Health inspection·December 13, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of abuse, in accordance with facility policy and procedure and with state law, for one resident (Resident 1), when the facility did not notify the appropriate agencies such as California Department of Public Health (CDPH), Local law enforcement, and Ombudsman of a potential allegation of abuse, within the required timeframe. This failure had the potential for the alleged abuse to continue and did not allow the appropriate agencies to investigate the allegations. Findings: A review of Resident 1's face sheet (admission record) indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE], with a medical diagnosis that included: Chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breathe), metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1), Spondylolysis, Lumbar region (a stress fracture through the pars interarticularis of the lumbar vertebrae), and Pleural Effusion (A buildup of fluid between the tissues that line the lungs and the chest) . Resident 1 had a Brief Interview for Mental Status (BIMS) score of 13, (BIMS score ranges 0 to 7 suggests severe cognitive impairment, 8 to 12 points suggests moderate cognitive impairment and 13 to 15 points suggests cognition is intact). During a telephone interview on 10/11/23 at 9:20 a.m., the Ombudsman stated she had been working with Resident 1 and the facility since hearing about complaints, starting in July, prior to the current abuse allegation reported on 10/6/23. During an interview on 10/11/23 at 10:30 a.m., the Administrator was asked about the abuse allegations for Resident 1 and when they occurred. The Administrator stated the current allegations of, rough handling, were reported and investigated on 10/4/23, when Resident 1 reported five incidences of rough handling by staff. During an interview on 10/11/23 at 11:15 a.m., Resident 1 stated the care was sometimes good and sometimes not good. Resident 1 stated she did not feel safe, and the CNAs smacked her foot into the closet. When asked, Resident 1 did not specify when the incident occurred. During a telephone interview on 12/5/23 at 2 p.m., the Administrator was asked for the time frame when the allegations of rough handling started and the policy and procedure for abuse reporting. An email was received on 12/6/23, indicating an incident involving three Certified Nursing Assistants (CNAs) was brought to an Interdisciplinary Team Meeting (IDT) on 08/08/23, and was reviewed. Education (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055003 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055003 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eureka Rehabilitation & Wellness Center, LP 2353 Twenty Third St Eureka, CA 95501 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)