Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Granada Rehabilitation & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with BPH, diabetes, and an indwelling Foley for urinary retention had orders and a care plan requiring catheter care each shift and monitoring for pain and UTI symptoms, yet CNAs did not document catheter care and there was no evidence of catheter securement with a leg strap as required by facility policy and CDC-based practices. The resident, who was dependent for toileting and hygiene, was repeatedly documented as having no genital skin issues until an OT noted unsecured tubing, yellow drainage on clothing and the penis, and a split penile opening, prompting nursing assessment. LNs then documented a lacerated urethral meatus with purulent green-yellow exudate tracking down the catheter, and subsequent testing showed pseudomonas aeruginosa UTI associated with the indwelling catheter, while the MD indicated the tearing and infection had developed over time and should have been detected during ordered foley care.
The facility did not complete required baseline care plans (BCPs) within 48 hours of admission for two residents, including one with dementia and stage 2 PUs on both buttocks and another with dementia and muscle weakness. For the resident with PUs, the BCP and a skin care plan addressing the wounds were not completed until nearly a month after admission. During an interview and record review, the DON confirmed that facility policy requires BCPs within 48 hours and that this was not done for either resident, despite the policy stating that timely BCPs are needed to promote continuity of care, staff communication, resident safety, and to safeguard against adverse events.
A resident with COPD and moderate cognitive impairment was allowed to self-administer a nebulizer treatment without a physician order or a completed self-medication assessment, and more than 1 ml of medication remained in the nebulizer cup when the nurse stopped the treatment. The resident also reported not receiving a prescribed laxative, despite the EMAR showing it as administered. An LN initially asserted the laxative had been given but, after failing to find the expected used cup in the trash, acknowledged it had not been administered and that documentation had been completed contrary to facility policy requiring documentation only after actual administration.
A resident with CHF, hypertensive heart disease, and muscle weakness was involved in an altercation with a roommate, and nursing staff failed to follow abuse and COC procedures. Although a nurse noted the altercation and the plan to monitor the resident, there was no immediate documented assessment for injury or distress, no timely COC entry, and no contemporaneous documentation of MD or family notification. The DON later entered a backdated COC note and 72-hour behavior monitoring notes were completed 48–72 hours late, and the DON confirmed that required 72-hour checks and assessments were incomplete and below expected standards, despite prior staff training and written policies requiring prompt assessment, notification, care plan updates, and 72-hour monitoring.
The facility failed to report an allegation of verbal abuse within the required timeframe. A cognitively intact resident with developmental delay, rheumatoid arthritis, MDD, and anxiety reported that a CNA told her he wanted to clean her vagina, which made her uncomfortable with male CNAs providing this care. The ADM and DON stated the incident was reported internally the same evening it occurred and that CDPH was called, but they could not provide documentation of timely reporting. Review of the SOC 341 showed that CDPH, the Ombudsman, and law enforcement were notified the following day, contrary to facility policy requiring notification of law enforcement and submission of SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours of any abuse allegation.
A licensed nurse gave a dose of a resident's prescribed propranolol to a staff member experiencing anxiety, in violation of facility policy and professional standards. The staff member did not take the medication and disposed of it, resulting in the loss of a resident's dose. The incident was confirmed through staff interviews and security camera footage.
A resident with multiple risk factors, including hemiplegia, dementia, and a history of falls, was not provided with a fall risk care plan upon admission despite being identified as high risk. The lack of a care plan led to an unwitnessed fall resulting in a rib fracture and significant pain, with staff and the DON confirming that required protocols were not followed until after the incident.
A facility failed to conduct a Level II PASARR for a resident who received new mental illness diagnoses of bipolar disorder and schizoaffective disorder. Despite the facility's policy requiring PASARR updates, staff interviews revealed a lack of awareness and action, with the only PASARR on file being from the resident's initial admission. The MDS Coordinator was responsible for ensuring updates, but this was not done, resulting in the deficiency.
A facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with multiple pressure ulcers. Despite the facility's policy requiring EBP for wound care, a nurse did not wear a gown, citing the wound's lack of exudate. Interviews revealed inconsistent understanding among staff about when EBP should be applied, contributing to the deficiency.
Failure to Provide and Document Proper Catheter Care Resulting in Meatal Injury and CAUTI
Penalty
Summary
Staff failed to provide appropriate urinary catheter care and monitoring for a male resident with benign prostatic hyperplasia (BPH) and diabetes mellitus who had an indwelling urinary catheter for urinary retention. The resident’s care plan identified the catheter and included a goal to be free from catheter-related trauma, with expectations that staff monitor, document, and report pain or discomfort and signs and symptoms of UTI to the physician. Orders were in place for insertion of an indwelling catheter and for catheter care starting on 1/4/26, and the MAR showed LNs documented catheter care every shift from 1/13/26 through 1/19/26. Earlier skin assessments and shower sheets documented no genital skin concerns, and the resident was documented as dependent for toileting hygiene, lower body dressing, and personal hygiene. On 1/19/26, an OT noted drainage from the catheter site while assisting the resident with a transfer and observed that the catheter tubing was not secured to the resident’s thigh. The OT saw a large smear of yellowish drainage on the resident’s pants and the tip of the penis, and observed that the opening of the penis appeared split, which she reported immediately to nursing. Subsequent nursing assessment documented that the resident’s urethra was split down the middle, approximately 1/2 inch thick, with purulent green and yellow exudate inside the urethra and extending down the catheter tubing. The resident reported that the catheter hurt, that it had been like that “for a while,” and that he had pain in the area when moving or when catheter care was provided. A skin assessment later that day identified a new, facility-acquired laceration on the urethra of the penis, measuring approximately 1.5 cm by 0.5 cm, with erythema, edema, increased exudate, and sharp pain. A UA and C&S subsequently showed turbid urine, 3+ leukocyte esterase, positive blood, positive nitrites, and many bacteria, with pseudomonas aeruginosa identified as the causative organism. An ED exam documented pus around the meatus, enlarged testicles with swelling, erythema, and tenderness, and diagnosed a UTI associated with the indwelling urethral catheter. The DON stated that CNAs were responsible for catheter care, including cleaning around the meatus, and confirmed there was no documented evidence in the EMR that CNAs had provided catheter care for this resident. The DON also acknowledged there was no documentation of use of a leg strap or other securement device for the catheter, despite facility policy and CDC guidance requiring securement and daily meatal assessment and cleaning. The physician stated the meatal tearing likely occurred in small increments over time and that the infection should have been detected by nursing staff given that foley care was ordered every shift. Facility policies on indwelling catheters and pressure injury prevention required securement of catheters to the thigh and daily observation for signs of potential or active pressure injury related to medical tubes and catheters. CDC guidance referenced by the facility emphasized proper catheter securement to prevent urethral traction, daily meatal cleaning during bathing, and assessment of the meatus for redness, irritation, drainage, and encrustation. Despite these expectations, there was no evidence that catheter securement devices were used or documented for this resident, and no CNA documentation of catheter care was found. The failure of LNs and CNAs to provide and document appropriate catheter care, to secure the catheter, and to identify and report progressive meatal injury and infection resulted in a facility-acquired mucosal membrane injury to the urinary meatus and a severe UTI with pseudomonas aeruginosa associated with the indwelling catheter.
Failure to Complete Timely Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to complete baseline care plans (BCPs) within 48 hours of admission for two residents, contrary to its policy and regulatory expectations. Resident 1 was admitted on 1/7/2026 with dementia and documented stage 2 pressure ulcers on both sides of the buttocks. Although the BCP noted that the resident was admitted with stage 2 pressure ulcers, the BCP itself was not completed until 2/5/2026, nearly one month after admission. Additionally, Resident 1’s skin care plan/care plan for the pressure ulcers was not initiated until 2/5/2026, despite the presence of existing pressure ulcers at admission. Resident 2 was admitted on 2/2/2026 with dementia and muscle weakness, but the BCP for this resident was also not completed until 2/5/2026, exceeding the 48-hour requirement. During an interview and concurrent record review on 2/5/2026 at 11:17 a.m., the DON confirmed that facility policy required BCPs to be completed within 48 hours of admission and acknowledged that neither resident’s BCP met this timeframe. The DON also confirmed that the absence of a timely BCP and skin care plan could increase the risk of unsafe care, including risk for skin breakdown and wound worsening. A review of the facility’s Person-Centered Care Planning policy, revised 4/24/2025, indicated that the baseline care plan was to be developed and implemented within 48 hours of admission to promote continuity of care, communication among staff, resident safety, and safeguard against adverse events.
Failure to Ensure Safe Self-Administration and Accurate Medication Documentation
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident with COPD and moderate cognitive impairment. The resident, admitted in November 2025 and scoring 12 on the BIMS, was observed on the morning of 2/5/26 self-administering a nebulizer treatment alone in her room without staff present. The resident reported she had always given herself the nebulizer treatment. During an interview and observation, LN B confirmed the resident had administered the nebulizer treatment herself, acknowledged there was no physician order for self-administration, and that no self-medication administration assessment had been completed. LN B also verified that more than 1 ml of medication remained in the nebulizer cup when the treatment was stopped. The DON later confirmed there was no order or assessment authorizing the resident to self-administer medications, despite facility policy requiring both before self-administration. The facility also failed to ensure accurate medication documentation for the same resident. Review of the EMAR for 2/5/26 showed that polyethylene glycol had been documented as administered at 9:00 a.m. The resident stated she had not received her laxative, which she expected to be mixed with water in a disposable cup. When challenged by the resident to locate the used cup in the trash, LN B checked the trash can, found no cup, and then recalled she had not actually given the laxative. During a concurrent record review, LN B verified that the EMAR indicated the polyethylene glycol had been administered and acknowledged she had not followed facility policy, which required documenting medication administration on the EMAR only after the medication was actually given. The DON confirmed the facility policy required immediate documentation after administration and stated that documenting a medication as given when it was not could mislead clinical decisions and put resident safety at risk.
Failure to Implement Abuse Policy and Change of Condition Procedures After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention and management policy and its change of condition documentation procedures following an alleged altercation involving one resident. The resident was admitted with chronic systolic CHF, hypertensive heart disease, and generalized muscle weakness, and had no documented memory impairment. On 12/25/25, a health status note by a licensed nurse recorded that the resident was in an altercation with his roommate and would be on alert charting and monitored for changes or concerns. However, there was no documented immediate assessment of the resident for physical injuries or emotional distress, no timely change of condition (COC) entry, and no contemporaneous documentation of physician or family notification as required by facility policy and the facility’s COC lesson plan. The DON later entered a COC note effective 12/25/25 but written on 12/26/25, documenting that the MD was notified and recommended monitoring, and stated she wrote it because she realized it had not been done and was needed to trigger alerts. Progress notes reflecting behavior monitoring for 72 hours after the alleged abuse incident, with effective dates of 12/27/25 and 12/28/25, were documented 48–72 hours late on 12/30/25. The DON confirmed that the 72-hour checks were incomplete, the assessments were not written to the expected standard, and there were no documented assessments immediately after the altercation. This occurred despite the DSD’s statement that nurses had been trained to chart assessments, COC, and 72-hour checks immediately after a resident was identified as a victim of an abuse allegation, and despite written policies requiring immediate assessment, MD and responsible party notification, care plan updates, and 72-hour monitoring documentation.
Failure to Timely Report Alleged Verbal Abuse to Required Agencies
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving one resident was reported to the California Department of Public Health (CDPH) within the required timeframe. The resident had been admitted with diagnoses including developmental delay, rheumatoid arthritis, major depressive disorder, and anxiety disorder, and had a BIMS score of 13, indicating cognitively intact status. During an interview, the resident reported that a CNA said to her that he wanted to clean her vagina. The resident stated that this disturbed her, that she did not feel comfortable having male CNAs clean her, and that she wanted to keep her dignity. The Administrator and DON stated that the resident reported the event to the Nurse Supervisor on the evening of 12/6/25, and that the Nurse Supervisor then notified them. The DON stated she called the incident in to CDPH that same evening; however, the Administrator and DON were unable to provide documented evidence that the event was reported to CDPH on that date. A review of the SOC 341 form showed that CDPH, the Ombudsman, and law enforcement were notified of the alleged abuse on 12/7/25. The facility’s Abuse Prevention and Management policy required the administrator or designee to notify law enforcement by telephone immediately or as soon as possible, but no longer than two hours after an initial report, and to send a written SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours, for all allegations of abuse.
Nurse Administers Resident Medication to Staff Member
Penalty
Summary
A licensed nurse failed to follow professional standards by removing a dose of propranolol, a prescription medication intended for a resident with hypertension, from the medication cart and offering it to an unlicensed staff member who reported experiencing anxiety. The staff member took the medication from the nurse but ultimately disposed of it in a hopper without ingesting it. The medication was specifically labeled for a resident who had an active physician's order for propranolol 40 mg three times daily for hypertension. The nurse had full access to the medication cart and did not have a physician's order to administer the medication to the staff member. Facility policy and the nurse's job description both require that medications be administered only as ordered by a physician and only to the intended resident. Interviews with staff confirmed that nurses are not permitted to give resident medications to staff, as these medications are not prescribed for them and could cause unknown side effects. The incident was observed on security cameras and verified through interviews with the involved staff, including the nurse who admitted to giving the medication to the staff member.
Failure to Initiate Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a fall risk care plan for a resident with multiple risk factors, including hemiplegia, morbid obesity, muscle weakness, dementia, and a history of falls. Upon admission, the resident was identified as high risk for falls due to recent hospitalization, incontinence, multiple diagnoses, and medication use. Despite this, no fall risk care plan was initiated at the time of admission or prior to a significant fall event. The resident experienced an unwitnessed fall, resulting in a closed rib fracture and significant pain. Documentation shows that the resident was found on the floor after calling for help, and subsequently required transfer to an acute care hospital for evaluation and treatment. The resident continued to experience pain after returning to the facility, necessitating stronger pain management interventions. Interviews with nursing staff and the DON confirmed that a fall risk care plan was not in place prior to the fall, despite facility policy requiring such plans to be developed upon admission for residents identified as high risk. The care plan was only initiated after the fall occurred, contrary to established procedures and expectations for resident safety.
Failure to Conduct Updated PASARR for New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was conducted for a resident who received new mental illness diagnoses. The resident, admitted on 05/05/2011, had a medical history including hemiplegia, hemiparesis, ataxia, protein-calorie malnutrition, and an unspecified mental disorder. The resident was later diagnosed with bipolar disorder on 11/20/2015 and schizoaffective disorder on 11/23/2018. However, the facility did not complete a PASARR evaluation following these new diagnoses, as required. Interviews with facility staff revealed a lack of awareness and action regarding the need for updated PASARR evaluations. The Social Services Director, who had been with the facility for several years, stated she had never conducted any PASARR-related activities. The Director of Nursing confirmed that the only PASARR on file for the resident was from the initial admission in 2011 and was unaware that a new PASARR should be completed with new mental illness diagnoses. The facility's policy indicated that the MDS Coordinator was responsible for ensuring PASARR updates, but this was not adhered to, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with multiple pressure ulcers and severe cognitive impairment. The resident, admitted with a diagnosis of a Stage 2 pressure ulcer in the sacral region, also had two unstageable pressure ulcers and two unstageable deep tissue injuries. During an observation of wound care, a Licensed Vocational Nurse (LVN) did not wear a gown, which is required under the facility's policy for EBP when performing wound care on residents at risk of transmission or acquisition of multi-drug resistant organisms (MDROs). Interviews with staff revealed inconsistencies in understanding and implementing EBP. The LVN believed EBP was not necessary due to the lack of exudate from the wound, while a Registered Nurse (RN) and the Director of Nursing stated that EBP should be applied for any wound care. The Infection Control Preventionists (ICPs) also indicated that EBP was not required for the resident's wound due to its dry state and healing progress. This discrepancy in staff education and understanding led to the failure to adhere to the facility's policy on EBP during wound care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eureka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eureka Rehabilitation & Wellness Center, Lp | 0.4 mi | — | 27 | 0 |
| Seaview Rehabilitation & Wellness Center, Lp | 4.6 mi | — | 10 | 0 |
| Fortuna Rehabilitation And Wellness Center, Lp | 13.2 mi | — | 31 | 0 |
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