Other·July 21, 2020

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 the annual RECERTIFICATION survey. Representing the California Department of Public Health: Health Facilities Evaluator Nurses, 32860, 29797, and 31594. The census on 01/29/18 was 80, with one bed hold. There were 18 sampled residents. Deficiencies were cited under F-557, F-761, F-770, and F-812 during the survey. There was one complaint investigated during the survey, CA 00531933; with a deficiency under F-686.

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 02/21/2018 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(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. This REQUIREMENT is not met as evidenced by: Based on observation, interview and facility document review, the facility did not treat 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: WD1311 Facility ID: CA010000078 If continuation sheet 1 of 12 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 02/02/2018 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 47 with dignity and respect, when he was observed dressed in badly stained tee shirts, poorly-fitting clothes, had copious drooling, and his hair was uncombed. This failure had the potential to cause Resident 47 psychological harm due to his family reducing their visits based on his appearance. Findings: During an interview on 1/31/18 at 10:15 a.m., Family Member 2 stated that she had not recently had the opportunity to come out to the facility to visit with Resident 47. Family Member 2 stated her friends had visited Resident 47, and reported to her that Resident 47 was never out of bed, always looked dirty, and generally unkempt. Family Member 2 stated she did not think the facility was taking care of his eyes; they seemed to be getting worse in her opinion. During observation on 01/31/18 at 03:16 a.m., Resident 47 was dressed poorly with his pants and shirt stained, his socks sliding off, and his eyes red and hair disheveled. On 2/1/18 at 9:20 a.m. Resident 47 continued to be dressed poorly and had a towel under his chin while sleeping, with some red drainage from his mouth. The CNA (Certified Nursing Assistant) came to replace a blanket that had fallen to the floor, but did not remove or replace the towel with a clean one. During a concurrent observation and interview on 1/31/18 at 12:10 p.m., Resident 47's clothes were in the closet: There were five tee shirts, and all five tee shirts had large stains on the left side of the shirt. The stains were about 12 inches long by 6 inches wide. Resident 47 had other dark-colored shirts, but was not observed wearing any of them. CNA B was asked why he did not where the other shirts. CNA B stated Resident 47 preferred tee shirts. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 2 of 12 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 02/02/2018 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 1/31/18 at 12 p.m., the Social Services Director stated the facility frequently received clothing donations. When asked why Resident 47 was wearing stained clothing and clothing too big for him, the Social Services Director stated she was waiting for Resident 47's wife to come in. During an interview on 1/31/18 at 4:45 p.m., the ADON (Assistant Director of Nursing), Manager for the Dementia Unit, where Resident 47 resided, stated the unit had a, "No Name Closet" which housed the donations of clothing. The process was for CNA's to report a lack of or need for, clothing to the nurse, who was to report the need to the ADON, who would report to the Social Services Director, who called the family. If family was unwilling or unable to provide, then the clothing was selected and given to the resident in need. This was not done for Resident 47. The facility policy and procedure titled, "Resident Rights," dated January 1, 2012, indicated: "...Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights...Residents are encouraged to participate in resident and family group meetings...Personal care needs, such as bathing methods, grooming styles and dress." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 3 of 12 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 02/02/2018 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

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/13/2018 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on interview, clinical record and facility document review, the facility failed to document progress of wound healing for Resident 1 during wound decline. This failure caused a delay in access of outside sources of care and may have contributed to the infection that spread to Resident 1's blood. Findings: During an interview on 5/2/17 at 12:40 p.m., the Treatment Nurse stated the facility was constantly making assessments of the residents' skin. The process was to have CNAs (Certified Nursing Assistants) observe the skin with diaper changes, showers, and when something appeared that was not there before; they reported to the nurse who would then do an assessment. The family could also advise her, the IDT, in morning stand up, could FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 4 of 12 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 02/02/2018 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 request an assessment, or the resident's Charge Nurse could informed her when need for intervention. During an interview on 6/21/17 at 1:20 p.m., Family Member 3 stated that initially he thought Resident 1's care at the facility was pretty good, but when Resident 1 tried to get up out of bed, the facility gave him drugs to the point he did not even move. Family Member 3 stated Resident 1 was burned with coffee twice and, because he had a history of shingles, was diagnosed with shingles. Then he was transferred to the, "Dementia Unit, that's when things got bad." Family Member 3 stated that he lived close so visited for one to two hours a day and was told Resident 1 had a pustule sore on his bottom, which made him think it was very small, and he never observed any treatment for it. Resident 1 no longer walked, and his speech was non-sensical. When Resident 1 was in the wheelchair squirming, maybe from pain, he was unable to tell Family Member 3. During an interview on 2/2/18 at 9:20 a.m., Practitioner C stated this was an extremely complicated case. Resident 1 was a strong healthy independent gentleman who was infected with racoon round worm while working under his home. This caused both viral encephalitis (swelling of the brain) and parasitic meningitis (infection of the brain that is usually fatal). When questioned as to why Resident 1 was admitted to the facility, Practitioner C stated that the facility had no choice; Resident 1 could no longer stay in the hospital and the family declined to take him home. The facility admitted Resident 1 based on the prognosis of potentially living three months longer. Practitioner C stated the wound care clinic was a separate business, so the facility did not have control over when they would respond to a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 5 of 12 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 02/02/2018 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 referral request. This was the reason given for delay, when the wound care clinic staff was not working in the facility. Resident 1 never actually went to the wound care clinic. During review of Resident 1's clinical record, the Nurses Notes, dated 8/21/16, 9/7/16, 9/8/16, 9/10/16, 9/14/16, 9/14/16, 9/15/16, 9/27/16, 9/30/16, 10/2/16, 10/6/16, 10/23/16, 10/23/16, 10/24/16, 10/26/16, and 10/30/16, indicated: Documentation of Resident 1's wound was either and incomplete wound assessment or there was no wound assessment at all. During review of Resident 1's clinical record, the Skin Variance Progress Notes, dated 10/13/16, 10/20/16, and 10/27/16, indicated the wound assessment on 10/13/16 was incomplete. There was no wound assessment documented for either 10/20/16 or 10/27/16. During review of the for Resident 1's clinical record, the Braden Scale-For Predicting Pressure Sore Risk, dated 3/3/15, 8/6/16, and 11/1/16, indicated: For 3/3/15, Resident 1's risk score was 16, which equaled a mild risk. For 8/6/16, Resident 1's risk score was 15, which equaled a mild risk. For 11/1/16, Resident 1's risk score was 10, which equaled a high risk. The facility policy and procedure titled, "Pressure Injury Prevention," dated 8/12/16, indicated: "The Licensed Nurses will document effectiveness of pressure injury prevention techniques in the resident's medical record on a weekly basis. The facility policy and procedure titled, "Pressure Injury and Skin Integrity Treatment," dated 8/12/16, indicated: "...The Licensed Nurses will document the status of all skin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 6 of 12 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 02/02/2018 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 conditions at least weekly or as otherwise indicated in the resident's Care Plan. i. Licensed Nurses will document effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 02/13/2018 §483.45(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. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(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. §483.45(h)(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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 7 of 12 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 02/02/2018 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 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, interview, and policy review, the facility did not dispose of four expired over-the-counter medications in one of the three medication rooms. The expiration date is the manufacturer's date after which it cannot guarantee the safety and efficacy of the medication. The failure of the facility to dispose of expired medication had the potential to result in the use of expired medication for a resident, which was not effective or was harmful. Findings: During an observation with concurrent interview, on 1-31-18 at 9 a.m., the following expired items were in the Medication Room of Nurses' Station A: Bacitracin 500 U, one box of 144 packets. Expiration Date 9/16. Curad Vitamin D ointment, one packet. Expiration Date 2/17. Iodine Swish Stick, one stick. Expiration Date 11/16. Procure Vitamin A and D, four packets. Expiration Date 11/17. When asked who was responsible for monitoring the expiration dates of the medications in the medication room, the Assistant Director of Nursing stated the Licensed Nurses at the station were responsible for monitoring the expiration dates of the medications. During a review of policies on 2/2/18, the policy titled, "Disposal of Medications and MedicationFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 8 of 12 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 02/02/2018 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 Related Supplies," undated, indicted if a medication expired, the medication container should be marked and stored in a separate location designated solely for this purpose. The policy indicated medications waiting for disposal were stored in a locked secure area designated for that purpose until destroyed or picked up by the pharmacy. The policy indicated medications were removed from the storage area prior to expiration.

F770 SS=D Laboratory Services CFR(s): 483.50(a)(1)(i)

F770 02/28/2018 §483.50(a) Laboratory Services. §483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. (i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide labs, per physician orders, for one of 18 sampled residents (Resident 33). This failure had the potential for Resident 33 to have undetected physiological damage to her liver, or other organs, related to routine use of pain medication. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 9 of 12 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 02/02/2018 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 initial tour on 1/29/18, at 4 p.m., Resident 33 appeared alert and oriented, lying supine (on her back) in bed. Resident 33 appeared limited in her range of movement and complained when the bed sheet touched her feet. During a concurrent interview, Resident 33 stated she had severe Rheumatoid Arthritis, saying pain management included Motrin and Methadone. (Rheumatoid arthritis affects fluids in the joints, causing pain, swelling, stiffness and loss of function.) Resident 33 said she had not had a laboratory test since her admission a year earlier, saying she thought a liver panel should be done to rule out possible damage by pain medications, or possible diagnosis of diabetes, as it ran in her family. Resident 33 said she had recently asked for laboratory tests, but had received no response from her physician, or nursing staff. A review of, "Physician Orders," indicated, on 1/27/17, Resident 33's physician-ordered Comprehensive Metabolic Panel (CMP), and Complete Blood Count (CBC), used to evaluate an individual's overall health and detect a wide range of disorders, was to be done every six months. The physician-ordered ThyroidStimulating Hormone lab (TSH), measuring amount of thyroid hormone produced by an individual's body, was to be done January 2018. During an interview on 2/01/18, at 1:33 p.m., the ADON (Assistant Director of Nursing) indicated the facility had no record of Resident 33 having CMP and CBC laboratory tests done six months after Resident 33's admission, nor was a TSH laboratory test done in January 2018, per physician orders. The facility's policy, "Laboratory Services," FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 10 of 12 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 02/02/2018 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 Policy number NP-70, page one, indicated the facility provided, "...laboratory services in an accurate and timely manner to meet the needs of residents per Attending Physician orders."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 02/22/2018 §483.60(i) Food safety requirements. The facility must §483.60(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. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain infection control practice, when a cook directly touched two of 81 residents' plated food, during meal service. This failure had the potential for crossFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 11 of 12 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 02/02/2018 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 contamination and food-associated illness. Findings: During a tray line observation on 01/31/18, at 12 p.m., Cook A patted a resident's meatloaf with his right gloved hand, after touching a cooking pot, stove top, counter top, and serving utensil. At 12:10 p.m., Cook A tore off pieces of another resident's meatloaf and re-arranged items on the resident's plate, placing the broken piece back in the communal pan. Cook A had not changed gloves between touching multiple surfaces and residents' food. In an interview on 1/31/18, at 4 p.m., Cook A stated it would not be 'ok' to touch foods with a glove that had touched multiple surfaces, and said he was unaware he had done so. During an interview on 1/31/18, at 4:30 p.m., the Dietary Manager stated he had also witnessed Cook A touching residents' food during tray line, saying, "I didn't like it." The Dietary Manager said touching residents' food with gloved hands that had touched multiple surfaces was against facility policy. A review of the facility's, "Glove Use Policy, 10.9A," indicated gloved hands were a food contact surface that could get contaminated or soiled and should be discarded after each use, including before handling cooked, or ready-toeat, food. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WD1311 Facility ID: CA010000078 If continuation sheet 12 of 12