverage on several weekends in April, May, and June 2023. During an interview on July 11, 2024, Administrative Staff A acknowledged that the PBJ data was inaccurate regarding the 24-hour LN coverage for the specified dates. The facility relied on its Facility Assessment policy for completing the PBJ, but this did not ensure accurate reporting. The failure to provide complete and accurate staffing information in a uniform format as specified by CMS constitutes a deficiency in the facility's compliance with federal requirements.
Facility Fails to Maintain Sanitary Environment and Fall Mat Maintenance
Penalty
Summary
The facility failed to provide a clean, home-like, and sanitary environment for residents in the special care unit. During an environmental tour, a pervasive odor of urine was detected throughout the unit and extended into the main hallway. Maintenance Director U attributed the odor to a resident who urinated in random places, and despite multiple interventions by nursing staff since September 2022, the issue persisted. Administrative Nurse E confirmed that the odor compromised the sanitary and home-like environment for the 11 residents in the special care unit. The facility did not have a policy related to the elimination of urine odors. Additionally, the facility failed to maintain sanitary conditions for two residents who had cracked and worn fall mats in their rooms. During an initial tour, it was observed that one resident had a fall mat with multiple cracks and worn surfaces, while another resident had two fall mats with similar issues. Administrative Nurse E confirmed that the condition of the fall mats made sanitation difficult and reduced their effectiveness. The facility lacked a policy for fall mat maintenance, contributing to the unsanitary and unsafe environment for these residents.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to uncommunicated care needs. For one resident, the MDS inaccurately documented the use of antiplatelet medication as an anticoagulant, despite physician orders and medication administration records indicating the use of aspirin, an antiplatelet medication. This discrepancy was confirmed by the Administrative Nurse, who acknowledged it as a clerical error and noted the absence of a facility policy for MDS completion. Another resident's MDS also incorrectly documented the use of anticoagulant medication instead of antiplatelet medication. The resident's care plan and medication records showed the administration of aspirin, but there was no documentation of anticoagulant use. The Administrative Nurse confirmed this error, attributing it to clerical mistakes and the lack of a specific MDS completion policy. Additionally, the MDS for a third resident failed to document contractures as impairments, despite the resident having a right-hand contracture and using a hand splint and carrot splint. Observations noted inconsistencies in the application of these splints, and staff reported that care sheets lacked information about the splints. The Administrative Nurse confirmed the oversight in the MDS documentation, again highlighting the absence of a facility policy for MDS completion.
Failure to Develop Timely Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R47, within the required timeframe. R47 was admitted with diagnoses including Alzheimer's disease, anxiety, and dementia, and had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Despite these conditions, the care plan was not completed within 21 days of admission, as required by the facility's policy. The policy mandates that a comprehensive care plan be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS). Observations and interviews revealed that R47's care plan lacked staff interventions to provide person-centered care. The resident was noted to be anxious, wringing her hands, and moving around her room, indicating potential unmet needs. The facility's policy, dated 03/28/24, emphasizes the importance of developing a care plan that includes measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. However, the facility did not adhere to this policy, resulting in a deficiency that could negatively impact the resident's well-being.
Failure to Update Care Plan for CAM Boot Use
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R30, to include the use of a controlled ankle movement (CAM) boot as ordered by the physician. The resident had a history of chronic obstructive pulmonary disease, diabetes, polyneuropathy, and a right above-knee amputation, and was dependent on staff for transfers and mobility. Despite a physician's order dated 05/23/24 for the CAM boot to be worn except during skin checks and range of motion exercises, the care plan was not updated to reflect this requirement. This oversight led to an incident where the resident sustained a laceration on his left lower extremity due to contact with an exposed piece of metal on his wheelchair during a transfer without the CAM boot being applied. Observations and interviews revealed that staff did not apply the CAM boot prior to transferring the resident, which was contrary to the physician's order and the facility's policy on accidents and supervision. The resident reported a previous incident where a shower chair wheel broke, resulting in a fall and a subsequent fracture, which required a cast and later a CAM boot. The facility's policy required changes in a resident's condition to be reflected in the care plan, but this was not done for R30, leading to inadequate protection during transfers and resulting in injury.
Failure to Apply Sheepskin Padding to Wheelchair Arm Rests
Penalty
Summary
The facility failed to apply sheepskin padding to the arm rests of Resident 34's wheelchair, as required by the care plan. Resident 34 had a history of arthritis and anxiety, with severely impaired cognition as indicated by a BIMS score of five on the Annual MDS. The care plan, dated July 4, 2024, specified the application of sheepskin padding due to a skin tear obtained on the same day. However, the physician orders dated July 10, 2024, did not document the need for sheepskin padding, and observations on July 10, 2024, confirmed the absence of sheepskin on the wheelchair arm rests. Certified Nurse Aide M verified the lack of sheepskin padding and stated she had never seen it on the resident's wheelchair. Administrative Nurse E expressed that the charge nurse responsible for the intervention should have ensured its completion according to the care plan. The facility's policy on accidents and supervision emphasized maintaining a hazard-free environment and implementing necessary interventions to prevent accidents. The failure to apply the sheepskin padding potentially increased the risk of additional skin injuries for Resident 34.
Failure to Implement Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to develop and implement trauma-informed and person-centered care for a resident with a history of personal trauma. The resident, who had diagnoses including Alzheimer's disease, anxiety, and dementia, was found to have a history of childhood sexual abuse and domestic violence. Despite this, the resident's care plan lacked interventions to address past trauma, adjustment difficulties, or indications of distress. The care plan did not include strategies to assist the resident in reaching and maintaining their highest level of mental and psychosocial well-being. Observations and interviews revealed that the resident exhibited signs of anxiety, such as hand-wringing and restlessness, yet the care plan did not reflect any trauma-informed interventions. Staff members, including CNAs and administrative staff, were unaware of any training on PTSD or the resident's trauma history. The facility's policy on Trauma Informed Care emphasized the importance of culturally competent care that minimizes triggers and re-traumatization, but this was not reflected in the care provided to the resident.
Sanitary Environment Deficiency in Soiled Utility Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the soiled utility room on the 400-hall, as observed during an environmental tour. A trash can in this room was found without a liner and a lid, which is against the facility's standard practice. The Maintenance Director confirmed that all trash containers should have liners and lids, and that trash and soiled linen containers are to be washed out at the end of every shift. However, the facility did not provide a policy related to the requirement for lids or coverings on trash cans, indicating a lapse in maintaining sanitary conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Eureka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Dorado Care And Rehab | 30 mi | ★★★★★ | 22 | 0 |
| Yates Operator, Llc | 30.3 mi | — | 0 | 0 |
| Lakepoint El Dorado, Llc | 31.2 mi | ★★★★★ | 0 | 0 |
| Lakepoint Augusta, Llc | 38 mi | ★★★★★ | 0 | 0 |
| Chase County Care And Rehab | 39.3 mi | ★★★★★ | 19 | 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 July 2026) and official state health department websites.