Health inspection·February 11, 2026

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Dependent.Personal hygiene= Dependent.A review of Resident 1's progress note dated 1/19/26 at 12:01 p.m., indicated, .Treatment RN [Registered Nurse] was notified by [Occupational] therapy of a possible ureteral infection.[Resident 1's] urethra [the tube connecting the bladder to the outside of the body allowing for excretion of urine] is split down the middle, approx. [approximately] 1/ 2 - inch thickness, with purulent [containing pus (a thick, milky, white-yellow to brown fluid that accumulates at the site of infection] green and yellow exudate [discharge] inside the urethra, and climbing down the [urinary] catheter tube. [Resident 1] states ‘this thing needs to come out. It hurts. It's been like this for a while.'A review of Resident 1's progress note dated 1/19/26 at 12:11 p.m. indicated, Resident has pain in the area when moving or providing catheter care.A review of Resident 1's skin check assessment dated [DATE] at 12:18 p.m., indicated Resident 1 had a new facility acquired skin issue which involved a laceration located on Resident 1's urethra on his penis. The assessment described the wound as having erythema (redness of the skin or mucosal membrane) and edema (swelling) with increased exudate. The wound measured 1.5 cm in length and 0.5 cm wide, and Resident 1 described the pain as sharp. A review of Resident 1's progress note dated 1/19/26 at 1:44 p.m. indicated, MD [physician] ordered UA [urinalysis- a common diagnostic test that analyzes urine to detect infections] & C&S [culture and sensitivity- a test used to identify the specific bacteria causing an infection].to be sent out today.A review of Resident 1's UA and C&S test results dated 1/22/26 indicated the bacteria known as pseudomonas aeruginosa was causing Resident 1's urine to: appear turbid (significantly cloudy); test 3+ positive for white blood cell esterase (an enzyme released by WBC as it fights off bacteria. 3+ indicates the highest amount the test can detect); test positive for blood; test positive for nitrites (a specific marker for UTI); and many bacteria which were all considered to be abnormal.A review of Resident 1's hospital emergency department (ED) note dated 1/23/26 indicated, .Physical Exam.GU [genitourinary- anatomy of the genitals and urinary system] Indwelling [urinary] catheter in place.chronic pressure wounds present. Pus around meatus. Enlarged testicles with swelling, erythema, and tenderness to palpation [touch].positive for large UTI.Final diagnoses [in ED].Urinary tract infection associated with indwelling urethral catheter.During an interview in the facility hallway on 2/11/26 at 1:31 p.m., the Treatment Nurse (TN) stated both the LNs and CNAs were responsible for providing catheter care for residents. The TN stated catheter care was a part of nurses' daily routine of perineal (small area of the body between the anus and the external genitalia) care. The LNs were responsible for following up with the physician for anything concerning.During an interview at the Side 1 nurses' station on 2/11/26 at 1:44 p.m., LN 1 stated CNA staff were responsible for providing catheter care to residents every two hours or sooner if needed. LN 1 further stated CNAs were supposed to report any concerns or if something is not looking right to the LN staff for follow up. LN 1 also stated catheter care was documented in the resident's electronic medical record (EMR).During an interview in the facility conference room on 2/11/26 at 2:14 p.m., the OT stated she was working on transferring Resident 1 from the bed to his wheelchair. The OT stated she pulled up his pants when he yelled, Ow, that hurts! The OT thought she pulled on Resident 1's catheter tubing, which she observed was not secured to his thigh. The OT stated when she looked at his catheter, she found a large smear of yellowish drainage on his pants as well as the tip of his penis. The OT stated the opening on the penis appeared split and she was surprised no one caught this before me. The OT stated she immediately reported her finding to Resident 1's primary nurse.During an interview in the Director of Nursing (DON) office on 2/11/26 at 3:20 p.m., the DON stated the CNA staff were responsible for catheter care, which included cleaning around the meatus. The DON stated CNAs had catheter care listed on the competency checklist which was completed upon hire and assessed annually. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056300 If continuation sheet Page 2 of 3 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 02/11/2026 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete DON confirmed there was no documented evidence in Resident 1's EMR that CNAs conducted or provided catheter care for Resident 1. During a phone interview on 2/24/26 at 8:41 a.m., the DON stated the facility used catheter leg straps to secure and stabilize the catheter tubing. The DON added the leg straps were available for staff to implement on residents with an indwelling catheter. The DON stated the use of a leg strap did not have a specific location to be documented aside from a nurse's progress note. The DON acknowledged she did not find evidence of the placement or use of a leg strap to secure Resident 1's urinary catheter in Resident 1's EMR. During a phone interview on 2/25/26 at 8:29 a.m., the physician (MD) stated Resident 1 likely had small increments of tearing of his meatus over a period of time but stated, It should have caught someone's attention at some point. The MD further stated she was concerned that the infection was not detected by nursing staff, considering foley care was ordered to be provided every shift. The MD stated an infected wound would begin pus formation, on average, between one or two days following bacterial exposure. The MD confirmed Resident 1's pressure injury to his penis and subsequent UTI did not happen in a matter of hours as it was evidenced by the amount of exudate from the tip of Resident 1's penis and the lack of blood from a new wound.During an interview on 2/25/26 at 12:39 p.m., the DON stated catheter care was validated upon hire and annually thereafter with the Director of Staff Development. A review of facility's policy titled Indwelling Catheter-Insertion, Maintenance, and Discontinued of, dated 8/19/25, did not indicate how catheter care was expected to be completed.A review of the facility's policy titled Indwelling Catheter-Insertion, Maintenance, and Discontinued of dated 8/19/25, indicated, Secure the catheter to the patient's thigh using a securement device or tape.A review of the facility's policy titled Indwelling Catheter dated 8/19/25 indicated, Purpose.To provide safe, appropriate, current guidance for the use of indwelling catheters for clinical use.A review of an undated Centers for Disease Control and Prevention's (CDC- the leading national public health agency in the United States) presentation titled Indwelling Urinary Catheter Insertion and Maintenance indicated, Interventions to Prevent CAUTI [catheter associated UTI].Properly secure catheters to prevent movement and urethral traction.Meatal Cleaning.Assess the patient for any pain or discomfort.Inspect the meatus for redness, irritation and drainage.Assess the catheter where it enters the meatus for encrusted material and drainage.Clean the meatus during daily bathing.Ensure the tubing does not go in and out of the urethra during cleaning.Consider the use of checklists.If the patient must have an indwelling urinary catheter, pay attention to maintenance practices.A review of facility policy titled Pressure Injury Prevention, dated 7/31/24, indicated Implement interventions.monitoring.medical tubes and catheters. Staff will observe for any signs of potential or active pressure injury daily. Event ID: Facility ID: 056300 If continuation sheet Page 3 of 3