Other·February 28, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual recertification survey. Representing the California Department of Public Health, Health Facilities Evaluator Nurses: 32961, 37335, 35842, 36894, and Pharmacy Consultant, 25447. The facility census on the date of entry, 12/5/16, was 67 with no bedholds. There were 16 sampled residents. Entity reported incidents (ERIs), CA00507521, CA00507095, CA00507100, CA00505897, CA00502931, CA00502935, CA00502773, CA00513397, CA00513391, CA00512244 and one complaint, CA00507020 were investigated during the annual recertification survey. ERI CA00507521 refer to F 323, F 353, and F 520 ERI CA00507095 refer to F 323, F 353, and F 520 ERI CA00507100 refer to F 323, F 353, and F 520 ERI CA00505897 substantiated with no deficiency ERI CA00502931 substantiated with no deficiency ERI CA00502935 refer to F 323, F 353, and F 520 ERI CA00502773 substantiated with no deficiency ERI CA00513397 refer to F 323 ERI CA00513391 refer to F 225 and F 323 ERICA00512244 refer to F 323, F 353 and F 520 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 1 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Complaint CA00507020 refer to F 323, F 241,

F 353, and F 520 Substandard quality of care was identified at F 323. Harm level findings were identified at F 309, F 323, F 353, and F 520

F223 SS=E FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 01/31/2017 483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to keep 3 Unsampled Residents (Resident 28, 33, and 34) free from abuse when Resident 7 who was in her wheelchair, was sitting in doorway of her room refusing to let her roommates (Resident 28, 33, and 34) out of the room and started yelling verbal threats. This failure resulted in Resident 28, 33, and 34 became "fearful of Resident 7 and afraid to go to sleep." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 2 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Review of Resident 7's "Nurse's Notes" dated 9/2/1/16, indicated Resident 7's behavior was out of control. Resident 7, who was in her wheelchair, was sitting in doorway of her room refusing to let her roommates (Resident 28, 33, and 34) out of the room and started yelling verbal threats such as, "I am going to kill you [expletive]," to roommates and staff. The Nurse's Notes indicated Resident 7, "threw the trash can down the hallway, threw a jar of vapor rub at staff, hit this staff member with a hair brush, scratched, kicked, slapped staff, came to nurse's desk, threw books, etc. on floor, threw cup of liquid all over floor... The "Nurse's Note" pointed out during Resident 7's out of controlled behavior, Resident 7 was cursing and making racial slurs toward staff and roommates (Resident 28, 33, and 34), who became "fearful of Resident 7 and afraid to go to sleep." During concurrent record review and interview on 12/7/16 at 8:40 a.m., Director of Nursing (DON) was asked if Resident 7's abusive behavior, which took place on 9/2/16 was reported to her and/or administrator. DON stated Resident 7's allegation of abusive behavior should have been reported to her and to the administrator in order for the allegation of abuse to have been investigated. During an interview on 12/8/16 at 5:32 a.m., when Licensed Staff J was asked why she did not report Resident 7's physical and abusive behavior to the DON and /or administrator, which took place during her shift (9/2/16 at 12:00 a.m.), Licensed Staff J stated she did not feel it was at the level of abuse to report the incident. Licensed Staff J stated Resident 7 had blocked the doorway with her wheelchair, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 3 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE so Resident 7's roommates (Resident 28, 33, and 34) could not leave. Licensed Staff J stated she documented Resident 7's verbal and physical abusive behavior on the "24 Hour Report," which should have gone to the Stand Up meeting whereby the DON attends; DON would have been aware of Resident 7's abusive behavior by way of the "24 Hour Report." Review of Resident 7's September 2016 Routine Medication Administration Record (MAR), indicated Resident 7 had a total of 6 verbal violent outburst on 9/1/16: three verbal violet outbursts between 7 a.m.-3 p.m. and three verbal violet outbursts between 3 p.m.11:00 p.m. Review of a document titled, "C Wing 24 Hour Report" flow sheet dated 9/1/16, which is filled out by the nurse each shift documenting relevant resident information, and the information is then passed on to the nurse on the following shift had no indication of Resident 7 having any verbal violent behavior on 9/1/16. Review of Resident 7's Care Plan for "Behavioral/Psychotropic Medication" indicated Resident 7 had psychosis, non-compliant behavior, and one of Resident 7's behavioral problems was verbal violence. The goals started for Resident 7 on 2/6/16 indicated Resident 7 will demonstrate decreased episodes of sadness, anxiety, and insomnia, but there was no mention of decreased episodes of verbal violence. Resident 7's Care Plan for "Behavioral/Psychotropic Medication" was re-evaluate on 5/16, 8/16, and 11/16, but no changes were made. Review of the facility policy and procedure titled, "Abuse - Prevention Program" revised 11/6/15, indicated "the facility does not condone any form of resident abuse,....and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 4 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The administrator as abuse prevention coordinator is responsible for the coordination and implementation of the facility's abuse prevention policies and training." "Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms directed to residents or their family...." The facility's steps for abuse prevention include: 1. The facility conducts rounds on each shift to observe for where potential conflicts can arise and 2. The facility maintains adequate staffing on all shifts to ensure that the needs of each resident are met.

F225 SS=E INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 01/31/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 5 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 6 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report one case of resident to resident altercation, which occurred on 9/2/16 at 12:00 a.m., involving one Sample Resident (Resident 7) and 3 Unsampled Residents (Resident 28, 33, and 34) to the Department within 24 hours of the occurrence. This had the potential to decrease the Department's ability to ensure a complete investigation and interventions were started to protect other residents as well as those residents involved so there was no reoccurrence of abusive behaviors. Findings: Review of Resident 7's "Nurse's Notes" dated 9/2/1/16, indicated Resident 7's behavior was out of control. Resident 7, who was in her wheelchair, was sitting in doorway of her room refusing to let her roommates (Resident 28, 33, and 34) out of the room and started yelling verbal threats such as, "I am going to kill you [expletive]," to roommates and staff. The Nurse's Notes indicated Resident 7, "threw the trash can down the hallway, threw a jar of vapor rub at staff, hit this staff member with a hair brush, scratched, kicked, slapped staff, came to nurse's desk, threw books, etc. on floor, threw cup of liquid all over floor... The "Nurse's Note" pointed out during Resident 7's out of controlled behavior, Resident 7 was cursing and making racial slurs toward staff and roommates (Resident 28, 33, and 34), who became "fearful of Resident 7 and afraid to go to sleep." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 7 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During concurrent record review and interview on 12/7/16 at 8:40 a.m., Director of Nursing (DON) was asked if Resident 7's abusive behavior, which took place on 9/2/16, should have been reported to: 1. her and/or the administrator, and 2. State licensing/certification agency, police, and ombudsman. DON stated Resident 7's aggressive behavior was documented on the "24 Hour Report" flow sheet, which was filled out by the nurse each shift documenting relevant resident information, and the information was then passed on to the nurse on the following shift. DON stated the "24 Hour Report" goes to the facility's daily Stand-up meeting, which includes all department heads. The "24 Hour Report" flow sheet dated 9/2/16 relevant to the residents on C Wing, indicated Resident 7 was abusive, both verbally and physically, and Resident 28 and 33 were fearful of Resident 7. DON stated she did not see the incident on the "24 Hour Report" due to she had been working nights and had not attended the Stand-up meeting on 9/2/16. DON stated Resident 7's allegation of abusive behavior should have been reported to her and to the Administrator in order for the allegation of abuse to have been investigated, and reported to the appropriate authorities. During an interview on 12/8/16 at 5:32 a.m., when Licensed Staff J was asked why she did not report Resident 7's physical and abusive behavior to the DON and/or administrator, which took place during her shift (9/2/16 at 12:00 a.m.), Licensed Staff J stated she did not feel it was at the level of abuse to report the incident. Licensed Staff J stated Resident 7 had blocked the doorway with her wheelchair, so Resident 7's roommates (Resident 28, 33, and 34) could not leave. Licensed Staff J stated she documented Resident 7's verbal and physical abusive behavior on the "24 Hour FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 8 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Report," which should have gone to the Standup meeting which the DON attends; DON would have been aware of Resident 7's abusive behavior by way of the "24 Hour Report." Review of the facility policy and procedure titled, "Abuse - Reporting & Investigation" revised date 11/18/15, indicated the facility needed to report the suspected incident of resident abuse to the administrator or designee in order for he or she to have: 1. started an investigation, 2. provided a safe environment for the residents involved, and 3. reported the allegation of resident to resident abuse to law enforcement by telephone and a written report (SOC 341) needed to be sent to the Ombudsman and to the California Department of Public Health Licensing and Certification within 24 hours of alleged physical abuse.

F241 SS=E DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 01/31/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 9 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, and record review, the facility failed to ensure each resident was treated with dignity and respect for two unsampled residents (Resident 17 and 18) when call lights were not answered in a timely manner and Resident 17's need of getting out of the bed earlier in the morning was not honored. These failures resulted in residents not being assisted timely, Resident 17 stayed wet with the urine and reported it made her feel bad, and potentially compromised residents' physical and psychosocial well-being. Findings: During a concurrent observation and interview on 10/25/16, at 8:05 a.m., Resident 17 was in bed and alert. Resident 17 stated sometimes she had to wait for a long time, up to approximately 30 minutes, for staff answering her call light and assisting her. Resident 17 stated this long waiting time happened anytime of the day. Resident 17 stated she felt really bad when she needed to go to the bathroom. When asked what would happen if she needed to go to the bathroom, Resident 17 stated "just have to wait." During a concurrent observation and interview on 12/5/16, at 3:05 p.m., Resident 17 was sitting in a wheelchair at bedside. Resident 17 stated she usually had to wait for more than 30 minutes for staff answering her call light and assisting her. Resident 17 stated she felt bad when she had to urinate on herself and stayed wet for a long time. Resident 17 also stated she told the CNA (certified nursing assistant) every day that she [Resident 17] wanted to be out of the bed by 9:30 a.m. She stated the CNAs said they would help her as soon as they could, but they were always late until 10 a.m. or after 10 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 10 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m. Resident 17 stated they did not have enough CNAs. Resident 17's MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 10/19/16, revealed Resident 17's BIMS (brief interview for mental status) score was 14, which indicated Resident 17 was cognitively intact. During an interview on 12/7/16, at 10:55 a.m., Unlicensed Staff AA stated she usually assisted Resident 17 up at 9:30 a.m. or 10 a.m. Unlicensed Staff AA stated she did not remember if Resident 17 told her about getting up by 9:30 a.m. Resident 17's care plan for activities of daily living initiated on 11/2/15 and re-evaluated on 11/16, indicated Resident 17 required assistance for activities of daily living including transfer, dressing, and personal hygiene. The care plan indicated an intervention "May be up in electric w/c [wheelchair]...10 am - 2 pm..." with a start date 11/10/16. The care plan did not indicate Resident 17 preferred to be out of bed by 9:30 a.m. During a concurrent observation and interview on 12/5/16, at 2:17 p.m., Resident 18 was in bed and awake. Resident 18 stated sometimes he had to wait for 5 to 10 minutes for the staff to answer the call light. When asked how the 5 to 10 minutes wait time affected Resident 18, Resident 18 stated "depends what I needed." Resident 18 stated they did not have enough CNA to help the residents. Resident 17 and 18 were identified by the facility to be interviewable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 11 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility's policy and procedure titled "Communication - Call System," revised 1/1/12, indicated "...Nursing Staff will answer call bells promptly, in a courteous manner..." During an interview on 12/9/16, at 7:20 a.m., regarding call light waiting time and the facility's policy and procedure of "...answer call bells promptly...", the DON (director of nursing) stated staff should respond to call lights as quickly as possible with the goal of 3-5 minutes. The DON stated Resident 17 was evaluated to be safe in resident's electric chair 10 a.m. to 2 p.m. The DON stated if Resident 17 liked to get out of bed earlier, they could assist resident out of bed in a manual chair.

F252 SS=E SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 01/31/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 12 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based an observations and interviews the facility failed to ensure: 1) All the bedrooms in the Wing B had no peeling paint on the door jams; 2) No Peeling paint on the entrance of the alcoves in the hallway in the Wing B; 3) No peeling paint on the door jams of the Bathroom, shower room, Utility and the radiator in the Wing B. These failures resulted in an environment for the resident that was not home-like, tidy and well kept. Findings: During a tour and concurrent interview with Licensed Staff NN on 12/5/16, at 2:30p.m., the following were noted: 1) All the Bedrooms in the Wing B had a peeling paint on the door jams inside and outside. 2) Alcoves in the Wing B had peeling paint on both sides of the entrance. 3) Bathroom, shower room, Utility room and the radiator had peeling paint on the door jams in Wing B. During a concurrent observation and interview on 12/5/16, Licensed Staff NN confirmed all the above mentioned peeling paints and stated they should have been painted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 13 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent environmental tour and interview on 12/8/16, at 8:30a.m., when asked, Maintenance supervised acknowledge the peeling paints on all the above mentioned areas and stated they would be painted.

F278 SS=D ASSESSMENT ACCURACY/COORDINATION/CERTIFIED CFR(s): 483.20(g)-(j)

F278 01/31/2017 (g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 14 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) Clinical disagreement does not constitute a material and false statement. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record review, and facility policy review the facility failed to ensure staff completed the MDS (Minimum Data Set, an assessment tool) accurately for 1 of 16 sampled residents (Resident 7). This failure had the potential to result in inappropriate care or treatment of the residents due to inaccurate assessment. Findings: During a review of the clinical record for Resident 7, the MDS, dated 11/10/16, indicated Resident 7 did not have any falls since the prior assessment (8/11/16). Review of a Resident 7's "Post Fall Assessment," "Nurse's Notes," and an "Interdisciplinary Team Conference Record," indicated Resident 7 had an unwitnessed non-injury fall on 10/16/16. During an interview on 12/7/16 at 9:45 a.m., Licensed Staff LL stated Resident 7's Quarterly MDS assessment should have been triggered for falls due to Resident 7 had a fall since the prior assessment. Licensed Staff LL stated part of doing a resident's quarterly assessment was reviewing their clinical record, which would include reviewing the resident's Fall Assessments, Nurse's Notes, Interdisciplinary Team Conference Record, etc. The Long Term Care Facility Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 15 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment Instrument Version 3.0 Manual," dated 10/2011, under section J1800: "Any Falls Since Admission/Entry or Reentry or Prior Assessment, which ever is more recent," should be counted as a fall. The "Care Area Assessment (CAA)," indicated: 1. a fall without injury is still a fall, and 2. falls may indicate a functional decline and /or the development of other serious conditions, such as delirium, adverse medication reactions, dehydration, and infections.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 01/31/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 16 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Adequately assess and treat Resident 3's pain and care plan to taper Norco (a medication for pain). These failures resulted in harm to Resident 3 who cried and was in tears and had difficulties with moving around due to severe pain in her left leg, secondary to a bone condition and a recent fall. 2. Follow through with a treatment order of Debrox (ear wax removal) for Resident 11. This failure caused Resident 11's left ear to be plugged up and loss of hearing. Findings: 1. Resident 3's admission record indicated Resident 3 was admitted to the facility on 8/2/16 with diagnoses including toxic encephalopathy (a nervous system disorder caused by exposure to toxic agents) and personal history of malignant neoplasm (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 17 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tumor), and paresthesia (a sensation of tingling, tickling, pricking, or burning) of skin. Resident 3's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 8/9/16 and 11/8/16, indicated Resident 3's BIMS (brief interview for mental status) score was 13 - 14, which indicated Resident 3 was cognitively intact. During a concurrent observation and interview that started on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 was sitting in her wheelchair tilted to her right side. Resident 3 stated she had to sit tilted to her right side because she was having pain 9/10 (pain scale 0-10, 0 indicates no pain and 10 indicates most severe pain) in her left hip since early morning. Resident 3 stated that it was difficult for her to move around and it made her irritable due to the pain. Resident 3 stated she already asked for pain medication but "they said I am a drug addict" and could not give me more medication. Resident 3 stated she fell from her bed to the floor at approximately 3 a.m. four days ago. Resident 3 stated she climbed back to bed because there were no staffs around to assist her. Resident 3 stated she told a nurse about the fall and pain at approximately 5:30 a.m. the day she fell. She stated the nurse just told her to go back to bed. Resident 3 stated she had arthritis pain 4-5/10 in her left hip down to the leg, but the pain in the left hip increased to 89/10 after the fall. Resident 3 stated she thought she "hurt something" from the fall. Resident 3 stated she told all of her nurses but nobody checked on her nor did they send her to the hospital. Resident 3 stated one of the nurses, Licensed Staff C, told her (Resident 3) she reported the fall because she wanted more pain medications. Resident 3 stated Licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 18 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Staff C told Resident 3 that eventually all her medications would be taken away. Resident 3 stated she always had to wait for the pain medication for one to two hours after the scheduled time. Resident 3 stated that staff were mad at her and acted like she was "a drug addict." When asked if she wished to have a staff member to check on her, Resident 3 started crying in tears and stated she was OK with the DON (director of nursing) or another one particular nurse but not the other nurses because they did not check on her and said she was a drug addict and that she was "tired of it." During an interview on 10/25/16, at 11:45 a.m., Licensed Staff C stated last night Resident 3 asked for Narcotics (opioid pain relievers). Licensed Staff C stated she explained to Resident 3 that her pain medication was not due and explained to her that her narcotic medication needed to be "tapered". Licensed Staff C stated Resident 3 mentioned about her left hip. Licensed Staff C stated she faxed a request for x-ray to the physician. During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately 7 hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head to toe assessment and documented the assessment. Licensed Staff B stated no injuries noted related to the fall. Licensed Staff B stated Resident 3 usually complained of pain 8-9/10 in her left lower extremity. Licensed Staff B stated Resident 3 asked for Narcotic medications for pain "no matter what." Licensed Staff B stated Resident 3 had history of drug seeking behaviors and asked for narcotic medications even though she was sleeping in her wheelchair. Once she opened her eyes, she would ask for Narcotic FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 19 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication. Resident 3 had PRN (as needed) Norco order and it was now changed to regularly scheduled Norco. A nurse's note dated 10/20/16, at 10:15 a.m., indicated "[Resident 3] [up out of bed] in [wheelchair]. Denies any residual pain [secondary to fall]. [Resident 3] in wheelchair, going up and down hallway [without] difficulty. Will continue to monitor." The note did not indicate a head to toe assessment. The nurse's note dated from 10/20/16 to 10/24/16, did not indicate a complete post fall assessment nor notified the physician of Resident 3's fall. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated no specific document was used for the head to toe assessment. Licensed Staff B stated he documented the head to toe assessment in the nurse's notes. When asked about the nurse's notes, Licensed Staff C stated the nurse's note dated 10/20/16 at 10:15 a.m. was written by him. When asked about the facility's fall protocol, Licensed Staff C stated staff would use a form which the night shift nurse should have done and should have turned in to the DON. During a concurrent interview and record review on 10/26/16, at 8:35 a.m., The DON reviewed Licensed Staff B's nurse note dated 10/20/16 at 10:15 a.m. and stated it was not well documented and did not show the head to toe assessment. The DON stated the post fall protocol included completing the incident report, post fall assessment, post fall huddle (staff meet together to discuss about the fall), and neurological check flow sheet for unwitnessed fall. The DON stated staff did not complete the post fall protocol procedures for Resident 3's fall on 10/20/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 20 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 11/8/16, at 9:10 a.m., the DON stated the facility's standard practice and her expectation was for the charge nurse to notify the physician on the same work shift the resident fell, either by fax or by calling the physician depending on the severity of injury. The physician's order dated 10/14/16 indicated: Schedule Norco 5/325 (strength of the Norco) as one tablet by mouth 4 times a day for one week, then one tablet by mouth 3 times a day for one week, then one tablet by mouth 2 times a day for one week, then one tablet by mouth every morning for one week and off (discontinue). The care plan for pain initiated on 8/4/16, did not indicate Resident 3 was to have Norco tapered and did not indicate approaches specific for to taper the medication. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., when asked what care plan for tapering the Norco was for Resident 3, Licensed Staff B provided the MAR (medication administration record) with the Norco administration schedule. When asked again for care planning and what would he do when Resident 3 kept asking for Norco, Licensed Staff B stated he would re-direct Resident 3 by telling her that physician ordered for her narcotics to be tapered and she had to wait for the next scheduled dose. Licensed Staff B stated he had not reviewed the chart if the chart contained any care plan for tapering the Narcotics. During an interview on 10/26/16, at 8:35 a.m., the DON stated she did not care plan the tapering Narcotics for Resident 3 and believed care plan was not in place. The DON reviewed Resident 3's chart and stated there was no care plan and she understood the need to care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 21 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE plan how the facility would help the resident in tapering the Norco besides telling her to wait. The DON stated Resident 3 had drug seeking behaviors, kept asking for Norco and staff had to tell her to wait. During an interview on 11/1/16, at 9:20 a.m., the DON stated Resident 3's recent x-ray result after the fall on 10/20/16 indicated a condition that required a physician's referral for Resident 3 to have a hip replacement. Resident 3's x-ray result dated 10/27/16, indicated Resident 3 had "Severe avascular necrosis of the left hip without evidence of acute fracture." Avascular necrosis is a condition commonly occurs in the hip when there is loss of blood to the bone and could cause the bone to die and collapse. The symptoms of avascular necrosis include severe pain that interferes with the ability to use the joint when the disease progresses and the bone and joint collapse. During an interview on 11/3/16, at 2:35 p.m., when asked if the facility evaluated the underlying cause of the pain since Resident 3's admission until the x-ray on 10/27/16, the DON stated she was not aware of an evaluation of the underlying cause of the pain. The DON stated Resident 3 had been treated for chronic pain and based on the admission diagnoses. The DON stated Resident 3 was not being sent out for imaging or work ups because Resident 3's insurance did not cover for rehabilitation. During an interview on 11/8/16, at 10:05 a.m., when asked what was her expectation of being notified a resident's fall, Physician S stated the facility staff usually notified her the same day or the day after the fall by fax or phone. Physician S stated staff should have notified her earlier of Resident 3's fall. Physician S stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 22 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3's avascular necrosis did not result from the fall, but avascular necrosis could cause increased pain. Physician S stated Resident 3 had chronic hip pain and after the fall, she looked deeper and found Resident 3 had avascular necrosis of the hip. Physician S stated she referred Resident 3 for a hip replacement. Physician S stated she tried to taper Resident 3's Narcotics, but now she could not taper the Narcotics because of Resident 3's left hip avascular necrosis. During a concurrent observation and interview on 12/6/16, at 8:16 a.m., Resident 3 was eating breakfast. Resident 3's face was grimacing. Resident 3 stated she was "in a lot of pain" and needed medications. Resident 3 put on the call light. Unlicensed Staff AA responded to the call light and told Resident 3 that she would tell the nurse about the pain. Unlicensed Staff AA left the room and came back at 8:21 a.m. and told Resident 3 that the nurse [Licensed Staff B] stated he would give Resident 3 medications when the nurse arrived here [Resident 3's room]. Resident 3 stated Licensed Staff B would go room by room giving residents medications and asked what room Licensed Staff B was at this time. Unlicensed Staff AA stated the nurse was at room 2, which was about four rooms away. During an interview on 12/6/16, at 12:40 p.m., regarding Resident 3's pain, Licensed Staff B stated Resident 3 had drug seeking behaviors and made up the pain. Licensed Staff B stated after x-ray of the left hip and found avascular necrosis, Resident 3 started complaining of left hip pain. Licensed Staff B stated he saw Resident 3 was in the wheelchair and selfpropelled down the hallway that morning, but Resident 3 did not complain of pain. Licensed Staff B stated when he was giving medications including pain medication to Resident 3 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 23 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE approximately 9 a.m., following his sequence, Resident 3 complained of pain 9/10 but Resident 3 closed her eyes resting. Licensed Staff B stated "If I have 9/10 pain, I will be screaming." The nurse's note and the MAR (medication administration record) from 12/6/16 to 12/9/16 did not indicate a nursing assessment for Resident 3's complaint of pain on 12/6/16 at 8:16 a.m. to 8:21 a.m. During an interview on 12/9/16, at 7:20 a.m., the DON stated the nurse should have assessed Resident 3 when the resident complained of pain. The DON stated the nurse should not wait for the sequence to give medication when the resident complained of pain because "you don't know" if it was a new onset of pain. The facility's policy and procedure titled "Pain Management," date revised November 2015, indicated "A Licensed Nurse will assess residents for pain on admission, quarterly, when there is a new onset of pain, or significant change in condition. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible...The Licensed Nurse will develop a Care Plan for pain management, including non-pharmacological interventions...Nursing Staff will implement timely interventions to reduce the increase in severity of pain...Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain...The Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication...Upon admission, quarterly, and with significant change in condition the IDT will meet to review the resident's Pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 24 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment. The IDT will document the following...i. Summary of event causing pain; ii. Root cause analysis; iii. Referrals, as necessary, and iv. Interventions to prevent future pain..." The facility's policy and procedure titled "Pain Management," revised November 2016, indicated "...Facility Staff will help the resident attain or maintain their highest level of wellbeing while working to prevent or manage the resident's pain to the extent possible...Licensed Nurse will assess each resident for pain upon admission, quarterly, when there is a new onset of pain, exacerbation of pain..." 2. During an interview on 12/5/16 at 3:40 p.m. and 12/7/16 at 11:20 a.m., Resident 11 complained of her left ear feeling plugged. Resident 11 stated she had informed her nurse (could not recall nurse's name) about her left ear feeling plugged and has been waiting for some type of treatment. Resident 11 stated she was having difficulties hearing out of the left ear now due to it being plugged. During a concurrent interview and clinical record review on 12/7/16 at 11:25 a.m., Licensed Staff TT was asked if Resident 11 had received any ear treatment for her left ear. Licensed Staff TT checked to see if an order had been written regarding treatment for Resident 11's left ear. Licensed Staff TT stated an order was written for Debrox (earwax removal and treatment) to be started, but it did not look like it was ever started. Review of the "Physician Telephone Orders" written at 11/30/16 at 5:00 a.m. indicated Debrox 2 drops was to be inserted into left ear and then irrigate with warm water every evening for three days. Review of Resident 11's "Routine Medication Administration Record" (MAR) for November indicated the Debrox treatment was to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 25 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE started 11/30/16 at bedtime and to be continued for the next two days, but there was no nurse's signature indicating it was ever started. Review of Resident 11's Routine MAR for December indicated Debrox treatment should have been given on 12/1/16 and 12/2/16, but there was no signature indicating the Debrox treatment was ever performed. Review of the facility's policy titled, "Physician Orders" revised 1/1/12, did not indicate how a licensed nurse would carry out the physician's order once the order was transcribed on to the resident's Routine MAR. Review of the facility's admission pack (given to all residents upon their admission), titled, "California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities" dated 5/11, indicated all residents who are admitted to the facility have "a right to prompt medical care and treatment." The facility's policy and procedure titled "Resident Rights - Quality of Life," revised 1/1/12, indicated "Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality."

F311 SS=E TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS CFR(s): 483.24(a)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F311 Event ID: G9FK11 01/31/2017 Facility ID: CA010000078 If continuation sheet 26 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the RNA (restorative nursing assistant) program was being continued as physician prescribed for 2 of 16 sample residents (Resident 7 & 11). This failure resulted in a disruption in treatment, and had the potential for residents to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in activities in daily living (ADLs). Findings: During an interview on 12/8/16 at 9:35 a.m., when DON was asked about the facility's RNA program, she stated we have been shorthanded due to one RNA left recently, which left us with one RNA. DON stated another RNA has been hired from one of our sister facility's; he is experienced and will be starting soon. Review of the clinical records titled, "Restorative Nursing Program Referral/Care Plan," indicated the physical therapist had referred Resident 7 and 11 to the RNA program on 11/21/16. Resident 7 was discharged from physical therapy (PT) on 11/21/16 and Resident 11 was discharged from PT on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 27 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/17/16. "RNA Record" for Resident 7 indicated Resident 7 was to start the RNA Program on 12/1/16, and was to receive therapeutic rehabilitation using a front wheeled walker (fww) two to three times per week; the records indicated Resident 7 started the RNA program on 12/7/16. "RNA Record" for Resident 11 indicated Resident 11 was to start the RNA Program on 12/1/16, and was to receive therapeutic rehabilitation using a front wheeled walker three to five times per week as tolerated; the records indicated Resident 11 had not been seen as of 12/8/16. During an interview on 12/7/16 at 11:00 a.m., Resident 11 was worried about becoming weaker due to she had not worked with physical therapy for awhile. Resident 11 stated, "I have not been out of this wheelchair for at least three weeks." During an interview on 12/8/16 at 1:50 a.m., Unlicensed Staff KK stated he started as the RNA in June of this year and works Tuesday through Saturday. Unlicensed Staff KK stated if the facility was short staffed a certified nursing assistant (CNA), he would get pulled to be a CNA that day, and residents would not receive therapeutic rehabilitation unless he was assigned residents who were in the RNA Program. Unlicensed Staff KK stated he had not started Resident 11's therapeutic rehabilitation yet and he started Resident 7's yesterday (12/7/16). Unlicensed Staff KK stated he had not started Resident 7 and 11's therapeutic rehabilitation sooner due to he was assigned to do all the scheduled resident weights on November 22, started vacation on November 23-28, and his regular days off were November 29-30. Unlicensed KK stated he also was pulled to accompany residents to doctor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 28 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE appointments. Review of facility's policy titled, "Restorative Nursing Program Guidelines" revised 1/1/12, indicated the RNA program: 1: "provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible, 2. actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning, and 3. initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation."

F323 SS=H FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 01/31/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 29 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an accident hazard free environment, provide adequate supervision and assistance, revise fall risk care plans and implement the care plan, follow fall protocol for post fall assessment and management to prevent accidents for seven of 16 sampled residents (Resident 1, 2, 3, 4, 5, 6, and 14) when: 1. Resident 1 walked to the restroom unassisted, grabbed the rod across the restroom entrance and fell on the floor on 8/28/16. This caused Resident 1 to sustain a left humeral neck (upper arm bone just under the shoulder joint) fracture which required admission to an acute care hospital for treatment. 2. Resident 2 had five falls during a one month period from 8/12/16 to 9/14/16. Resident 2 sustained a head injury from the last fall on 9/14/16 which required Resident 2 to be sent to an acute care hospital for evaluation and treatment. After 9/14/16, Resident 2 had three more falls on 10/26/16, 11/5/16, and 11/26/16. 3. Staff did not follow their fall protocol for post fall assessment and notify the physician of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 30 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE fall when Resident 3 reported having fallen on 10/20/16. This resulted in Resident 3 not being evaluated after the fall until 10/25/16 (five days after the fall). 4. Resident 5 had six falls during a six and a half months period from 5/24/16 to 12/6/16. On 5/24/16, Resident 5 fell and sat on the floor in the bathroom which was wet with urine. A fall on 11/23/16 resulted in Resident 5 sustaining a small skin tear on the top ridge of the nose on 11/23/16 at 9:35 p.m. (which was the second fall on the same day 11/23/16). 5. Resident 4 had three falls during a one month period from 8/16/2016 to 9/17/2016. Resident 4 sustained a skin tear on the right hand from a fall on 8/16/2016 and reopened a skin tear on the right hand from a fall on 8/21/2016. Resident 4 had three more falls during a one week period from 10/13/2016 to 10/17/2016, which resulted in a nasal bone (nose) fracture from a fall on 10/13/2016. 6. Resident 6 had multiple falls in a six months period from 5/22/16 to 11/25/16. Resident 6 sustained bleeding in the head from the fall on 8/1/16; a laceration (cut) on the left side of the head which required eight staples from the fall on 10/13/16. Resident 6 sustained a laceration on the right side of the head from the fall on 11/25/16. 7. Licensed Staff did not revise Resident 14's (who had one unwitnessed fall on 11/4/16, which resulted in a skin tear to the left elbow and a fractured pelvis) "Fall Care Plan" to indicate Resident 14 was to be on "one on one" with staff at all times starting 11/5/16 per physician's order. This failure to revise Resident 14's "Fall Care Plan" had the potential for Resident 14 to fall again causing injury or even death. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 31 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: 1. Resident 1's admission record indicated Resident 1 was admitted to the facility on 1/22/16 with diagnoses including blindness both eyes, difficulty in walking, and generalized muscle weakness. Resident 1's minimum data set (MDS, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 7/29/16, revealed a BIMS (brief interview for mental status) score of 14, which indicated that Resident 1 was cognitively intact. The MDS assessment indicated that Resident 1 required limited assistance of one person with physical assistance for walking in the corridor and toilet use. The fall risk assessment dated 7/27/16, indicated Resident 1 was at high risk for fall due to multiple problems including intermittent confusion, one to two falls in past three months, and being legally blind. Resident 1's care plan for fall risk prevention and management initiated on 1/22/16 and reevaluated on 7/16, indicated approaches for fall risk prevention and management including "Orient resident to environment each time changes are made and provide an environment that supports minimized hazards over which the Facility has control..." The care plan did not specify how the facility would provide supervision to prevent the resident from falling. Resident 1's care plan for visual impairment initiated on 1/22/16 indicated "Provide environment with items kept in consistent location, free from obstacles and clutter...uses handrails in hallway..." The care plan for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 32 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE activities of daily living initiated on 1/22/16 indicated Resident 1 required assistance for toilet use. The nurse's note dated 8/28/16, revealed Resident 1 had an unwitnessed fall at 9:10 a.m. when Resident 1 was ambulating to the restroom and walked onto wet floor sign. The IDT (interdisciplinary team) Conference Record dated 8/29/16, indicated on 8/28/16, at 9:10 a.m., Resident 1 walked to the bathroom and stopped at the restroom doorway. Resident 1's hands grabbed the spring rod, which the housekeeper placed in the doorway for cleaning, and simultaneously leaned her weight backward expecting the rod to be stable like a hand rail. Resident 1 fell to her left side and had left shoulder pain and left hip discomfort. Resident 1 was sent to an emergency department and admitted to an acute care hospital. The CT (computerized tomography, combines of X-ray images using computer process to create images) examination result dated 8/28/16, and the history and physical report from the acute care hospital dated 8/28/16, indicated Resident 1 sustained a non operable left humeral neck (upper arm bone) fracture and was admitted to the hospital for pain control and evaluation. During an interview on 10/26/16 at 10:02 a.m., regarding Resident 1's fall on 8/28/16, Licensed Staff A stated Resident 1 usually used the handrails in the hallway when Resident 1 was walking. Licensed Staff A stated Resident 1 had visual impairment. Resident 1 liked to grab the handrail and leaned backward while talking to the staff or other resident. Licensed Staff A stated on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 33 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE day Resident 1 fell, Resident 1 walked to the restroom in the hallway and grabbed the spring rod, which the housekeeper placed in the doorway for cleaning. Licensed Staff A stated Resident 1 thought the rod was the handrail, so Resident 1 leaned her body backward while grabbing the rod. Licensed Staff A stated Resident 1 fell on the floor because the rod was not stable and fell off the doorway. Licensed Staff A stated no staff walked with Resident 1 because it was Resident 1's routine to walk to the restroom by herself using the handrails. Licensed Staff A stated the biggest mistake was lack of communication. Licensed Staff A stated the housekeeper did not tell her (Licensed Staff A) about placing the rod in the restroom doorway,otherwise she would have educated Resident 1 and let her feel the rod or walked with her. Licensed Staff A stated the rod was a new product but they should not use it on the floor because it was dangerous. During an interview on 10/26/16, at 11:50 a.m., regarding Resident 1's fall on 8/28/16, Housekeeping Staff P stated she put the rod with a sign across the restroom doorway and two signs on the floor when she was mopping the restroom. Housekeeping Staff P stated she told Resident 1 the restroom was closed. Housekeeping Staff P stated after she cleaned the restroom, she left the rod with a sign across the restroom doorway and went to another hall. Housekeeping Staff P stated she did not tell Resident 1 that the rod was left in the doorway. Housekeeping Staff P stated she did not tell any staff about the rod because they could see it. Housekeeping Staff P stated from the beginning of using this type of rod, she told the housekeeping supervisor that the rod was terrible and not good for use because the rod did not have spring and was easy to fall off. She stated the rod was not stable and when people grabbed the rod, the rod fell. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 34 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent observation and interview on 10/26/16, at 11:25 a.m., in the housekeeping supervisor's office, Housekeeping Supervisor Q showed a yellow rod with a yellow sign "CLOSED FOR CLEANING" hanging to the rod. Housekeeping Supervisor Q stated this was the rod with the sign Housekeeping Staff P used when she cleaned the restroom where Resident 1 fell. Housekeeping Supervisor Q stated the housekeeper put the rod across the doorway to indicate the room was being cleaned. Housekeeping Supervisor Q stated the housekeeper should tell the nurse when the rod was placed. Housekeeping Supervisor Q stated the rod was light metal and was not strong. Housekeeping Supervisor Q stated the facility had been using the rod for about six to seven months, but they did not have a policy and procedure regarding the use of the rod. Upon request for the manufacturer's guidelines for the rod, Housekeeping Supervisor Q provided a page documentation titled "FACILITY MAINTENANCE," undated, under A. Site Safety Hanging Sign, which did not indicate how to use the rod and sign safely. The CT (computerized tomography, combines of X-ray images using computer process to create images) examination result dated 8/28/16, and the history and physical report from the acute care hospital dated 8/28/16, indicated Resident 1 sustained a left humeral neck fracture and was admitted to the hospital for treatment. 2. Resident 2's admission record indicated Resident 2 was re-admitted to the facility on 8/11/16 with diagnoses including Alzheimer's disease (a brain disease causing memory loss, impaired thinking and disorientation), dementia, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 35 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and neuromuscular (relating to the nerves and muscles) dysfunction of bladder. Resident 2's MDS assessment dated 8/19/16 indicated Resident 2 was not able to complete the brief interview for mental status (BIMS). The MDS assessment indicated staff interview for mental status was conducted and indicated Resident 2's cognitive skills for daily decision making was "moderately impaired - decisions poor; cues/supervision required." Resident 2's fall risk evaluation dated 8/12/16 indicated Resident 2 was at high risk for fall due to multiple problems including mental status, history of falls, ambulatory and elimination status, and gait/balance problems. The care plan for fall risk prevention and management initiated on 8/12/16 with approach started date 8/11/16 indicated approaches including "Bed in low position, pad alarm (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or the bed) in bed..." The care plan did not specify how the facility would provide supervision to prevent the resident from falling. First Fall: The nurse's note dated 8/12/16 at 12 a.m., revealed Resident 2 had an unwitnessed fall in the resident's room. Resident 2 sustained a 3 cm X 3 cm skin tear with bruising at left elbow. The care plan for the actual fall on 8/12/16, indicated a goal "No serious injury from fall [for 7 days]. The approaches included observing and monitoring for 72 hours, mobility alarm, pads at bedside, and visual monitor just for one shift. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 36 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The IDT (Interdisciplinary Team) Conference Record, dated 8/12/16, regarding Resident 2's fall on 8/12/16 at midnight, did not indicate new approaches to the fall risk care plan to prevent further falls. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Second Fall: The nurse's note dated 8/29/16, at 7 a.m., indicated nursing staff from the last two work shifts reported Resident 2 had a fall at 7:15 a.m., on 8/28/16. However, there were no documentation of nurses' notes on 8/28/16 regarding the fall. The IDT Conference Record, dated 8/30/16, indicated Resident 2 had a fall with no injury on 8/28/16. The IDT note indicated to resume Risperdal (an antipsychotic medication, which works by changing the effects of chemicals in the brain), which was discontinued, due to increased agitation, re-emergence of aggressive verbal outbursts, pressured speech, and etc. The care plan for the actual fall on 8/28/16 included to teach the new nurses on fall follow up process and continue plan of care. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Third Fall: The nurse's note dated 9/5/16, at 4:20 p.m., indicated Resident 2 fell out from the wheelchair when Resident 2 was watching TV in the TV room with other residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 37 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The IDT Conference Record, dated 9/6/16, regarding Resident 2's fall on 9/5/16, indicated the Resident 2 had "very poor safety awareness." The IDT determined to continue using the alarm with a goal "no serious injury [with] fall." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/5/16 was to continue plan of care. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fourth Fall: The nurse's note dated 9/10/16 with unknown time of the note indicated "Am shift reports fall [with] no injury 10:30 Am..." The nurse's note did not describe how Resident 2 fell. The IDT Conference Record, dated 9/12/16, indicated Resident 2 stood up and fell at the nurse's station. The IDT note indicated Resident 2 to continue having poor safety awareness. The IDT note indicated "Comfort is goal and [with] regard to falls, minimizing serious injury is goal..." The IDT note indicated "Will continue use of alarm, encourage wheelchair..." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The care plan for the actual fall on 9/10/16 was to continue plan of care. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. Fifth Fall: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 38 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The nurse's note dated 9/14/16, at 7:55 p.m., revealed Resident 2 had an unwitnessed fall and sustained a skin tear at left elbow and injury in Resident 2's back of the head that required Resident 2 to be sent to an emergency room for evaluation. The IDT Conference Record, dated 9/15/16, indicated on 9/14/16, at 7:55 p.m., Resident 2 was found on the floor next to the bed. The IDT note indicated alarm presented but was not engaged. The IDT note indicated fall prevention plan included care alert posted in Resident 2's room. The IDT note did not specify how the facility would provide supervision to prevent Resident 2 from further falls. The Care Alert dated 9/15/16 posted in Resident 2's room indicated "[Resident 2] is a high fall risk with a recent fall requiring a trip to the ER. Please make sure [Resident 2] has his loud alarm attached at all times! Check frequently as he is able to inadvertently remove the alarm..." The Care Alert did not specify how frequently to check the alarm or the resident. During an interview on 11/3/16, at 2:35 p.m., regarding "Check frequently" for the alarm indicated in the Care Alert, the DON (director of nursing) stated she expected the staff checked the alarm when staff made rounds every two hours; the Hall Monitor (an employee) walked back and forth in the hall and when walked to Resident 2's room, the Hall Monitor could look inside the room from the hallway to see if the alarm was intact. When asked if the Hall Monitors were trained on how to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff if anything was out of the ordinary. The DON stated a Hall Monitor was a staff, but was not a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 39 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care giver. The DON stated the Hall Monitors did not do hands on resident care; they could guide the resident and gently hold the resident's hands/elbows. The IDT Conference Record, dated 9/16/16, for safety review related to the fall on 9/14/16 indicated to evaluation Resident 2's room to "reconfigured room to have bed at a slight angle decreasing the likelihood of striking head during a fall. Mats at both side of bed." The IDT note did not specify providing supervision to Resident 2 to prevent further falls. The fall risk care plan initiated on 8/12/16 did not indicate new approaches and did not specify providing supervision to Resident 2 to prevent further falls. During a concurrent observation and interview on 10/25/16, at 10 a.m., Resident 2 was in bed and awake. One floor mat was placed on Resident 2's right side and one mat was up leaning against the wall below the window. When asked about his fall on 9/14/16, Resident 2 stated he did not remember the fall. During an interview on 10/25/16, at 3 p.m., regarding Resident 2's fall on 9/14/16 at 7:55 p.m., Licensed Staff C stated a Hall Monitor found Resident 2 on the floor. Licensed Staff C stated when she arrived at the scene, Resident 2 was laying on the floor mat with the head against the wall on the left side of the bed. Licensed Staff C stated she did not hear the alarm. She stated Resident 2 took off the alarm all the time. When asked about fall prevention, Licensed Staff C stated when Resident 2 was not in bed, sit Resident 2 at the nurse station. When Resident 2 was in bed, staff would listen to the alarm or Resident 2 yelling. Licensed Staff C stated they did not have a set time to check on Resident 2 because Resident 2 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 40 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not on an every 15 minutes check. During a concurrent observation and interview on 10/25/16, at 3:05 p.m., in Resident 2's room, one floor mat was on the right side of the bed and one mat was up against the wall. Licensed Staff C stated the floor mat should be on the left side because Resident 2 got out of the bed from his left side. During a concurrent interview and record review of Resident 2's care plans for fall and fall risk on 10/25/16, at 3:13 p.m., Licensed Staff C stated a care plan described what best care provided to the resident and communication with the care team. Licensed Staff C stated all nurses should review the care plans. When asked if the care plans specify providing supervision to Resident 2, Licensed Staff C reviewed the care plans initiated on 8/12/16 and 8/15/16 and stated the supervision was to observe and monitor Resident 2 for 72 hours. When asked what happened after 72 hours, Licensed Staff C stated "none" and the care plans did not specify supervision. During an interview on 10/25/16, at 4:40 p.m., Unlicensed Staff O stated when Resident 2 was in bed, she would check Resident 2 approximately every five minutes. When asked how she knew about the five minutes, Unlicensed Staff O stated "from the text book." When asked how she knew the care needed for a resident, Unlicensed Staff O stated she would ask other staff or look at the care plans, which would tell her about the resident. When reviewed Resident 2's care plan, which indicated Resident 2 had four falls from 8/12/16 to 9/10/16, Unlicensed Staff O stated she did not know Resident 2 had so many falls "like constantly falling." Unlicensed Staff O stated by looking at the falls indicated in the care plan, Resident 2 should not be left alone. Unlicensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 41 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Staff O stated the care plan did not specify the frequency of checking Resident 2. During a concurrent interview and record review on 10/26/16, at 2:50 p.m., the DON stated they tried different interventions including alarm, pad, and visual monitor for one shift only. The DON reviewed the fall and fall risk care plans and stated the care plans did not specify providing supervision to Resident 2 to prevent falls. During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated he did not witness Resident 2's fall. Unlicensed Staff L stated he was not assigned to Resident 2, but he still helped check on Resident 2 and the alarm function at least every hour. Unlicensed Staff L stated when Resident 2 had repeated falls (4 5 times in a month), staff should be with Resident 2 all the times. Unlicensed Staff L stated they did not have enough CNA (certified nursing assistant) in the hall where Resident 2 resided. Unlicensed Staff L stated because of short staffing, they were not able to check residents as frequently as they could to prevent residents from falling. The Emergency Department Report dated 9/14/16, indicated Resident 2 sustained a wound 2 cm in length in the head and the wound was repaired with staples. The emergency department report indicated Resident 2 did not receive any imaging or extensive workup because Resident 2 was on hospice with comfort measures only. Resident 2 had three more falls after 9/14/16 as follows: a. The IDT note dated 10/26/16 indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 42 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 2 fell from a wheelchair to the floor in the TV room; b. The IDT note dated 11/7/16 indicated Resident 2 fell on 11/5/16 witnessed by a Hall Monitor; and c. The IDT note dated 11/28/16 indicated Resident 2 fell on 11/26/16, slid out of a wheelchair. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to "us" [certified nursing assistants]. Unlicensed Staff BB stated they just put up signs in the utility room and in the resident's room and hoping us would know what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote "keep bed low, keep bed at an angle." During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent resident from injuries from falls. The DON stated she educated the staff about the sign but did not have a log to ensure all staff were educated and understood the sign. 3. During a concurrent observation and interview on 10/25/16, at 8:30 a.m., in Resident 3's room, Resident 3 stated she fell approximately at 3 a.m. four days ago from her bed to the floor. Resident 3 stated she climbed back to bed because no staff were around to assist her. Resident 3 stated she told a nurse about the fall at approximately 5:30 a.m., the day she fell. She stated the nurse just told her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 43 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to go back to bed. Resident 3's MDS dated 8/9/16, indicated Resident 3's BIMS (brief interview for mental status) score was 13, which indicated Resident 3 was cognitively intact. Resident 3's Fall Risk Evaluation dated 8/4/16, indicated Resident 3 was at high risk for fall due to multiple problems including history of falls, ambulatory and elimination status, and gait/balance problem. During an interview on 10/25/16, at 11:10 a.m., Licensed Staff B stated approximately 7 hours after Resident 3 fell last Wednesday or Thursday, Licensed Staff B assessed Resident 3 by asking how Resident 3 was doing and also performed a head to toe assessment. Licensed Staff B stated he documented the assessment. The nurse's note dated 10/20/16 at 10:15 a.m., indicated "[Resident 3] [up out of bed] in [wheelchair]. Denies any residual pain [secondary to fall]. [Resident 3] in wheelchair, going up and down hallway [without] difficulty. Will continue to monitor." The note did not indicate a head to toe assessment. There was no documentation of physician notification. During a concurrent interview and record review on 10/26/16, at 8:10 a.m., Licensed Staff B stated no specific document for the head to toe assessment. Licensed Staff B stated he documented the head to toe assessment in the nurse's note. When asked about the nurse's note, Licensed Staff B stated the nurse's note dated 10/20/16 at 10:15 a.m. was written by him. When asked for the fall protocol, Licensed Staff B stated they filled out the information forms which the night shift nurse should have done and turned it in to the DON. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 44 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent interview and record review on 10/26/16, at 8:35 a.m., the DON reviewed Licensed Staff B's nurse note dated 10/20/16 at 10:15 a.m., and stated it was not well documented and did not show the head to toe assessment. The DON stated the post fall protocol included completing the incident report, post fall assessment, post fall huddle, and neurological check flow sheet for unwitnessed fall. The DON stated staff had not notified her of Resident 3's fall. The DON stated staff did not complete the post fall protocol procedures for Resident 3's fall on 10/20/16. Review of the Fall Management Program Policy No. FA-01 documented following each fall, the licensed nurse will perform a post fall assessment, the licensed nurse will notify the Director of Nursing and / or Administrator and the Licensed Nurse will notify the resident's attending physician and responsible party of the fall incident. 4. Resident 5's admission record indicated Resident 5 was admitted to the facility on 3/10/16, with diagnoses including difficulty in walking, muscle weakness, dementia with behavioral disturbance. Resident 5's fall risk evaluation dated 10/10/16, 11/24/16, and 12/6/16, indicated Resident 5 was at high risk for falls due to multiple problems including mental status (disoriented or intermittent confusion), history of falls, gait and balance problems, and medications. Resident 5 was on Risperdal (an antipsychotic medication which works by changing the effects of the chemicals to the brain. Common side effects includes dizziness, drowsiness, and tired feeling) 0.5 mg by mouth every day and haldol (an antipsychotic medication which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 45 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE may work by blocking some chemical effects in the brain. Major common side effects include loss of balance control, muscle spasms, and shuffling walk) 70 mg intramuscularly every month for dementia with psychosis. Resident 5's MDS dated 3/17/16 and 9/16/16, indicated Resident 5's cognition was moderately to severely impaired. First fall: The nurse's note dated 5/24/16 at 11 p.m. and the IDT note dated 5/25/16 indicated Resident 5 had an unwitnessed fall on 5/24/16 at 7:45 p.m. in the bathroom. Resident 5 was found in the bathroom sitting on the floor wet with urine. Resident 5 complained of left shoulder pain and treated with Norco (pain medication). The IDT note indicated Resident 5 received antipsychotic (Haldol injection) prior to the fall. The IDT note indicated the charge nurse's plan to increase monitoring for a few hours after the monthly Haldol injection and recommended non-slip shoes for Resident 5. Resident 5's care plan for fall risk prevention and management initiated on 3/11/16 and had been re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including "Call light within reach, Remind resident to use call light unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue Bwing for increase supervision. The fall risk care plan did not reflect nor specifiy how to increase monitoring after the monthly Haldol injection. Second fall: The IDT note dated 10/3/16, indicated Resident 5 had an unwitnessed fall in the resident's room on 10/3/16 at 1:15 a.m. The IDT note FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 46 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated referring for physical and occupational therapy and continued to encourage wearing the hipster (Padded pants that cover the hip to cushion a fall to prevent injuries of the hip) when ambulating. The IDT note did not specify providing supervision to Resident 5. Third fall: The nurse's note dated 10/9/16 at 2:30 a.m. and the IDT note dated 10/10/16, indicated Resident 5 had an unwitnessed fall in the resident's room on 10/9/16 with unknown time of fall. The IDT note indicated referring for physical and occupational therapy and continued to encourage wearing the hipster when ambulating. The IDT note did not specify providing supervision to Resident 5. Fourth fall: The IDT note dated 11/24/16 indicated Resident 5 had a fall on 11/23/16 at 12 p.m. The IDT note indicated Resident 5 was walking in the hallway "but still asleep." The Hall Monitor headed toward Resident 5 "but before she got to him he fell onto his [left] hip and elbow." The IDT note indicated "will make a referral to PT/OT [physical therapy/occupational therapy]..." The IDT note did not specify providing supervision to Resident 5. Fifth fall: The nurse's note dated 11/23/16 and the IDT note dated 11/24/16, indicated Resident 5 had an unwitnessed fall in the resident's room on 11/23/16 at 9:35 p.m. Resident 5 sustained a small skin tear on the top ridge of the nose. The IDT note indicated "observe and monitor for 72 hours and "on 15 [minutes check]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 47 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Sixth Fall: The nurse's note dated 12/6/16 at 3 a.m. and the IDT note dated 12/6/16, indicated Resident 5 was found on the floor in the room. The IDT note indicated every 15 minutes check was initiated after the first hour of neuro checks. Resident 5's care plan for fall risk prevention and management initiated on 3/11/16 and had been re-evaluated on 6/16, 9/16, and 12/16, indicated interventions including "Call light within reach, Remind resident to use call light unable to use call light due to dementia, bed in low position..." The care plan indicated an intervention started on 11/7/16: Continue Bwing for increase supervision. The fall risk care plan did not reflect the 15 minutes check and how/who to check the resident. During a concurrent interview and record review on 12/8/16, at 8:35 a.m., regarding supervision for Resident 5, Unlicensed Staff CC stated she checked on Resident 5 whenever she saw the resident. Unlicensed Staff CC stated every staff in the hall was responsible to check on Resident 5. Unlicensed Staff CC stated she also reviewed the care plan for resident care. When she reviewed Resident 5's fall risk care plan and asked her what did "...increase supervision..." mean to her, Unlicensed Staff CC stated "To me, may need one-to-one..." When asked her if Resident 5 was on one-to-one supervision, Unlicensed Staff CC stated she needed to check the documentation and found Resident 5 was on every 15 minutes check. Unlicensed Staff CC stated all staff were responsible for monitoring and documentation. During a concurrent interview and record review on 12/8/16, at 8:55 a.m., Licensed Staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 48 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE NN reviewed the fall risk care plan and stated "...increase supervision..." meant every 15 minutes check. Licensed Staff NN stated the DON or ADON was responsible to review and update the care plans. Licensed Staff NN stated the care plan was used for following up on residents and making goals for resident care. During an interview on 12/9/16, at 7:20 a.m., reviewed Resident 5's fall risk care plan with the DON, the DON stated the care plan did not specify supervision for Resident 5 and she understood that staff could have interpreted differently for "...increase supervision." 5. Resident 4's MDS, dated 10/3/16 documented Resident 4 was admitted 4-1-10. Resident 4's diagnoses included Chronic Obstructive Pulmonary Disease, Hypertension (high blood pressure), Cardiac Arrhythmia (problem with the rate or rhythm of the heartbeat), schizophrenia (a mental illness in which someone cannot think or behave normally and often experiences delusions), and muscle weakness (general). Resident 4's MDS, dated 10/03/2016, revealed the BIMS (brief interview for mental status) score was 3, which indicated Resident 4 was severely cognitively impaired. The MDS assessment indicated Resident 4 required supervision with one person physical assist with transfers and walking in his room. The MDS assessment indicated Resident 4 required one person physical assist for walking in the corridor and toilet use. The care plan for Resident 4 for fall risk prevention and management, initiated on 10/04/2016, indicated fall risk prevention and management approaches included, "Orient resident to environment each time changes are made, remove hazards from environment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 49 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintain bed in low position and continue alarms in place on bed..." The care plan did not specify providing supervision to prevent Resident 4 from falling. The short term care plan (written care plan done for the actual fall) initiated on 10/14/2016 indicated fall risk prevention and management approaches including "hipsters" (padded type pants that cover the hips to cushion a fall), continue alarms-"replace when resident removes." Short term care plan reevaluated on 10/18/2016 indicated fall risk prevention and management approaches including video monitor of Resident 4's bed area, continue frequent observation, per discretion of nurse, every 15 minute minichecks, and all other monitoring as needed. During an interview on 11/09/2016 at 9:15 a.m., Licensed Staff B was asked what every fifteen minute minichecks and all other monitoring would mean to him. Licensed Staff B stated it would mean different things depending on what the issue was. When asked about falls in relationship to every fifteen minichecks and all other monitoring he stated that would mean neuro checks for the licensed personnel and for the CNA (certified nursing assistant) it would mean vital signs. Regarding all other monitoring he stated it would mean wanderguards, tag alarms, and alarms for bed and wheelchair. During an interview on 11/9/2016 at 3:55 p.m., Unlicensed Staff R was asked about "minichecks" and what that meant to him. Unlicensed Staff R stated it would mean the nurse would do neuro checks and I would do vital signs every 15 minutes times 2 hours, then every 30 minutes for 2 hours, then every hour FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 50 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for 4 hours. When asked about "all other monitoring" he stated I'd watch for pain, level of consciousness and safety. When asked regarding safety he stated it could be done with alarms like bed and chair alarms and a 1:1 (one staff to one resident) if possible. During an interview on 11/9/2016 at 4:05 p.m., Unlicensed Staff K was asked about "minichecks" and what that meant to her. Unlicensed Staff K stated it would mean vital signs (not sure how frequently) and checking them [the residents] to see how alert they were. When Unlicensed Staff K was asked what "all other monitoring" meant to her, she stated alarms can be used, "sometimes a 1:1." First Fall: The nurse's note, dated 8/15/2016, no time, indicated Resident 4 was found on the floor by his bed. Resident 4 had open abrasions to his knuckles that were cleaned and bandaged. He was placed in geri-chair in front of the nurse's station on A-wing. A bed alarm, bed lowered, floor mat and alarm placed on resident. The Interdisciplinary Team Conference Record, dated 8/16/2016, regarding Resident 4's fall on 8/15/2016 at 5:45 p.m., indicated Resident 4 had attempted a self transfer and fell at the side of the bed. It indicated "alarm" was on and hipsters were in place. The IDT Conference Record indicated to continue hipsters and alarms and care plans updated. There was no short term care plan found. Second Fall: There was no documentation in the nurse's note from fall 8/21/2016. The IDT Conference Record, dated 8/22/2016, indicated Resident 4, at 1:30 p.m., was up in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 51 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE chair and he attempted to reposition himself and he slid down to the floor. Resident 4 slightly reopened his right hand skin tears and they were rebandaged. The IDT Conference Record indicated to continue alarm and hipsters. The IDT Conference Record indicated care plans updated. There was no short term care plan found. Third Fall: The nurse's note, dated 9/20/2016, no time, indicated a "Late Entry" for 9/17/2016 at 9:55 a.m., Resident 4 was sitting in bed and leaned forward. The nurse's note indicated Resident 4 went to the floor. There were no visible injuries and no complaint of pain per the nurse's note. The IDT Conference Record, dated 9/19/2016, no time noted, indicated Resident 4's fall was not witnessed. The record indicated Resident 4 was sitting up in his chair and leaned forward and fell forward on his knees. The record indicated Resident 4 was at risk for falls related to his end stage chronic obstructive pulmonary disease (lung disease that makes it hard to breath), and he has poor safety awareness and often tries to transfer himself. The record indicated Resident 4 was to have a wheelchair and bed alarm in place. The IDT note did not specify providing supervision to Resident 4 to prevent further falls. The fall risk care plan for Resident 4, dated 10/4/16 indicated Resident 4 had an actual fall 9/20/16, and alarms were in place on the bed. No other changes indicated. Fourth Fall: There was no documentation of a nurse's noted found for the fall that occurred on 10/13/2016. Physician's progress note dated 10/14/16 indicated patient had another fall. Patient attempted to get up as he felt strong enough. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 52 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE He has poor balance. Medically stable, physically and mentally failing. "Very high risk to fall." Within the nurse's note, dated 10/17/16, at 2:30 p.m., written by RT (respiratory therapist), it as indicated Resident 4 sustained a fall which included bruising around the nose. The IDT (Interdisciplinary Team) Conference Record dated 10/14/16, indicated he [Resident 4] "had been safe in bed with hipsters on and alarm in place per care team, when he unexpectedly got up, took his own alarm and hipsters off but had his boots on and ambulated to the closet area near a lift, falling to the floor..." Physician had requested trial of mattress on the floor. Per PT (physical therapy) it was indicated the mattress on the floor would increase risk, so will use low bed, mats at bedside. The record indicated care plans updated. The fall risk care plan dated 10/04/16 did not indicate any changes were made. During an interview on 10/26/16 at 11:05 a.m., Licensed Staff F stated she found him [Resident 4] in his room but nearer the wall by the door on his hands and knees trying to get up. Licensed Staff F did not witness the fall. She stated Resident 4 had a bloody nose. She called code STAT (immediately) for a fall and had help immediately. Licensed Staff F stated the resident went to the emergency room. Licensed Staff F stated the resident had a 1:1 after he returned from the emergency room, but it did not occur too often due to staffing issues and stated there were not enough staff to cover for current residents and not able to find someone to come in to stay with resident. Fifth Fall: There was no documentation of nurses notes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 53 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for the fall that occurred on 10/15/2016. During an interview on 10/26/16, at 12:01 p.m., Unlicensed Staff M stated she was aware (she stated she was in the shower room on 10/15/16 when the resident fell) that Resident 4 "tripped over a hoyer lift (a mechanical lift) that someone forgot to take out." Unlicensed Staff M stated she came over (the hoyer lift was still in the room), but there were staff already helping him. She was aware Resident 4 went to the emergency room. Unlicensed Staff M stated with the 1:1 for the resident it was much better. Unlicensed Staff M stated, "Especially on PM's there is not enough staff to watch everyone so a 1:1 for the resident really helps." During an interview on 12/9/16 at 7:20 a.m., regarding Resident 4's fall on 10/15/16, with a hoyer lift in resident's room, the DON stated two CNAs were getting ready to assist Resident 4's roommate with a hoyer lift. The DON stated the two CNAs heard a code "STAT" [immediately] from another room. The two CNAs left Resident 4's room to attend to the code "STAT." The two CNAs left the hoyer lift in Resident 4's room. After the two CNAs left the room, Resident 4 might have gotten up from bed and fell. Resident 4's face might have hit the base of the hoyer lift because the base of the hoyer lift had blood. The DON stated the two CNAs should have removed the hoyer lift from Resident 4's room prior to attending to the code "STAT" and should not put one resident in danger in order to help another resident. The IDT (Interdisciplinary Team) Conference Record dated 10/17/2016, indicated he [Resident 4] on 10/15/2016 was found in a seated position in room next to nightstand. "Resident is on 15 minute checks due to prior fall"... "Resident will be observed and monitored for 72 hours." The IDT conference FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 54 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE record indicated to continue with hipsters and a mat at the bedside. The Conference Record indicated Resident 4 had a, "history of falls" related to forgetting to use his call light/waiting for assistance, taking off bed/chair alarms and could not stand or ambulate with staff assistance. The fall risk care plan dated 10/04/16 did not indicate any changes were made. Sixth Fall: There were no documentation of nurse's notes for the fall that occurred on 10/17/16. The IDT (Interdisciplinary Team) Conference Record dated 10/18/16, indicated on 10/17/16 Resident 4 had an unwitnessed, noninjury fall while attempting to get of of bed. Resident 4 had been at the nurses station with a nurse before this fall and had requested to go back to bed. The nurse's note dated 10/24/16, indicated he [Resident 4] continued to attempt to ambulate and self transfer. "High fall risk.... Resident turning off alarm and picking it up and walking with it. Poor Safety awareness." The Care Alert dated 8/22/16, and updated/reviewed on 10/17/16, and posted in Resident 4's room stated, "[Resident 4] is at high risk of fall with injury due to his restlessness and frailty. Please make sure he is offered assistance with a urinal/toileting at least every 2 hours. Please make sure he has an alarm on at all times, keep a mat on the floor next to his bed; if he is out of bed, assist him to wear hipsters and appropriate non-slip foot wear. [Resident 4] may enjoy being up in a Geri-Chair for relaxation. If he does not choose to utilize a Geri-Chair, offer him his regular FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 55 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE wheelchair. If he does use the Geri-Chair, please supervise him closely and assist him to safely get up when he wants to get up." The Care Alert did not specify timeframe for, "supervise him closely." During a concurrent observation and interview with Resident 4, on 10/25/16, at 10 a.m., Resident 4 was in the activity room, currently painting alone at a table. Resident 4 stated he enjoyed painting. Resident 4 stated he did not remember the fall. He hurts, "all the time." When asked about pain he stated he had arthritis. He stated they gave him pain medication and it helped. The activity assistant was helping 2 other residents at another table with art work. There were no other personnel in activity room. During an interview with Licensed Staff B, on 10/26/16, at 10:15 a.m., when asked about Resident 4 he stated the resident had days when he was "hyperactive" (moving around, can't keep still) and other days when he was "hypoactive" (sleeps most of the day-only awake for meals). He stated the 1:1 (resident has 1 staff member that stays with them at all times) makes a difference, but due to staffing it doesn't always happen. 6. Resident 6's admission record indicated Resident 6 was admitted to the facility on 3/25/16, with diagnoses including Alzheimer's disease (a brain disease causing a memory loss and disorientation), epilepsy (seizure) and depressive disorder. The Admission Minimum data Set dated 4/1/16, and the most recent quarterly MDS dated 9/29/16, indicated Resident 6 had a short-term and long-term memory loss and severely impaired cognition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 56 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The CAA (CAA, a tool used to identify concerns and develop an individualized care plan), dated 4/1/16, indicated Resident was a risk for falls, Alzheimer's type dementia, and was on Psychotropic drugs. During a record review on 12/7/16, a nurse's note, dated 11/25/16, indicated on 11/25/16, at 2:45 a.m., while ambulating on B Hallway, Resident 6 tripped on a pedal of another resident's wheel chair; thus causing fall. Resident had a laceration on right side of the head. Resident 6 had a hipster on. The nurse's note also stated, "prior to the fall, Resident 6 per report from the night shift nurse, was agitated, combative and in constant motion. Resident 6's behavior escalated to screaming, hitting staff and kicking other residents. PRN was given, but no avail." Staff was planning to notify husband to help calm her prior to the fall. During observation, and interview on 12/7/16 at 8:45 a.m., Resident 6 was walking down the hallway back and forth multiple times without being accompanied by anyone. When asked why Resident 6 was walking alone, Licensed Staff NN stated she did not know why the hall monitors were not walking with her. Licensed Staff NN also stated Resident 6 did not like hall monitors getting closer to her and if they did Resident 6 started pushing and yelling at them and got agitated and combative, so they had to walk behind Resident 6. When asked, how was that going to prevent Resident 6 from falling, Licensed Staff NN stated she did not know what to do. During record review on 12/7/16, a care plan dated 11/25/16, documented an intervention for Resident 6 to have 1:1 supervision upon return from ED. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 57 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/9/16 at 7:20 a.m., the Administrator stated on 11/25/16 Resident 6 tripped on another resident's wheelchair while she walked in the hallway. The Administrator stated there were hall monitors walking with Resident 6 when she fell. When asked if the fall was avoidable, the Administrator acknowledged it was avoidable. During an interview on 12/9/16 at 8:20 a.m., Licensed Staff D stated she witnessed the fall on 11/25/16 at 8:45 a.m. Resident 6 was walking the hallway and tripped on the pedal of another resident's wheel chair and fell. Licensed Staff D stated she assessed Resident 6 and noted Resident 6 had laceration to her right forehead. Licensed Staff D stated she called the treatment nurse who came, cleaned and put pressure on the wound. Licensed Staff D then called an ambulance that came and took Resident 6 to the hospital for evaluation and treatment. During record review on 12/7/16 IDT (interdisciplinary team) notes indicated Resident 6 had multiple falls from the date of admission (3/25/16) to date of the survey (12/5/16). Three of these falls caused injuries to the head that required Resident 6 to be sent to acute care hospital for evaluation and treatments. During a record review on 12/7/16, an IDT note, dated 8/2/16, indicated on 8/1/16, Resident 6 was ambulating all morning as Resident 6 usually was, unable to sit still. Resident 6 was noted to be irritable and poking staff as they walked by. At one point Resident 6 grabbed the neck of one staff who was attempting to pick up Resident 6's Teddy Bear. Resident 6's gait was shuffling as was usual, was leaning back as Resident 6 stood. Suddenly, Resident 6 witnessed to be standing and fell backward bumping her right elbow and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 58 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE back of her head. Resident 6 had some bleeding in the head, pressure was applied and 911 called for transport to ED for evaluation and treatment. The physician was faxed regarding reducing meds. During a record review on 12/7/16, an IDT note, dated 10/26/16, indicated on 10/13/16, Resident 6 had a fall and sustained an injury to the left side of the head laceration with eight staples. The physician ordered increased Depakote (anti seizure medication) for seizures and Resident 6 continued to be risk for falls. Resident 6's gait was steady and hall monitors were available in B wing, according to IDT notes. During a care plan review and interview on 12/7/16 when asked, why care plan was not done after this fall dated 10/13/16, Licensed Staff NN stated she was not there at the time; she also stated the director of nursing did the care plan and did not know why it was not in the chart. The facility failed to develop a care for Resident that would prevent Resident 6 from falling constantly. 7. Review of Resident 14's admitting History and Physical, indicated Resident 14 had severe dementia and was being admitted to facility on 7/6/16 after increasingly falling. The "Fall Risk Assessment" dated 7/6/16; indicated Resident 14 was at high risk for fall due to multiple problems including disoriented, three or more falls in the past three months and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 59 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE poor vision. Resident 14's "Fall Risk Assessment" dated 11/7/16, indicated the resident was high risk for fall due to one to two falls in the past three months. Review of Resident 14's Post Fall Assessments, Nursing Notes, and IDT Conference Record, indicated Resident 14 had a witnessed non-injury fall on 8/19/16 and 8/12/16, and an unwitnessed fall with injury on 11/5/16. IDT Conference Record dated 11/5/16, indicated certified nursing assistant (CNA) found Resident 14 on the floor next to his bed on 11/4/16 at 9:15 p.m., laying on his left elbow and had a skin tear at left elbow. Resident 14's Nurse's Notes dated 11/5/16, indicated: 1. CNA notified nurse Resident 14 was not able to bear weight on left leg and was complaining of pain, 2. Nursing assessment indicated Resident 14's left leg had a slight external rotation, and 3. Resident 14 was sent to the emergency department (ED) per physician's order. IDT Conference Record indicated ED nurse contacted facility's charge nurse who reported Resident 14 had a pelvic fracture. Review of "Physician Orders" dated for the month of December, indicated starting on 11/5/16 Resident 14 was to be "one on one with staff at all times." Review of "Resident Care Plan Fall Risk Prevention and Management" revised and rewritten on 11/8/16, indicate Resident 14: 1. Was at high risk for falls, 2. Had severe dementia, and 3. Had a significant change in condition whereby Resident 14 had a pelvic fracture, which occurred on 11/4/16; there was no indication for Resident 14 to be "one on one with staff at all times." Review of Resident 14's Care Plan Short Term FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 60 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (start date 12/5/16), indicated approach to fall problem was for staff to notify charge nurse immediately of any changes in behavior for reassessment of supervision needed;" there was no indication for Resident 14 to be "one on one with staff at all times." The facility's policy and procedure titled "Fall Management Program," date revised 3/1/16, indicated "The Facility will implement a Fall Management Program that supports providing an environment free from the hazards...The IDT will initiate, review, and update resident fall risks and Plan of Care at the following intervals: admission, quarterly, annually, upon significant change of condition identification, and post fall as needed...Post-Fall Response A. Following each resident fall, the Licensed Nurse will perform a Post-Fall Assessment utilizing FA-01-Form A-Post Fall Assessment, and update, initiate or revise a Plan of Care. B. The Licensed Nurse will complete the FA-01-Form B-Neurological Flow Sheet for an un-witnessed fall, or witnessed fall with suspected or known head injury for seventy-two (72) hours following the fall incident. The Attending Physician will be informed if there is a deviation from the resident's normal status for further instruction...D. The Licensed Nurse will notify the resident's Attending Physician and responsible party of the fall incident...Post Fall Huddle A. Within 15-20 minutes after a fall the Licensed Nurse will initiate a post fall huddle utilizing the Post fall Huddle form...Fall Investigation/Reporting and Documentation A. Following a resident incident of fall, the Licensed Nurse who has the most knowledge about the incident will complete AP-31-Form AIncident and Accident Report Forms...E. The IDT will summarize conclusions after their review of the fall and circumstances surrounding the fall on an IDT note. The plan of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 61 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care will also reviewed and the care plan will be revised as necessary in an effort to prevent further falls with major injury...Recurrent Falls...These residents may require more frequent observation of activities and whereabouts..."

F329 SS=E DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.45(d)(e)(1)-(2)

F329 01/31/2017 483.45(d) Unnecessary Drugs-General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-(1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 62 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; This REQUIREMENT is not met as evidenced by: Based on observation, interview, record and facility document review, the facility failed to ensure each resident's drug regimen was free from four unnecessary drugs for 1 of 15 sampled residents (Resident 7) when Resident 7 was administered unnecessary medications which increased her risk for fall injuries, an adverse consequence, especially in the elderly, because of sedative side effects. Ativan is a benzodiazepine anxiolytic. Norco is an opiate pain reliever. Benadryl is an antihistamine. Seroquel is an antipsychotic. While on these sedating medications, Resident 7 suffered five documented falls between 3/7/16 and 10/16/16. Ativan and Seroquel were given without adequate monitoring. Ativan and Benadryl were duplicative as they were different drugs prescribed for the same condition of insomnia. Seroquel and Norco were given without an indication which justified its use. The facility's failure to ensure the resident's medication regimen was free of unnecessary drugs placed her at risk for over FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 63 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sedation and serious injury from future repeated falls. Findings: A review of the undated Facesheet showed Resident 7 was an 84 year-old admitted to the facility on 2/4/16 with diagnoses including: diabetes, unspecified dementia without behavioral disturbances, gastro-esophageal reflux disease and chronic obstructive pulmonary disease. A review of the Resident Admission Assessment, dated 2/4/16, showed as part of Resident 7's behavioral/cognitive assessment that she had poor safety judgement. Her musculoskeletal assessment showed she used a walker and had weakness. Her fall risk factors showed she had no history of falls within the last six months, she was not visually impaired, and had no impaired balance. A review of Resident 7's history and physical (H&P), dated 2/5/16 indicated she had no pain. There was no reference to anxiety. The H&P was signed by the resident's attending physician (Physician S). A review of Resident 7's physician orders below showed Physician S ordered the following medications which, according to the manufacturers, have sedating effects: On 2/4/16 Physician S ordered, "Ativan 1 milligram (mg) po BID prn [by mouth twice daily as needed] for anxiety m/b [manifested by] insomnia." Monitoring instructions for efficacy showed, " Ativan: Monitor # [number] of hours of sleep." Monitoring instructions for adverse effects showed, "Sedation, drowsiness, ataxis (drunk walk), dizziness ..." Orders dated 2/18/16 showed Ativan was increased to 1mg prn q8 hours for anxiety manifested by insomnia. Orders dated 7/16/16 showed Ativan was decreased to 1mg BID prn anxiety. On 2/4/16 Physician S ordered, "Norco 5/325 mg 2 tabs po prn q 4 hours for severe pain" and "Norco 5/325 mg 1 tab po prn q 4 hours for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 64 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE moderate pain." Orders dated 8/12/16 increased Norco to two tablets every eight hours. Orders dated 8/25/16 changed Norco to prn. On 2/4/16 Physician S ordered, "Benadryl 25 mg po prn qhs for insomnia." On 2/4/16 Physician S ordered, "Seroquel 50 mg po q pm [every evening] for dementia with verbal violence" and "Seroquel 25 mg po q am [every morning] for Psychosis with verbal violence." Monitoring instructions for efficacy showed, " Seroquel: Monitor dementia with verbal violence qsh [every shift]. Monitoring instructions for adverse effects showed, "Seroquel: Monitor Tardive Dyskinesia (facial tongue movement) q shift & tally by hash marks. Seroquel: Monitor Cognitive Behavior (decreased mental status) q shift & tally by hash marks. Seroquel: Monitor Akathisia (inability to sit still) q shift and tally by hash marks. Seroquel: Monitor Parkinsonism (tremors, drooling, rigidity) q shift and tally by hash marks." On 12/7/16 at 10:30 a.m., in an interview with a registered nurse, (Licensed Staff TT), she indicated Resident 7 had fallen four times. According to the nurse, in March, the resident had an unwitnessed fall and was found sitting on the floor. She indicated the ITD attributed the fall to a slippery sole. In April the resident fell twice. The first time she was sitting in her wheelchair and fell out on her bottom. The second time she was found on the floor and said she slid out of her chair. In October there was an unwitnessed fall in her bedroom she stood up to ...wash her hands. The wheelchair was not locked. On 12/7/16 at 2:12 p.m., in an interview with Physician S indicated she prescribed orders on 2/18/16 for Resident 7 to receive Ativan every 8 hours as needed for anxiety manifested by insomnia. A record review showed she reduced that to Ativan twice daily, then to once daily on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 65 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/1/16 as needed for anxiety manifested by insomnia. She acknowledged that her intent was not to treat insomnia at all hours of the day; rather it was to offer it at bedtime if the resident could not sleep due to anxiety. Physician S indicated that on 2/4/16 she prescribed Benadryl 25 mg prn for insomnia. Benadryl is an antihistamine that causes sedation. Physician S indicated the addition of Ativan was duplicative for insomnia but the Resident manifested anxiety in other ways that were not captured as targeted behaviors on the MAR . A review of the residents PRN MAR for April showed she received Benadryl 25mg once on 4/23/16 and that it was still an active order. In the same interview, Physician S indicated she prescribed Seroquel for "psychosis manifested by verbal violence." Physician S said, "The documentation is wrong." She indicated that her intent was for the resident to receive antipsychotics to treat psychosis manifested by visual hallucinations and striking out and episodes of being combative with staff. Physician S indicated that staff were monitoring for episodes of "verbal violence" such as "yelling at people" rather than "visual hallucinations" or "hitting or grabbing staff." Physician S indicated staff provided summary data on behavioral monitoring as requested but acknowledged it was not useful in targeting specific behavior patterns to consider when evaluating changes to the resident's medication regimen. On 12/8/16 at 10:53 p.m., in an interview with the Consultant Pharmacist (CP) he said, "I am trying to explain to the facility and the MD antipsychotics should not be used for dementia and if they are to be used there are steps to go through." On 12/8/16 at 11:15 a.m., in an interview and concurrent record review, the Director of Nursing (DON) provided the facility's Incident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 66 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Logs which documented when and which residents suffered falls in the facility during the survey period. The DON said, "We have had 218 falls between January 2, 2016 and December 6, 2016. Fifteen of them resulted in serious injury." The DON described the serious injuries included six hip fractures, three head lacerations, two or three skin tears, a pelvic fracture, a shoulder fracture, and a wrist fracture. The DON indicated that Resident 7 did not sustain any serious injuries as a result of falls. When asked if the facility had identified a cause or pattern to the resident's falls, the DON indicated she thought it had to do with the resident's wheelchair. She indicated that the majority of falls happened on B wing and she thought there had been no falls reported "in the summer months when the students are here." The DON indicated the facility had not determined sedating drugs were a factor in any of the reported falls. A review of the facility's Incident Logs for the survey period showed Resident 7 had five documented falls on: 3/7/16 at 11:36 a.m.; 3/27/16 at 5:30 p.m.; 4/21/16 at 5:55 p.m.; 9/29/16 "p.m."; and 10/16/16 at 1:35 p.m. On 12/8/16 at 3:30 p.m., in an interview, Resident 7 complained of pain but did not discuss falling. On 12/8/16 at 3:50 p.m., in an interview with a regional nurse consultant (Licensed Staff VV) indicated the facility had determined the majority of falls occurred on B Wing. The reasons for the falls included: the residents were "ambulatory", they "take shoes off", "impulsive behavior", "cognitively impaired" and they "don't know their limits." She indicated the facility had not ruled out that contributing factors could be lack of staffing, lack of supervision, lack of monitoring, the effects of sedating medications, unnecessary medications, lack of staff motivation, the condition of the residents, or not having an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 67 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE organized system to intervene. A review of all available Interdisciplinary Team Conference Records (ITC) corroborated that the Resident 7 sustained falls in March, April, and October. None of the records indicated that over sedation from medications had been considered as contributing factors for Resident 7's falls. An ITC dated 3/8/16 showed, "Res [Resident] found sitting on floor next to bed stating that her slippers were too slippery." The document indicated Resident 7 had a non-injury fall at 11:35 a.m. on 3/7/16. The only intervention was "footwear inspected and does have a worn slippery sole. New footwear provided ..." An ITC 4/22/16 showed, "84 yr old female with fall on 4/21/16 out of w/c onto her bottom on the floor. The only interventions listed were to see if the resident could move all her extremities and "educate on need to lock her wheelchair when attempting to reposition herself." An ITC dated 4/28/16 showed, "Last pm resident slid out of w/c. The only intervention recorded was the physician was called and "Will assess result of UA [urinalysis] for fall planning." An ITC dated 10/17/16 showed, "Resident had a non-injury fall on 10/16/16" while standing in her room. The only intervention on the record was, "will address w/c [wheelchair] safety with locking brakes. Remind resident to get assistance with ADLs [activities of daily living], toileting. A U.S. Boxed Warning is the strongest warning the Food and Drug Administration can mandate manufacturer's to place on the drug label to warn prescribers of the serious adverse effects of using the drug. The manufacturer of Ativan tablets includes a U.S Boxed Warning: "Concomitant use of benzodiazepines and opioids may result in profound sedation [Reference: Valeant FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 68 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Pharmaceuticals Package Insert 9/16]." According to Lexi-Comp ONLINE, a nationally recognized medication reference resource, Seroquel , Norco and Benadryl could both produce sedative effects, including drowsiness. A review of Resident 7's April Medication Administration Record (MAR) showed the following: Resident 7 was given her morning and evening doses of Seroquel every day in April except for the morning dose on 4/9/16 and 4/23/16. The diagnosis for Seroquel for the first 12 days of April was "dementia with verbal violence." On April 13 the diagnosis was changed to "Psychosis NOS" and added to the MAR. She had zero episodes documented for "verbal violence" on all shifts for the month. Resident 7 was given Ativan on 4/1/16, 4/6/16, and 4/9/16. The reason documented by the nurse on 4/1/16 was "c/o [complaint of] anxiety" not "insomnia". No reasons for administration were documented for the other doses. The April MAR showed she slept between 6-7 hours on average that month. Resident 7 was given Ativan on 9/6/16 and 9/22/16. The reason documented by the nurse on 9/6/16 for the 6:30 p.m. dose was "inability to sleep". There was no documentation for the other dose. The resident averaged 6-7 hours of sleep per night in the month of September. Resident 7 was given Ativan on 10/3/16 and 10/20/16. The reason documented by the nurse on 10/20/16 at 2:30 p.m. was "anxiety" not "insomnia". The October MAR showed she slept between five to seven hours every night that month. Resident 7 was given her morning and evening doses of Seroquel every day in September. She had zero episodes documented for "verbal violence" on all shifts for the month except for 9/1/16, 9/2/16, 9/4/16, 9/5/16, 9/19/16, and 9/24/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 69 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 7's October MAR showed the following: Resident 7 was given her morning and evening doses of Seroquel every day in October. She had zero episodes documented for "verbal violence" on all shifts for the month except for 10/21 and 10/23. A review of the facility's Pain Management Orders, dated 2/3/16, showed Resident 7's pain was assessed each shift using the facility's subjective pain scale. On a scale of 0-10, zero indicated no pain; 1-3 indicated mild pain; 4-7 indicated moderate pain; and 8-10 indicated severe pain. The order for moderate pain signed by Physician S showed, "Norco 5/325 mg [milligrams] one tablet every four hours PRN [as needed] Moderate pain Moderate Pain Score 4-7 (1-10)."The order for severe pain signed by Physician S showed, "Norco 5/325 mg two tablets every four hours PRN Moderate pain Moderate Pain Score 4-7 (1-10)." Resident 7 was given two tablets of Norco 5/325 mg (prescribed for severe pain) on the following dates when her pain score was documented as a number less than "7": 2/25/16 at 2:00 a.m. 2/29/16 ay 10:30 a.m. 2/8/16 at 11:30 a.m. 2/10/16 at 5:15 p.m. 2/6/16 at 10:30 a.m. 2/8/16 at 8:00 p.m. 2/9/16 at 9:00 a.m. 2/12/16 at 1:00 a.m. 2/12/16 at 7:20 p.m. 2/13/16 at 5:00 a.m. 2/13/16 at 9:00 a.m. 2/13/16 at 2:00 p.m. 2/19/16 at 10:45 a.m. 3/16/16 at 3:30 p.m. 3/16/16 at 11:00 a.m. 3/17/16 at 11:45 a.m. 3/20/16 at 4:05 p.m. 3/6/16 at 9:45 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 70 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5/4/16 at 1:05 p.m. 5/9/16 at 12:00 p.m. 5/26/16 at 12:20 p.m. 5/29/16 at 11:35 a.m. 9/16/16 at 9:00 a.m. 10/1/16 at 2:15 a.m. 10/6/16 at 4:00 p.m. 10/10/16 at 11:00 a.m. 10/12/16 at 4:10 p.m. 10/12/16 at 9:00 p.m. 10/14/16 at 3:35 p.m. 10/15/16 at 11:45 a.m. She received two tablets of Norco at 4:30 a.m. on the day of her 10/17/16 fall.

F353 SS=H SUFFICIENT 24-HR NURSING STAFF PER CARE PLANS CFR(s): 483.35(a)(1)-(4)

F353 01/31/2017 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e). [As linked to Facility Assessment, §483.70(e), will be implemented beginning November 28, 2017 (Phase 2)] (a) Sufficient Staff. (a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 71 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Except when waived under paragraph (e) of this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. (a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. (a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care. (a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide adequate nursing staff to provide quality care to their residents. This failure had resulted in resident care needs not being met and contributed to resident falls and injuries due to inadequate staff supervision of residents. This failure also had the potential to prevent residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Cross reference F 241 and F 323 Findings: During a concurrent observation and interview on 10/25/16, at 8:05 a.m., Resident 17 was in bed and alert. Resident 17 stated sometimes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 72 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she had to wait for a long time, up to approximately 30 minutes, for staff answering her call light and assisting her. Resident 17 stated this long waiting time happened anytime of the day. Resident 17 stated she felt really bad when she needed to go to the bathroom. When asked what would happen if she needed to go to the bathroom, Resident 17 stated "just have to wait." During a concurrent observation and interview on 12/5/16, at 3:05 p.m., Resident 17 was sitting in a wheelchair at bedside. Resident 17 stated she usually had to wait for more than 30 minutes for staff answering her call light and assisting her. Resident 17 stated she felt bad when she had to urinate on herself and stayed wet for a long time. Resident 17 also stated she told the CNAs (certified nursing assistant) every day that she [Resident 17] wanted to be out of the bed by 9:30 a.m. She stated the CNAs said they would help her as soon as they could, but they were always late until 10 a.m. or after 10 a.m. Resident 17 stated they did not have enough CNAs. Resident 17's MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 10/19/16, revealed Resident 17's BIMS (brief interview for mental status) score was 14, which indicated Resident 17 was cognitively intact. During a concurrent observation and interview on 12/5/16, at 2:17 p.m., Resident 18 was in bed and awake. Resident 18 stated sometimes he had to wait for 5 to 10 minutes for the staff to answer the call light. When asked how the 5 to 10 minutes wait time affected Resident 18, Resident 18 stated "depends what I needed." Resident 18 stated they did not have enough FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 73 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CNA to help the residents. Resident 17 and 18 were deemed by the facility to be interviewable. During an interview on 10/26/16, at 3:55 p.m., Unlicensed Staff L stated they did not have enough CNA. Unlicensed Staff L stated the facility reduced the number of CNAs from three to two CNAs on B wing (a memory unit for residents who have memory problems). Unlicensed Staff L stated it was very stressful because Unlicensed Staff L could not do things for the residents as he wanted to do (i.e. brush their teeth, wash their hands, giving a bed bath, and other things) because of short staffing. Unlicensed Staff L stated they were not able to check residents as frequently as they would to prevent residents from falling. Unlicensed Staff L stated two CNAs were not enough and they needed three CNAs. Unlicensed Staff L stated the Hall Monitors (staff) could not provide any resident care; they just watched the residents and walked with the residents. During an interview on 10/26/16, at 2:50 p.m., regarding staffing for fall prevention and management, the DON stated they increased Hall Monitor to B wing. During an interview on 11/3/16, at 2:35 p.m., when asked if the Hall Monitors were trained to prevent falls, the DON stated the Hall Monitors were trained to look if alarms were intact or pads were on the floor and to report to the nursing staff for anything was out of ordinary. The DON stated a Hall Monitor was a facility staff member but was not a care giver. The DON stated the Hall Monitors did not do hands on resident care; they could guide the resident and gently hold the resident's hands/elbows. During an interview on 11/10/16, at 10:40 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 74 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the Administrator stated B wing was the memory unit (residents had memory problems). The Administrator stated originally they had a total of three Hall Monitors covering from 6 a.m. to 8:30 p.m, but not at one time. The Administrator stated the first Hall Monitor worked from 6 a.m. to 2:30 p.m.; the second Hall Monitor worked from 9 a.m. to 5:30 p.m.; and the third Hall Monitor worked from 12 p.m. to 8:30 p.m. The Administrator stated about a week ago they increased the Hall Monitor to a total of four to cover 24 hours. She stated now the third Hall Monitor worked from 2:15 p.m. to 10:45 p.m., and the fourth Hall Monitor worked from 10:45 p.m. to 7:15 a.m. the next day. During an interview on 12/6/16, at 5:20 p.m., in B wing. Unlicensed Staff K stated she usually worked in C-Wing where residents were more stable. Unlicensed Staff K stated she worked PM (afternoon/evening) shift from 2:45 p.m. to 11:15 p.m. and cared for 10 to 12 patients each work shift. Unlicensed Staff K stated she felt they had enough staffing and she could stay with and help the residents as long as she needed. When asked what tasks included in one work shift for 10 to 12 residents, Unlicensed Staff K itemized the routine tasks with time required as following: (the numbers in parentheses at the end of each task were used for calculation of the minimum minutes required for one work shift) 1. Changing briefs (cloth protectors): 30 min (minutes) per resident for 3-4 residents every 1.5-2 hours equals to 90 - 120 min (90) 2. water round: 15 - 20 min (15) 3. Dinner set up: 5 min per resident for 4 - 5 residents equaled to 20 - 25 min (20) 4. feeding resident: 15 min for set up and 30 min for feeding for one resident equaled to 45 min (45) 5. changing and emptying urinals: 10 min per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 75 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident for 2 - 3 residents equaled to 20 - 30 min (20) 6. emptying urinary catheter bags: 10 min per resident for 2 residents equaled to 20 min (20) 7. routine changing/making beds: 5 min per resident for 2 - 3 residents equaled to 10 - 15 min (10) 8. changing wet beds: 5 min per resident for 2 residents equaled to 10 min (10) 9. taking vital signs (blood pressure, temperature, etc.): 5 min per resident for 3 - 4 residents equals to 15 - 20 min (15) 10. recording intake and output: 5 min (5) 11. documentation of activities of living flow sheet: 20 min (20) 12. shift change report: 15 min each for 2 reports equals to 30 min (30) 13. breaks: 10 min each for 2 breaks equals to 20 min (20) 14. meal break: 30 min (30) 15. shower for residents: 20 - 30 min per resident for 2 - 3 residents equaled to 40-90 min (40) 16. cleaning resident after meals: 20 min for total of 4 residents (20) 17. assisted resident to bed: 10 min per resident for 4 - 5 residents equaled to 40-50 min (40) 18. oral care: 5 - 10 min per resident for 2 residents equals to 10 - 20 min (10) 19. toileting: 5 - 10 min per resident for 6 residents equals to 30 - 60 min (30) 20. nail care: 10 min per resident for 3 resident equals to 30 min (30) 21. peri care: 5 min per resident for 4 residents 4 times per shift equals to 80 min (80) 22. grooming/shaving: 10 min for 4 residents equals to 40 min (40) 23. dressing: 10 min per resident for 6 residents equals to 60 min (60) 24. snack: 10 min (10) 25. hand washing: before and after resident care: uncalculated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 76 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 26. answering call light: uncalculated The calculation revealed: One CNA had a total of 510 minutes per shift from 2:45 p.m. to 11:15 p.m including breaks. A minimum of 710 minutes were required to complete the routine tasks in one work shift including breaks. This 710 minutes did not include the time for hand washing, answering call lights, reporting change of condition, and other unexpected circumstances. There were 200 minutes short for the staff to complete the routine tasks. During an interview on 12/7/16, at 9:44 a.m., Unlicensed Staff PP, who worked in A wing (one of the resident care unit), stated she worked both AM (morning) and PM shift. Unlicensed Staff PP stated they usually had three CNAs in morning shift and each CNA had eight residents; they had two CNAs PM shift and each CNA had 13 residents. Unlicensed Staff PP stated they needed three CNAs for PM shift. Unlicensed Staff PP stated they had not been had enough CNA since she returned to work on June 2016. Unlicensed Staff PP stated they needed adequate staffing to feed residents properly and ensure safety and prevent falls. When asked about the tasks and time required for caring the residents for one work shift, Unlicensed Staff PP provided the time for the routine tasks. The calculation of the time required for completion of the routine tasks revealed a minimum of 754 minutes for AM shift and 1052 minutes for PM shift including all tasks and breaks. The CNAs shifts (AM, PM, & Nights)consisted of a total of 510 minutes, which included the breaks. There were a minimum of 244 minutes short for AM shift and 542 minutes short for PM shift. This calculation did not include time for hand washing, answering call lights, reporting change of condition, other unexpected situations, and toileting as she stated toileting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 77 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE required 6 - 10 minutes per one resident and assisted different residents through out 8 hours. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB, who worked in B wing, stated they "never" staffed sufficiently. Unlicensed Staff BB stated they had two CNAs and she had 12 residents. Unlicensed Staff BB stated they needed at least three CNAs. During an interview on 12/7/16, at 4:45 p.m., Staffing Coordinator DD stated she did the schedules for all CNAs and RNAs (restorative nursing assistant). Staffing Coordinator DD stated she scheduled staff according to the resident census and number of falls. Staffing Coordinator DD stated for full census, she usually scheduled three CNAs for AM and PM shifts in one unit (facility had three units: A wing, B wing, C wing) and each CNA had 12 residents; two CNAs for night shift each unit and each CNA had 22 residents. Staffing Coordinator DD stated if there were a lot of falls (on 12/8/16 at 10:35 a.m., she stated to her, one fall was a lot) in a unit, she would schedule more CNAs or Hall Monitors to that unit. Staffing Coordinator DD stated Hall Monitors walked back and forth in the hallway. If the Hall Monitor saw a resident getting out of bed, the Hall Monitor reported to the CNA or the nurse. The Hall Monitors were not certified for resident care. Staffing Coordinator DD stated the Hall Monitor might not be able to prevent the fall because when the CNA or nurse arrived to the resident's room, the resident might have already fallen. Staffing Coordinator DD stated the staffing one CNA to 12 to 22 residents was "doable" because the resident census and care fluctuated. She stated she was also a CNA. When asked about the routine tasks required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 78 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for one CNA in one work shift, Staffing Coordinator DD provided time required for each routine task. She stated AM and PM shifts were about the same. The calculation of the time revealed a minimum of 850 minutes for one CNA to complete the routine tasks in a given AM or PM shift; each CNA had a total of 510 minutes per shift, which was 340 minutes short. Staffing Coordinator DD did not provide details of all tasks for night shift but stated the tasks for night shift were more on repositioning, toileting, catheter care, and peri care (cleaning the urinary, vaginal, and rectal areas). Upon requested for the days and shifts when Staff Coordinator DD scheduled more CNAs than a routine schedule because of "a lot of falls," twice on 12/8/16 at 10:35 am., and 6:40 p.m., Staff Coordinator DD did not provide the days and shifts. During an interview on 10/26/2016, at 8:45 a.m., Licensed Staff E stated she doesn't use the care plan/update as it is difficult to use and she was not sure how to use it. Licensed Staff E stated, "sometimes there's a 1:1(person who cares for just one resident), but not often." Licensed Staff E stated the staff at the facility kept an eye on residents in the hallway. She stated, "This is how we manage." During an interview on 10/26/2016, at 11:05 a.m., Licensed Staff F stated 1:1 care doesn't occur too often-because of "census and staffing issues, "not enough staff available and low census. During an interview on 10/26/2016, at 12:01 p.m., Unlicensed Staff M stated, "Especially on PMs there is not enough staff to watch everyone so a 1:1 for a resident really helps". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 79 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/8/16, at 9:40 a.m., Unlicensed Staff QQ, who worked in Wing A (one of the resident care units), stated she worked AM (morning) shift. Unlicensed Staff QQ stated they usually had two CNAs in morning shift and each CNA had 14 residents, and she had 14 residents today. Unlicensed Staff QQ stated they needed more staff for each shift to provide good care for the residents. Unlicensed Staff QQ also stated they needed adequate staffing to feed, shower, and bath residents properly and ensure safety and prevent falls. When asked about the tasks and time required for caring the residents for one work shift, Unlicensed Staff QQ stated it was a lot of work and it was very hard to complete all the work adequately. When asked, how long each of the routine daily tasks she performed took her to complete? She stated the following: 1. Shower per resident: 25/30 minutes times (2/ 3) residents equaled to 50-90 (50). 2. Bathing bed path per resident: 25/30 minutes X (2/3) residents equaled to 50-90 (50). 3. Oral care: 10minutes X (14) residents equaled to (140) minutes. 4. Making a bed when resident is out: 10 minutes X (10) residents (100) minutes. 5. Making a bed when resident is in bed: 20 minutes X (2) residents equaled to (40) minutes. 6. Meal tray setup/document %: 10 minutes X (4/5) resident equaled to 40-50 (40) minutes. 7. Hand feeding: 40 minutes X (2/3) residents equaled to 80-120 (80) minutes. 8. Toileting residents: 10 minutes X (5/6) residents equaled to 50-60 (50) minutes. 9. Nail care: 15 minutes x (3/4) residents equaled to 45-60 (45) minutes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 80 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10. Peri-care: 15 minutes X (4/5/) residents equaled to 80-100 (60) minutes. 11. Grooming/shaving: 15 minutes X (3/4) residents equaled to 45-60 (45) minutes. 12. Dressing residents: 20/30 minutes X (4) residents equaled 80-120 (80) minutes. 13. Catheters (empty/measure): 10 minutes X (3) residents equaled to (30) minutes. 14. Vital signs: 10 minutes X (14) residents equaled to (140) Minutes. 15. Charting each resident at the end of the shift: 5 minutes X (14) residents equaled to (70) minutes. 16. Serving supplements: 3 minutes X (10) residents equaled (30) minutes. 17. Massage to bony prominence: 10 minutes X (4/5) residents equaled to 40-50 (40) minutes. 18. Reposition each resident: 10 minutes X (7) residents equaled to (70) minutes. 19. Handwashing prior to each resident: 2 minutes X (14) residents equaled to (28) minutes. 20. Reporting change in condition: 10 minutes X (3) residents equaled to (30) minutes. 21. Answering call lights: 5 minutes X (14) residents equaled to (70) minutes. 22. Changing wet beds: 10 minutes X (3) residents equaled to (30) minutes. 23. Breaks: 10 minutes X 2 equaled to (20) minutes. 24. Meal break: 30 minutes X (1) equaled (30) minutes. 25. Assisted residents in bed: 5 minutes X (5) residents equaled to (25) minutes. 26. Recording in and output: 10 minutes (10) minutes. 27. Recording of activities of daily living: 20 minutes (20) minutes. 28. Water rounds not included. The calculation indicated a minimum of 1593 minutes were required for one CNA to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 81 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE complete all the tasks including breaks for an AM shift. The 510 minutes allotted for the morning Shift starting from 7:15 a.m. to 2:45 p.m. was not enough; it required more than 3 times of that (1593) minutes to provide an adequate care for the residents. During an interview on 12/8/16, at 2:20 p.m., Unlicensed Staff RR stated she worked on C Wing for a long time, mostly on AM shift. Unlicensed Staff RR stated working on C Wing was a lot of work, but she got used to it. Unlicensed Staff RR had 13 Residents today. During an interview on 12/8/16, 2:45 p.m., Unlicensed Staff SS stated she worked morning shifts on B wing for a long time and she always had 12 residents except this week. Unlicensed Staff SS stated this week she had 8 residents because the State was here. Unlicensed Staff SS stated they need to have more staffing on the B Wing because there were a lot of confused residents who required more help and care. Unlicensed Staff SS added even though there were hall monitors on this floor they could not do a lot of things the CNAs could do such as caring, cleaning, bathing, assisting residents to bed, and making beds. During an interview on 12/7/16, at 8:15 a.m., a family member of Resident 6, who was there everyday, stated he was not complaining, but he thought the facility needed more staffing for the B wing because of the large number of confused residents in the wing. During an interview on 12/7/16 at 5:50 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 82 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when Unlicensed Staff MM was asked how long it took her to do her CNA duties on the PM Shift for the 13 residents she was assigned to on C wing, Unlicensed Staff MM stated: 1. Shower depended on if the resident was a total lift or just needed supervisions: Total lift: 25-30 min, Bed bath: 20-30 min, wheel chair/stand: 15-20 min, or supervised: 20 min. Unlicensed Staff MM had two residents whose baths were scheduled: 40 mins 2. Oral care: 5-15 min depending if residents were mobile, had dentures, or bedridden: 2 bedridden (30 min) plus if 11 residents were mobile (55 min): 85 min 3. Meal tray set-up: 20 min 4. Feeder: 20-30 min. Unlicensed Staff MM had one feeder: 20 min 5. Toilet resident at least 3 times: 10 min. Unlicensed Staff MM had one resident that used the toilet: 30 min 6. 12 residents were incontinent: checked each resident 3 times per shift; if residents were dry it took 15 min and if half the residents are wet it took 40 min. 1 round all dry: 15 min and, 2 rounds whereby half the residents were wet: 40 x 2= 80 min for a total of 95 min 7. Dress for bed: 12 min per resident x 13 residents = 156 min 8. Empty a Foley catheter: 2 min (Unlicensed Staff MM had 1) 9. Vital Signs: on average 3/4 residents took 15 -20 min: 15 min 10. Passing Snack/Supplements: 20 min 11. Changing residents' water cup for the entire hall took 30-40 min: 30 min 12. Charting on 13 residents took 30-40 min: 30 min 13 Unlicensed Staff MM breaks include a 30 min meal break and two 10 min breaks: 50 min The calculation revealed if Unlicensed Staff MM was to perform all the above PM tasks on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 83 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE her own during a total of 510 minutes per shift from 2:45 p.m. to 11:15 p.m. including breaks for 13 residents, it would have taken her a minimum of 593 min. This did not account for hand washing in between each resident, reporting change of condition, reposition residents every two hours (Unlicensed Staff MM had 2 bedridden residents), answering call lights, and other unexpected circumstances. The facility's policy and procedure titled "Nursing Department - Staffing, Scheduling & Postings," revised 1/1/12, indicated "The Facility will employ Nursing Staff that will be on duty in at least the number and with the qualifications required to provide the necessary nursing services for residents admitted for care."

F363 SS=E MENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED CFR(s): 483.60(c)(1)-(7)

F363 01/31/2017 (c) Menus and nutritional adequacy. Menus must(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; (c)(2) Be prepared in advance; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 84 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (c)(3) Be followed; (c)(4) Reflect, based on a facility’s reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; (c)(5) Be updated periodically; (c)(6) Be reviewed by the facility’s dietitian or other clinically qualified nutrition professional for nutritional adequacy; and (c)(7) Nothing in this paragraph should be construed to limit the resident’s right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on food distribution observation, interview, and department record review, the facility failed to ensure residents' menus were implemented per the therapeutic spreadsheet when a full slice of cornbread was served instead of a half slice of cornbread to 5 Sampled Residents (Resident 3, 7, 8, 11, &13) and 14 Unsampled Residents (Resident 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32) in a census of 67 with a physician order of small portions. Failure to ensure preparation of meals in accordance to a physician order may put residents at nutritional risk through inadequate nutrition, which may further compromise resident's medical status. Findings: During concurrent observation and interview on 12/6/16 at 12:32 p.m., Dietary Aide G was plating a full size slice of cornbread to all residents during tray line. When Dietary Aide G FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 85 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was asked what size slice of cornbread did she give the residents whose diet indicated small portions, she did not understand the question at first and then stated residents whose diet indicated small portions should have been plated a half size slice of the corn bread. Dietary Aide stated, "I forgot." During an interview on 12/6/16 at 12:36 p.m., Cook H stated Dietary Aide G should have been plating residents whose diet indicate small portions a half size slice of cornbread. Cook I stated she should have caught Dietary Aide G plating a full size slice of cornbread to all residents. Review of the "Master Resident Diet" flow sheet dated 12/9/16, indicated 5 Sampled Residents (Resident 3, 7, 8, 11, &13) and 14 Unsampled Residents (Resident 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32) were on "Small Portions." Review of the "Fall Menu" for the week of 12/5/16, indicated the cornbread served on 12/6/16 at lunch was to be cut 2 x 2 and 1/2 inch thick for regular and large portion servings and 1/2 the size for small portion servings.

F364 SS=E NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP CFR(s): 483.60(d)(1)(2)

F364 01/31/2017 (d) Food and drink FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 86 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Each resident receives and the facility provides(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature; This REQUIREMENT is not met as evidenced by: Based on food test tray, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner that maintained palatability and nutritional content when test tray evaluation of the noon meal found to have: 1. food temperatures for hot and cold food items not holding at the appropriate temperature and 2. cornbread tasted salty and dry. Failure to ensure food distribution and food production systems which ensured food palatability may result in decreased dietary intake, which may result in weight loss and further compromise residents' medical status. Findings: During concurrent test tray evaluation and interview on 12/6/16 at 1:00 p.m., it was noted by surveyors and Dietary Supervisor: 1. food temperatures per facility's thermometer were not appropriate; milk was 53.6º F (Fahrenheit), rosemary chicken: 110.3º F, red potatoes: 102º F, peas: 103º F, and pureed chicken: 113.2º F, pureed mashed potatoes: 116.2º F, pureed cornbread: 96.4º F, and pureed peas: 102.3º F and 2. cornbread tasted try and salty. Dietary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 87 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Supervisory stated he liked sweet cornbread and food items . During an interview on 12/6/16 at 12:50 p.m., Resident 7 stated the cornbread tasted "awful, very dry." During a concurrent observation and interview on 12/5/16, at 2:17 p.m., Unsampled Resident 18 was in bed and awake. Resident 18 stated the food served by the facility did not taste good. Resident 18 stated hot food was cold when served. Resident 18 stated the facility did not have enough CNA (certified nursing assistant) to assist residents. Resident 18 were deemed by the facility to be interviewable. Review of dietary document titled, "Meal Service" dated 3/13, indicated food items should be plated at the following temperatures during tray line: potatoes and vegetables: 160180º F, meat: 155-160º F, and milk: 41º F or less.

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 01/31/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 88 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on food storage observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by: 1. freezer products were not sealed, 2. freezer products had frost burn, 3. opened and unopened food products had no use by date and/or open date, 4. freezer products pulled from freezer to thaw in refrigerator had no date and were not written on freezer pulled log, 5. food products were expired per facility's storage guidelines, and 6. tub for emergency 3 step manual dishwashing process was not large enough to sanitize pots and cookie sheets. Failure to ensure effective dietetic services operations that prevent foodborne illness may result in compromised medical status and in severe instances may result in death. Findings: 1. During an observation on 12/5/16 at 2:05 p.m., freezer products were not sealed: a) 30 pound bag of opened carrots was not sealed inside cardboard box FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 89 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b) 10 pound bag of sausage links was wide opened inside cardboard box Review of the facility's dietary policy titled, "Procedure for Freezer Storage" dated 3/13, indicated frozen foods should be stored in an airtight moisture-resistant wrapper to prevent freezer burn. 2. During concurrent observation and interview on 12/5/16 at 2:05 p.m., freezer products had frost burn and no dates on packages: a) 4 2.5 pound bags of broccoli (out of their original box) were frozen solid with snowy ice crystals b) Wide opened box of veggie burgers (2 per pack) had ice crystals on the veggie burgers When Dietary Supervisor was asked why there were no dates on frozen food products, he stated there were no dates on freezer products due to the stickers did not stay on, so new freezer products went to the back of the shelves and older freezer products were rotated to the front of the shelves. When Dietary Supervisor was asked how he knew when freezer products were expired, he stated the freezer products are used fast. Dietary Supervisor stated the broccoli arrives from the distributor in frozen blocks. Review of the facility's dietary policy titled, "Produce Storage Guidelines" date 3/13, indicated frozen vegetables could only be stored in the freezer up to 6 months. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 90 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the facility's dietary policy titled, "Procedure for Freezer Storage" dated 3/13, indicated all freezer food should be labeled and dated. Review of the facility's dietary policy titled, "Procedure for Refrigerated Storage" date 3/13, indicated: 1. "Food items should be arranged so that older items will be used first, 2. dating the packages or containers will facilitate this practice, and 3. individual packages of refrigerated or frozen food taken from original packing box need to be labeled and dated. Freezer burn may occur before that and reduce the maximum shelf life. Food that has been freezer burned must be discarded." 3. During concurrent observation and interview on 12/5/16 at 2:05 p.m., multiple of food products had no open date and/ or use by date: a) There was no use by date on unopened frozen bacon pieces, mini corn digs, and hot dogs. b) Liquid egg whites were opened with no opened and/or use by date c) Bag of unopened iceberg lettuce and bag of mixed greens had no dates d) Box of uncovered green bell peppers were in refrigerator with no date. Bell peppers looked wilted and some had brown spots When the Dietary Supervisor was asked how he knew when unlabeled, unopened and opened food products were expired, he stated food products in the refrigerator and freezer are used fast. Review of the facility's dietary policy titled, "General Receiving of Delivery of Food and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 91 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Supplies" dated 3/13, indicated all food products should be labeled with the delivery date or a use-by-date. Review of the facility's dietary policy titled, "Storage of Food And Supplies" dated 3/13, indicated liquid foods which have been opened needed to be labeled and dated. Review of the facility's dietary policy titled, "Refrigerated Storage Guide" dated 3/13, indicated, "All egg products and egg substitutes used should have expiration dates or you are to have manufacturers information as to shelf life." Review of the facility's dietary policy titled, "Storing Procedure" dated 3/13, indicated, 1. "Check boxes of fruit and vegetables for rotten items. One rotten tomato... in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items, and 2. "Keeping fresh vegetables tightly wrapped with as little air in the bag/container as possible will keep them fresh longer." 4. During concurrent observation and interview on 12/5/16 at 2:35 p.m., freezer products pulled from freezer to thaw in refrigerator had no date and were not written on freezer pulled log: a) Frozen liquid coffee thawed in refrigerator with no date b) Pack of unopened turkey lunch meat thawed in the refrigerator had no date Dietary Supervisor stated all freezer products pulled from freezer to thaw in refrigerator should be indicated on the "Freezer Pull Log," FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 92 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which is located on the front of the refrigerator. Review of the facility's dietary policy titled, "Procedure for Freezer Storage" dated 3/13, indicated, "Once thawed, uncooked meats are to be used within two days. Exception is cured meats, to be used within 5 days." 5. During an observation on 12/5/16 at 3:00 p.m., there were a multiple of food products expired in food pantry: a) Chocolate diet pudding packs (24 oz mix for instant pudding/pie filling) were dated 1/16/16 b) Canola oil had a received date of 3/16, but no open date c) Dark corn syrup had a buy date of 5/8/16 and a received date of 4/28/16, but no opened date Review of the facility's dietary policy titled, "Storage of Food And Supplies" dated 3/13, indicated, "All food products will be used per times specified in the "Dry Food Storage Guidelines." Review of the facility's dietary policy titled, "Dry Goods Storage Guidelines" dated 3/13, indicated: 1. opened vegetable oil expired after 3 months, 2. unopened pudding mixes expired after 6 months, and 3. opened corn syrup expired after 6 months. 6. During concurrent observation and interview on 12/6/16 at 9:15 a.m., Cook H explained the steps for the "Manual Three Compartment Washing" of dishes. Due to the kitchen had a two compartment sink, staff used a tub (approximately 20 inches x 15 inches x 7 inches) for step three, which was the sanitizing step. When Cook H was asked how he sanitized large pots and cookie sheets in the tub, he stated he would submerge half of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 93 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pot or cookie sheet for 1 minute and then flip it, and submerge the other half for one minute. The facility's large pots and cookie sheets were too large to be properly sanitized in the tub per the facility's policy. Review of the facility's dietary policy titled, "Steps For 3 Compartment Washing" (no date), indicated all washed items must be immersed in sanitizer solution for 30 seconds.

F425 SS=D PHARMACEUTICAL SVC - ACCURATE PROCEDURES, RPH CFR(s): 483.45(a)(b)(1)

F425 01/31/2017 (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(1) Provides consultation on all aspects of the provision of pharmacy services in the facility; This REQUIREMENT is not met as evidenced by: Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services to ensure the safe dispensing of medications to meet the needs of each resident. Medications labeled "for external use only" were in active stock on the same shelf as medications labeled "for internal use only" in two of three of three medication rooms (Medication Room 1 and Medication Room 3). A vial of insulin, used to treat diabetes, was in active stock in the refrigerator and not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 94 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE segregated for three days after the unsampled resident (Resident 35) was discharged. Written policies and procedures were not developed to provide guidance to staff to ensure medications were segregated to prevent accidental dispensing. The facility's failure had the potential to cause a dispensing error and subsequent harm to all residents as a result of accidental selection of the wrong medication from stock. The facility census was 68. Findings: 1. On 2/5/16 at 2:16 p.m., during an observation of a medication room (Medication Room 3) on C wing with a registered nurse (Licensed Staff TT), a tube of triple antibiotic ointment, 30 grams (g) was observed on the shelf of the medication room. Triple antibiotic ointment is a topical antibiotic used for minor wounds. The tube had a label affixed by the manufacturer which showed, "For external use only." On the same shelf, the surveyor observed a bottle of docusate sodium, 250 mg, and quantity 100 gelcaps. Docusate sodium is s stool softener intended for internal use only. The bottle of docusate sodium had a label affixed by the manufacturer which showed, "For internal use only." On 12/5/16 at 2:44 p.m., during an observation of a medication room (Medication Room 1) on A wing with a licensed vocational nurse (Licensed Staff B), a bottle of Risperidone Oral Solution, 1 milligram (mg) per milliliter (mL), 30 mL, was observed on the second shelf of the medication room. Risperidone Oral solution is an antipsychotic medication intended for internal use. The bottle of Risperidone had a label affixed by the manufacturer which showed, "For internal use only." On the same shelf, the surveyor observed three bottles of benzoin compound, 29 mL. Benzoin is used to protect small wounds. The bottles of Benzoin Compound had a label affixed by the manufacturer which showed, "For external use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 95 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE only." On 12/5/16 at 2:44 p.m., during an interview, Licensed Staff B said, "You don't store medications for internal use with external use." He indicated that the facility's policies and procedures prohibited storage of medications indicated for internal use with medications intended for external use only because it could cause resident harm if there was an accidental mix up. On 12/8/16 at 10:53 a.m., during an interview, the Consultant Pharmacist (CP) indicated he was unaware that medications intended for internal use were being stored next to medications intended for internal use only. He indicated this was a potentially dangerous practice because staff could select the wrong product and accidentally administer it to a resident via the wrong route. A review of the facility's policy titled, MEDICATION STORAGE IN THE FACILITY, dated 2/23/16, showed, "Orally administered medications are kept separate from externally used medications, such as suppositories, liquids, and lotions. 2. On 12/5/16 at 3:02 p.m., during an observation of a medication room (Medication Room 1) in A wing with a licensed vocational nurse (Licensed Staff B), a vial of Lantus insulin 10 milliliters (mL) 100 units per mL, a medication used to treat high blood glucose levels for diabetic patients, was observed in stock in the refrigerator in a red plastic bin. The label on the insulin showed the name of an unsampled resident (Resident 35). On 12/5/16 at 3:02 p.m., during an interview, Licensed Staff B said, "She [Resident 35] was discharged December 2nd Friday. Licensed Staff B indicated that the on-duty nurse at the time of Resident 35's discharge should have pulled the vial from stock and segregated it at the time of discharge. Licensed Staff B said, "Should have been put in the blue bin marked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 96 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discontinued meds." He said, "The red bin is for storage of refrigerated injectable meds for residents with current orders." The Director of Nursing (DON) was asked to provide all written policies and procedures related to disposition of discharged medications. A review of these did not provide guidance to staff on how to dispose or handle discharged medications. A review of the facility's policy titled, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, dated 2/23/15, showed, "When discharged, remaining medications that have been administered to the resident while in the facility may be provided to the resident at the time of discharge.." The policy showed," Medications remaining in the facility after the time of discharge will be disposed in accordance with state and federal regulations." On 12/6/16 at 10:09 a.m., in an interview the DON indicated she could not find a written policy and procedure for disposition of noncontrolled substance medications for discharged residents when medications were not taken home by the resident.

F428 SS=E DRUG REGIMEN REVIEW, REPORT IRREGULAR, ACT ON CFR(s): 483.45(c)(1)(3)-(5)

F428 01/31/2017 c) Drug Regimen Review (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. (3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 97 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. (4) The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon. (i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record. (5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 98 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review the facility did not ensure that irregularities in the drug regimen of one sampled resident of 15 (Resident 7) reported by the consultant pharmacist (CP) were acted upon within two weeks in accordance with the facilities policies and procedures. The facility's failure had the potential to cause harm (e.g. serious injuries such as fractures from falls) to Resident 7 as a result of administration of unnecessary medications. Duplicate medications Ativan (an anxiolytic) and Benadryl (an antihistamine) were not identified as an irregularity when they were both prescribed for insomnia. Findings: A review of the facility's regular monthly reports, titled, Consultant Pharmacist's Medication Regimen Review, signed by the facility's Consultant Pharmacist (CP), showed he identified irregularities in the drug regimen of Resident 7 between the months of January 2016 and November 2016. The reports were provided by the Director of Nursing (DON). A review of the reports with the DON showed recommendations by the CP were documented on a separate, written report and included the Resident 7's name and the irregularities the pharmacist identified with respect to specific unnecessary drugs. [Reference F - 329] A review of the Consultant Pharmacist (CP) contract showed the CP was responsible for documenting "potential or actual medication therapy problems and communicates them to the responsible physician and the director of nursing." The contract stated, "The physician provides a written response to the report to the facility within two weeks after the report is sent." On 12/7/16 at 3:30 p.m., in an interview the DON indicated she received all the pharmacist's recommendations and ensured the facility had faxed them all to Physician S FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 99 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE timely. The DON indicated she was uncertain whether or not all the recommendations had been acted upon by the facility. She said, "I believe so." She indicated that some of the recommendations were routed to medical records to address and the others went to the Medical Director (Physician S). She indicated there was no organized system in place currently to ensure follow up. On 6/22/16 the CP sent a written recommendation to Physician S which showed, "Would you consider DC [discontinue] Ativan 1mg [milligrams] prn [as needed] q8h [every eight hours] for anxiety." Note: Insomnia is generally treated at bedtime not every eight hours. A review of Physician Orders dated 7/16/16 showed Ativan was not discontinued as recommended. Physician S ordered Ativan decreased to 1mg BID [twice daily] prn anxiety manifested by insomnia. A review of the resident's record showed no documentation by Physician S to discontinue Ativan and there was no rational documented for its use twice a day as needed to treat anxiety manifested by insomnia. On 9/28/16 the CP sent a written recommendation to Physician S which showed, "The Care Plan has no info in the "At Risk For" section of the Behavioral / Psychotropic page. This should contain side effects and any other risks involved with this medication." A review of the Care Plan section for Behavioral / Psychotropic showed it was not updated until 10/11/16 to include "side effects sedation, drowsiness ..." Other than a box checked, "Resident will show minimal side effects of medications" the Care Plan did not address the risk of falls at all. The Fall Risk and Prevention Page listed "Seroquel 25mg" under medications as a problem, but as of 12/5/16 it had not been updated since the entry on 2/6/16 and did not reflect Resident 7's routine daily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 100 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dose of 75 mg per day. On 9/28/16 the CP sent a written recommendation to Physician S which showed, "The MAR reveals 2 episodes [verbal violence] recorded in the last 30 days. Would you consider DC Seroquel 50 mg QPM for Psychosis ... and begin Seroquel 25 mg QPM for Psychosis..." The recommendation was faxed on 10/11/16 to Physician S. A review of the current physician orders on 12/5/16 showed no change and no written rationale by the prescriber. Seroquel is not indicated for dementia or dementia-related psychosis manifested by "verbal violence". On 2/4/16 Physician S ordered, "Benadryl 25 mg po prn qhs for insomnia." Concomitant use of Ativan and Benadryl for insomnia is duplicative. A review of the residents PRN MAR for April showed she received Benadryl 25mg once on 4/23/16 and that it was still an active order as of 12/5/16. On 12/7/16 at 2:12 p.m., in an interview with Physician S indicated she prescribed orders on 2/18/16 for Resident 7 to receive Ativan every 8 hours as needed for anxiety manifested by insomnia. She acknowledged that her intent was not to treat insomnia at all hours of the day; rather it was to offer it at bedtime if the resident could not sleep due to anxiety. She indicated she follows up on the consultant pharmacists recommendations. She said, "The documentation is wrong." On 12/8/16 at 10:53 p.m., in an interview with the CP he said, "I am trying to explain to the facility and the MD [physician] antipsychotics should not be used for dementia and if they are to be used there are steps to go through."

F431 SS=F DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 01/31/2017 The facility must provide routine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 101 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 102 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for one of three medication carts (Medication Cart B). The facility's failure placed all residents in B Wing, a memory care unit, at risk for accessing medications in the medication cart which had the potential to cause accidental ingestion and overdose. The facility's census on B wing was 27. Findings: On 2/5/16 at 4:15 p.m., during a medication pass observation with licensed vocation nurse (Licensed Staff Z) on B wing, a memory care unit used to treat residents with dementia, Licensed Nurse Z prepared medications from Medication Cart B outside Medication Room B for a resident (Sampled Resident 14). The nurse walked away from the cart towards the resident's room without locking the cart. The cart had a push button keyed lock mechanism which protruded one inch when open and was flush with the cart when locked. The surveyor opened the second drawer where unit dose medications for residents on the unit were stored. There was no other staff in the area and Licensed Nurse Z did not attempt to lock the cart or ask authorized personnel to attend the cart in her absence. On 12/5/16 at 4:55 p.m., during an interview with the Director of Nursing (DON), she said, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 103 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Residents on a memory unit would eat something thinking it was candy. It is my expectation that staff lock the cart when unattended." On 12/5/16 at 5:00 p.m., during an interview, Licensed Nurse Z said, "I usually lock the cart always. I didn't realize it was unlocked." A review of the facility's policy titled, "MEDICATION STORAGE IN THE FACILITY", dated 2/23/15, showed under the policy section, "Medications and biologicals are stored safely, securely, and properly..." The medication supply is accessible only to license nursing personnel, or staff members authorized to administer medications. The same policy showed, under the procedures section, "Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access.

F441 SS=F INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 01/31/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 104 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 105 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observations, interview, and record review, the facility failed to maintain: 1) Washer Machine temperature on or above 160° Fahrenheit (F) for 25 minutes during hot water cycles. 2) Essential Equipments are maintained according to manufacturers' recommendation. 3) Quaternary sanitizer solution to clean kitchen countertops was not tested according to manufacturers recommendation. These failures had the potential for cross contamination and the spread of infections. Findings: 1) During initial tour observation on 12/6/16 at 8:30a.m., when asked, what kind of temperature do you run your washing machines? housekeeping Supervisor stated they only use hot water and she does not the temperature; when asked, who knows whtat temperature washing machines are running? housekeepng supervisor stated Maintenance Supervisor knows the temperature. During an interview on 12/6/16, at 9:00a.m., when asked, how the temperature for the washing machines in the laundry room is determined? Maintenance Supervisor, opened the boiler room which contained what he described as "hot water generator" that had a temperature gauge indication of 140° FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 106 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Fahrenheit (F); when asked, how often did he check the temperature and if he recorded it, Maintenance Supervisor stated he checks once every week, he does not record it; when asked, if he had policy and procedure for washing machine temperature? Maintenance supervisor stated he does not have one, he can get it. 2) During an environmental tour and interview on 12/8/16 at 8:30a.m., when asked, how he maintains the 2 washing machines? Maintenance supervisor stated he does not maintain them; he also stated the only thing he does is he calls for repair when they break down. When asked, if he had manufacturers' guidelines for maintenance, Maintenance Supervisor stated he does not have it, but he can get one from the internet. On 12/8/16, at 4:30p.m., the Administrator brought to the surveyors' meeting room 2 items titled: 1) Laundry Services; and 2) WASCOMAT Spare Parts Catalogue. However, neither of these items contained temperature for the washing machines or manufacturer's guidelines for maintenance. A Manufacturer's guidelines for maintenance retrieved from the company's (WASCOMAT/W620) website stated the facility should do mechanical checks and maintenance every day and every three months. Center for Disease Control (CDC), "Guidelines for Environmental Infection Control in Health Care Facilities," Morbidity and Mortality Weekly Report 52(RR10); 1-42, dated 6/6/2003, Included the following: II. Laundry Facilities and Equipment: C. Use and maintain Laundry equipment according to manufacturers' instructions. IV. Laundry Process: "A. If hot-water laundry FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 107 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cycles are used, wash with detergent in water greater than, or equal to, 160° F for 25 minutes...," and; for low-temperature washing (less than 160° ( F) facilities should use "...chemicals suitable for low-temperature washing at a proper concentration. 3) During concurrent observation and interview on 12/6/16 at 9:30 a.m., Cook I was asked to test the concentration of the quaternary sanitizer solution in the red sanitizer bucket used in the dishwasher room. Cook I tested the solution correctly, but test strip read zero parts per million (ppm). Cook I was sure the programmed quaternary solution was dispensed into the red bucket. During concurrent observation, interview, and manufactures recommendation review on 12/6/16 at 9:32 a.m., Dietary Supervisor tested the water temperature of the sanitizer solution, which was 64º F. Dietary Supervisor tested the sanitizer solution, which still read zero ppm. Dietary Supervisor stated we have been having problems regulating the water temperature of the facet used for the preprogrammed quaternary sanitizer solution. Manufactures recommendation (posted above kitchen sink in dishwasher area) indicated the water temperature should be between 65º F-75º F when testing the strength of the solution. During concurrent observation and manufactures recommendation review on 12/6/16 at 9:35 a.m., Cook I changed the sanitizer solution used for the cooking/prep FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 108 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE countertops. Dietary Supervisor checked the temperature of the solution, which was 102.5º F and tested the strength of the solution, which was 500 ppm. Manufactures recommendation for the ppm range of the quaternary sanitizer solution strength was 150-400 ppm. During an observation on 12/6/16 at 9:38 a.m., Dietary Supervisor dispensed quaternary sanitizer solution into a red sanitizer bucket and let it sit for a two minutes before testing the concentration. The temperature of the water was 90º F and the concentration of the sanitizer solution was 200 ppm.

F514 SS=E RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5)

F514 01/31/2017 (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 109 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record, and facility policy review the facility failed to ensure: 1. The post-fall assessments of Resident 7 were complete and accurate following an unwitnessed fall. This failure had the potential to result in inappropriate care or treatment of Resident 7 due to inaccurate assessment with the potential for serious injury to go unnoted. 2. Complete and accurate documentation of Resident 11's belongings upon her admission when her "Resident's Clothing and Possessions" document was left blank. This had the potential for Resident 11's belongings to get lost or not returned to her when belongings were not recorded. 3. Resident 6's Physician's Telephone orders did not include: signature of the ordering physician, the date, time and licensed nurse received the order. 4. Resident 6's Medication Recap orders were improperly documented. These failures had the potential for incomplete or inaccurate data necessary for medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 110 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE continuity. Findings: 1. Review of a clinical record titled, "Post Fall Assessment," indicated Resident 7 had an unwitnessed fall on 10/16/16 at 1:35 p.m., and was to have neurological (neuro) checks (assessment of level of consciousness, ability to move, speech,...) for 72 hours. Review of Resident 7's "Nurse's Notes" and "Neurological Flow Sheet," indicated Resident 7's neurological checks were only performed from 10/16/16 at 1:35 p.m. to 10/17/16 at 9:30 a.m. During an interview on 12/8/16 at 9:35 a.m., DON stated when a resident has an unwitnessed fall the nurses are supposed to perform neuro checks on the resident per facility policy for 72 hours and at least one entry in the Nurse's Notes per day for 72 hours. DON stated nurses should have performed neuro checks on Resident 7 and made an entry in the Nurse's Notes post Resident 7's unwitnessed fall, which occurred on 10/16/16, for 72 hours. Review of the facility policy/procedure, titled "Fall Management Program" revised 1/1/12, indicated nurses will complete a Neurological Flow Sheet (FA-01-Form B) for an unwitnessed fall for 72 hours (Every 15 minutes x 1 hour then; Every 30 minutes x 1 hour then; Every hour x 4 hours then; Every 4 hours x 66 hours...). 2. Review of Resident 11's clinical record, indicated Resident 11's "Resident's Clothing and Possessions" document had not been filled out upon her admission. Review of the facility's personal belongings inventory sheet titled, "Resident Inventory" was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 111 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE inconsistent with the one found blank in Resident 11's clinical record. The "Resident Inventory" sheet consisted of 3 pages where as the one found in Resident 11's chart titled,"Resident's Clothing and Possessions" was only one page. The "Resident Inventory" sheet indicated resident's personal belongings needed to be identified by including quantity and identifying attributes (brand, color, engraving...) at time of the resident's admission. 3) During a record review, on 12/8/16, 10:30 a.m., Resident 6's Physician's Telephone orders did not include: signature of the ordering physician, the date, time and licensed nurse received the order for the following orders: 3a. Telephone Order (TO): Change Order: Depakote (used for seizure disorder) 125 mg Sprinkles BID (twice a day). The order did not have the physician's signature and date. 3b. TO dated 7/24/16: Increase Keppra (used for seizure) to 500 mg (milligrams) PO (by mouth) BID (twice 2 day); D/C(discontinue) 250 mg PO ( by mouth) BID (twice a day). The order did not have the time. 3c. TO date 9/22/16: Increase Xanax 1 mg Q4H (every 4 hours) PRN (as needed); RT (Respiratory Therapist) Evaluation; Cranberry Tab 450mg PO (by mouth) BID (twice a day) for UTI (urinary tract infection) prevention. The order did not have the name of the licensed nurse who received the order, and time. 3d. TO dated 9/22/16: 1. RT Eval: Loose cough. 2. 10cc (cubic centimer) Guaifenesin (used for cough) PO (by mouth) Q8H (every 8 hours) PRN (as needed) for congestion X 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 112 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The order did not have time. 3e. TO dated 8/3/16: Referral to Tele-pysch to eval for unusual behaviors and aphagia. If not available refer to Dr. Sopei, psychiatrist. If we get an apt. husband need to go with her. The order did not have the name for the licensed nurse who received the order, and time. 3f. TO dated 9/26/16: 1. Duo-Neb, BID (twice a day) before lunch and dinner while her husband here X 3 days: wheezing. 2. Geritussin 9 (used for cough)10 ml (mililiter) PO BID X 5 days for cough. 3. When Wellbutrin (used for depression) XK 300mg (milligrams) PO Q AM finishes, D/C, then decrease to 150mg PO Q AM (every morning). The order did not have time. 3g. TO dated 9/28/16: 1. Increase Depakote to 250mg PO BID (D/C 125mg BID), ICO (informed consent obtained) is done. 2. When Keppra 125mg AM used up, D/C it. 3. Appt. with Dr. McKenzie flapping motions. The order did not have the name of the licensed nurse who received the order, and time. During an interview on 12/9/16, at 7:20a.m., when asked, why there are so many omissions on the medication telephone orders, Administrator stated she did not know why the nurses were not documenting right. A review of the Facility's policy titled "Physician orders:" 1. Telephone orders: A). A Licensed Nurse will record telephone orders on the telephone order sheet with the date, time and signature of the person receiving the order. Clinical Nursing Skills and Techniques, 8th FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 113 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Edition, by Perry, Potter and Ostendorf, Chapter 20 Safe Medication Preparation:"...write 'TO' (telephone order) or VO (verbal order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse...Follow agency policies. 4) During a record review, on 12/8/16 11:00 a.m., Resident 6's medication orders were inaccurate: Physician's Recap (resident's monthly ordered mediation record) orders were altered with or without signature. 4a) A Medication Recap dated 10/2016, indicated 1) Depakote 125 mg sprinkles PO BID for disorder with agitation and violent behavior was crossed out and 250 mg was written over it with a signature; 2) Xanax 1 mg PO PRN Q6H for anxiety was cross out. 4b) A Medication Recap dated 12/2016, indicated 1) Norco (Hydrocodone-APAP) (used for pain) 5/325 mg 1 tab PO Q4H for moderate pain was cross out; 2) Norco (HydrocodoneAPAP) 5/325 mg 2 tabs PO Q4H PRN for severe pain was crossed out. During an interview on 12/9/16, at 7:20 a.m., when asked, why those orders were crossed out, Administrator stated she did not know why they did that; when the Administrator was informed that this was against the Accepted Professional Standards, Administrator acknowledged. Review of Mosby's 18th edition, 1992, titled "Pharmacology in Nursing," indicated: "The medication order must be written and ordered in such a way that it is correct, complete, legible, and clearly understandable. If it is not, clarification must be sought from the prescriber....It is wise to avert such incidents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 114 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ..."guessing," "assuming," "and not wanting to bother the doctor." by clarifying the prescribing situation. If an order is believed to be in error...1. Validate the order."

F517 SS=F WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 01/31/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on food storage observation, interview, and dietary document review, the facility failed to ensure adequate food supplies for disaster FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 115 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE preparedness as evidenced by inadequate supplies for one of nine meals needed during an emergency or disaster. Failure to ensure adequate food supplies to be utilized in the event of a widespread disaster may compromise the nutritional and medical status of residents. Findings: During concurrent observation, interview, and review of the "Emergency Inventory Guide" and "Emergency Menus"on 12/7/16 at 10:10 a.m., indicated there were no canned "Pork and Beans." Review of the "Emergency Menus, indicated canned "Pork and Beans" was scheduled for Day 3's emergency dinner entree. The "Emergency Inventor Guide," indicated there should have been 10 cans of "Pork and Beans," which was the minimum amount for 120 residents and staff (99 resident capacity and 21 staff members). Dietary Supervisor could not find any canned "Pork and Beans." Review of the facility policy/procedure titled "Disaster Planning" revised 11/1/14, indicated, "the Dietary Manager will be responsible for maintaining a minimum of 3 days supply of food in the Disaster Food Supply. Amounts of each item will be based on the facility size plus three shifts of staff."

F518 SS=E TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 01/31/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 116 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observations, interviews and facility policy review, the facility failed to ensure 4 of 5 unlicensed staff could correctly answer emergency and disaster preparedness questions. These failures had the potential to endanger residents, family members, visitors and staff during an emergency or disaster situations. Findings: 1a) During an observation and concurrent interview on 12/6/16, at 9:00a.m.,Unlicensed Staff R, when asked, where are the fire alarms and fire extinguishers located at? Unlicensed Staff R stated in the lobby, in the nursing station and the dining room; when asked, what would you do if there was an earthquake right now? Unlicensed Staff R stated he would go under the door way; when asked where the water shut off? Unlicensed Staff R did not know; when asked, what emergency sources are powered by the generator? Unlicensed Staff R looked puzzled and stated he does not know. 1b) During an observation and concurrent interview on 12/6/16, at 9:30a.m., Unlicensed Staff OO, when asked, if fire alarm goes off what would you do? Unlicensed Staff OO stated she would close doors and bring out the residents in the hallway; when asked, if you discover a resident missing what do you do? Unlicensed Staff OO stated she would call the nurse; when asked, what would you do if you discovered a fire in the resident's room? Unlicensed Staff OO stated safe resident and put blanket under the door to prevent smoke coming out; when asked, what would you do if there was an earthquake right now? FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 117 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Unlicensed Staff OO did not know. 1c) During an observation and concurrent interview on 12/6/16, at 10:05a.m., Unlicensed Staff PP, when asked, if fire alarm goes off what would you do? Unlicensed Staff PP stated she would secure residents, call code red and call the Fire Department; when asked, if you discovered a resident missing what do you do? Unlicensed Staff PP stated she would call code green and call punch of staff to locate the Resident; when asked, what would you do if you discovered a fire in a resident's room? Unlicensed Staff PP stated she would call code red and would call the authority; when asked, where are the fire alarms and fire extinguishers located at? Unlicensed Staff PP stated behind the maintenance; when asked, what would you do if there was an earthquake right now? Unlicensed Staff PP stated she would get residents out of the windows. 1d) During an observation and concurrent interview on 12/8/16, at 10:00a.m., Unlicensed Staff QQ, when asked, if fire alarm goes off what would you do? Unlicensed Staff QQ stated she would notify the charge and make sure the residents are Safe; when asked, where are the fire alarms located at? Unlicensed Staff QQ did not know; when asked, how do you use a fire extinguisher? Unlicensed Staff QQ did not know; when asked, where is the disaster manual located? Unlicensed Staff QQ did not know. During a review of the facility's policy, a document titled "Orientation to Fire Safety & Disaster Preparedness," stated: 1. Facility Staff, including, volunteers, students, and other trainees, must participate in an orientation regarding the Fire Safety and Disaster Preparedness plans within two (2) working days of beginning his/her employment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 118 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or work assignment at the Facility.

F520 SS=H QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS CFR(s): 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i)

F520 01/31/2017 (g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (g)(2) The quality assessment and assurance committee must : (i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 119 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility's quality assessment and assurance committee (QAA) failed to: 1. Develop formal corrective action plans or implement the action plans to prevent falls, (Cross Reference F 323) 2. Identify staffing issues and ensure sufficient staffing to provide quality resident care, (Cross Reference F 241 and F 353) 3. Communicate QAA minutes to the staff. These failures prevented the QAA committee from implementing and evaluating an action plan to correct quality deficiencies and therefore was not able to determine effectiveness of changes to be implemented. Findings: 1. During a concurrent interview and record review regarding QAA on 10/26/16, at 2:50 p.m., regarding resident falls, the DON (director of nursing) stated the QAA committee collected data including number of falls each month, but did not develop formal action plans to prevent falls. The DON stated direct care staff including CNAs (certified nursing assistant) and nurses were not included in the QAA process and were not invited to the QAA meeting. During an interview on 11/3/16, at 2:35 p.m., when asked if the Hall Monitors were trained to prevent falls, the DON stated the Hall Monitors were trained to look if alarms (a device attached to the resident that triggers an alarm FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 120 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when the resident attempts to get up from the wheelchair or the bed) were intact or pads were on the floor to prevent injuries from a fall and to report to the nursing staff if anything was out of the ordinary. The DON stated Hall Monitors were facility staff but were not care givers. The DON stated the Hall Monitors did not do hands on resident care; they could guide the resident and gently hold the resident's hands/elbows. During an interview on 11/10/16, at 10:40 a.m., the Administrator stated B wing was the memory unit (residents had memory problems). The Administrator stated originally they had a total of three Hall Monitors covered from 6 a.m. to 8:30 p.m. The Administrator stated the first Hall Monitor worked from 6 a.m. to 2:30 p.m.; the second Hall Monitor worked from 9 a.m. to 5:30 p.m.; and the third Hall Monitor worked from 12 p.m. to 8:30 p.m. The Administrator stated about a week ago they increased the Hall Monitor to a total of four to cover 24 hours. She stated now the third Hall Monitor worked from 2:15 p.m. to 10:45 p.m., and the fourth Hall Monitor worked from 10:45 p.m. to 7:15 a.m. the next day. During a concurrent interview and record review on 12/8/16, at 3 p.m., regarding QAA, the Administrator stated the QAA developed an action plan for fall prevention and management and the plan was started at the end of October, 2016. The Administrator provided and reviewed the action plan. The Administrator stated they tried to find the root cause of each fall but did not find the root cause of high incidence of falls or repeated falls in the facility as a whole. The Administrator stated some of the approaches of the action plan had not been implemented. When asked the reasons for the approaches not being implemented, the Administrator did not provide an answer. Regarding the effectiveness of the action plan when the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 121 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility had 17 falls on October 2016 and 20 falls on November 2016 (numbers of falls were based on incident logs), the Administrator stated they had not evaluated the action plan because the next QAA meeting had not occurred but will be coming up soon. The action plan did not indicate a measurable goal with a target date. 2. The Administrator stated their target for staffing was to have six to seven CNAs (certified nursing assistant) in the whole building for AM (morning) and PM (afternoon/evening) shifts so each CNA took care of 9 - 11 residents in an eight-hour shift. When asked if a CNA had sufficient time to take care of 9 - 11 residents, the Administrator stated "yes" because the activity staff, scheduler, and RNA (restorative nursing assistant) were also CNAs and helped for dining. The Administrator further stated one CNA had more than 15 residents in night shift. The Administrator stated the facility did not have staffing problems. 3. During an interview on 12/7/16, at 11:45 a.m., Unlicensed Staff BB stated there was no communication from the management to "us" [certified nursing assistants]. Unlicensed Staff BB stated they just put up signs in the utility room and in the resident's room and "hoping us to know" what was going on. Unlicensed Staff BB stated when she looked at the sign with a picture of a bed without written instructions in Resident 2's room, she thought it was the instruction to put the head of the bed down with feet up and so she did. Unlicensed Staff BB stated after that they wrote "keep bed low, keep bed at an angle." During an interview on 12/9/16, at 7:20 a.m., the DON stated the plan was to put the bed in an angle to prevent resident from injuries from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 122 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE falls. The DON stated she educated the staff about the sign but did not have a log to ensure all staff were educated and understood the sign. The facility's policy and procedure titled "Quality Assessment and Assurance Committee - Composition & Duties," date revised 1/1/12, indicated under Purpose "To promote the quality of resident care by overseeing, identifying, tracking, addressing and follow-up on all quality issues." The policy and procedure did not specify how to communicate the QAA minutes to other staff who did not attend the QAA meetings. During an interview on 10/26/2016, at 8:45 a.m., Licensed Staff E stated she was unsure of what QA/PI( Quality Assurance/Performance Improvement) did and what the subject was currently. She stated there were meetings where they talked about the patients and falls. During an interview on 10/26/2016, at 11:05 a.m., Licensed Staff F stated she knew that the DON (director of nursing) and the DSD (director of staff development) were involved. She stated she is not sure what they were working on at this time. She stated as a travel nurse ( a nurse who travels to work in a temporary nursing position) she did not know much about the PI (performance improvement) process at the facility. During an interview on 10/26/2016, at 12:01 p.m., Unlicensed Staff M stated she did not know what that was. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G9FK11 Facility ID: CA010000078 If continuation sheet 123 of 124 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055003 (X3) DATE SURVEY COMPLETED 12/09/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EUREKA REHABILITATION & WELLNESS CENTER, LP 2353 23rd St Eureka, CA 95501 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: G9FK11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA010000078 (X5) COMPLETE DATE If continuation sheet 124 of 124