Health inspection·January 28, 2026

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to implement their abuse policy for one resident (Resident 1) of nine sampled residents when licensed nurses did not document an assessment, a Change of Condition (COC), notification of the incident to the physician (MD), and 72-hour monitoring for Resident 1 immediately after an alleged abuse incident.This failure decreased the facility's potential to ensure Resident 1's needs were met after his involvement in an altercation.Findings:A review of Resident 1's admission record indicated he was admitted in September 2025 with a diagnosis of chronic systolic (congestive) heart failure (CHF - a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), hypertensive heart disease (heart failure due to high blood pressure), and muscle weakness (generalized). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/22/25, indicated Resident 1 had no memory impairment.A review of Resident 1's Health Status Note dated 12/25/25 at 7:49 p.m. written by Licensed Nurse 1 (LN 1) stated Resident 1 was in an altercation with his roommate and he will be on alert charting and monitored for any changes or concerns. In an interview on 1/29/26 at 2:06 p.m., the Director of Nursing (DON) confirmed she was aware of the allegation of abuse that occurred on 12/25/25. The DON stated she expected nurses to have charted a Change of Condition (COC) in the resident's chart, documented when the MD and family were notified, updated the residents' care plan and monitor the residents for 72 hours after the alleged abuse incident. The DON also stated she expected the Social Services Director (SSD) to follow-up with the resident and document what occurred during the conversation.A review of Resident 1's late charted COC which was effective 12/25/25 at 11:34 a.m. but was written on 12/26/25 at 3:37 p.m. by the DON indicated the MD was notified and recommended nursing staff monitor the Resident a day after the incident occurred. In an interview on 2/4/26 at 9:29 a.m., the DON stated, I wrote the note [COC]. I wrote it because I realized it hadn't been done and needed to be [in order] to trigger the alerts.A review of Resident 1's progress notes with effective dates of 12/27/25 and 12/28/25 were all documented between 48-72 hours late on 12/30/25. These notes included behavior monitoring 72 hours after the alleged abuse incident.In a concurrent interview and record review on 1/29/26 at 2:25 p.m., the DON confirmed the 72-hour checks were incomplete and the assessments were not written to the expected standard. The DON also confirmed there were no documented assessments of the residents immediately after the altercation.In an interview on 1/29/26 at 3:20 p.m. the Director of Staff Development (DSD- a person who is responsible for training staff) stated she had trained the nurses to chart assessments, COC, and 72-hour checks immediately after a resident was identified as being a victim of an abuse allegation.A review of the facility's undated Change of Condition lesson plan indicated Licensed Nurses were to document the following: date, time and pertinent details of the incident in the nursing notes, the time and how the Attending physician was contacted and if there were any new orders, the time the family or responsible person was contacted, update the care plan and document each shift for at least 72 hours on the status of the Residents Affected - Few (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: 056300 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 056300 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Granada Rehabilitation & Wellness Center, LP 2885 Harris Street Eureka, CA 95503 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)