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 Eureka Nursing Center during CMS and state inspections, most recent first.
A long-term care facility failed to protect residents from abuse, as evidenced by a resident-to-resident sexual abuse incident and inadequate investigation of employee-to-resident abuse allegations. A resident with a history of hypersexual behavior inappropriately touched another resident, and the facility's response was insufficient. Additionally, another resident was found with multiple bruises, but the facility did not conduct a thorough investigation or report the findings, placing residents at risk for further harm.
A resident with a history of hypersexual behaviors in a LTC facility grabbed another resident's breast without consent. Despite the resident's known history of inappropriate actions, the facility failed to implement adequate interventions or update the care plan to prevent such incidents. Staff interviews revealed a lack of awareness and documentation regarding the resident's behaviors, highlighting deficiencies in the facility's abuse prevention policies.
A resident with multiple medical conditions, including a right above-knee amputation, experienced two unsafe transfers at the facility. In the first incident, a shower chair's wheel broke, causing the resident to fall and fracture his tibia. In the second incident, the resident was transferred into an electric wheelchair with exposed metal, resulting in a laceration that required sutures. The facility failed to update the care plan to include a CAM boot and did not maintain the shower chair properly.
The facility failed to maintain sanitary conditions in food storage and preparation, potentially risking foodborne illnesses. Observations revealed undated food items, an open garbage can near food prep areas, and kitchen equipment with scratches and debris. Dietary staff confirmed these issues, and the facility lacked a food storage policy.
The facility did not maintain the required RN coverage for at least eight continuous hours on 29 days between August 2023 and January 2024, as confirmed by the Payroll Based Journal and Daily Staff Postings. With a census of 48 residents, this lack of coverage placed residents at risk for unsupervised nursing care. Administrative Staff A confirmed the absence of RN coverage on the specified days.
The facility failed to submit accurate staffing data to CMS, missing 24-hour Licensed Nurse coverage on 16 dates. This was confirmed by Administrative Staff A, who admitted inaccuracies in the Payroll Base Journal (PBJ) data for specific weekends in April, May, and June 2023.
The facility failed to provide a clean and sanitary environment for residents in the special care unit due to a persistent urine odor, despite multiple interventions. Additionally, two residents had cracked and worn fall mats, making sanitation difficult and reducing their effectiveness. The facility lacked policies for urine odor elimination and fall mat maintenance.
The facility failed to accurately complete the MDS for three residents, resulting in uncommunicated care needs. Errors included misdocumenting antiplatelet medication as anticoagulant for two residents and failing to document contractures for another. These discrepancies were confirmed by the Administrative Nurse, who noted the lack of a facility policy for MDS completion.
A facility failed to develop a comprehensive person-centered care plan for a resident with Alzheimer's, anxiety, and dementia within the required timeframe. The resident, with a BIMS score indicating moderately impaired cognition, did not have a care plan completed within 21 days of admission, contrary to the facility's policy. Observations noted the resident's anxiety and lack of documented interventions, highlighting unmet needs.
A resident with multiple health conditions, including a right above-knee amputation, was not provided with a revised care plan to include the use of a CAM boot as ordered by a physician. This oversight led to a laceration on the resident's leg during a transfer without the boot, due to contact with exposed metal on the wheelchair. The facility's policy required care plan updates for changes in condition, which was not followed.
A facility failed to apply sheepskin padding to a resident's wheelchair arm rests as required by the care plan, despite the resident's history of arthritis and a recent skin tear. Observations confirmed the absence of the padding, and staff verified it had never been applied. This oversight potentially increased the risk of further skin injuries.
A resident with a history of trauma, including childhood sexual abuse and domestic violence, did not receive trauma-informed and person-centered care. The care plan lacked interventions for past trauma, and staff were unaware of the resident's trauma history or PTSD training. The facility's policy on Trauma Informed Care was not followed, leading to inadequate care for the resident's mental and psychosocial well-being.
The facility was found to have a deficiency in maintaining a sanitary environment in the soiled utility room on the 400-hall. A trash can was observed without a liner and lid, contrary to the facility's standard practice. The Maintenance Director confirmed the requirement for liners and lids, but the facility lacked a policy on this matter.
Failure to Prevent and Respond to Abuse in LTC Facility
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of a resident-to-resident sexual abuse incident. Resident 2, who had a history of hypersexual behaviors, grabbed Resident 1's breast without consent. Despite Resident 2's documented history of inappropriate sexual behavior towards staff, the facility did not have adequate interventions in place to prevent such incidents. The care plan for Resident 2 lacked specific interventions related to sexual abuse, and the facility's response to the incident was insufficient, as it did not include a thorough investigation or appropriate updates to the care plan. Additionally, the facility failed to investigate and report potential employee-to-resident abuse involving Resident 10, who was found with multiple bruises of unknown origin. Despite the presence of bruises documented during skin assessments, the facility did not conduct a thorough investigation or report the findings to the state agency or local police. The lack of investigation into the bruises and the failure to identify them as potential abuse placed Resident 10 at risk for further harm. The facility's inaction in both cases demonstrates a failure to ensure the safety and well-being of its residents. The lack of appropriate interventions, failure to update care plans, and inadequate response to allegations of abuse highlight significant deficiencies in the facility's handling of abuse prevention and response.
Removal Plan
- R2 was placed on a one on one and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges.
- To ensure the psychosocial well-being of R1, a follow-up interview was conducted. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically when a resident with a history of hypersexual behaviors, including groping and making inappropriate comments, grabbed another resident's breast without consent. This incident occurred despite the resident's known history of such behaviors, which included previous inappropriate actions towards staff and other residents. The facility did not have adequate interventions in place to prevent this behavior, and the care plan for the resident lacked any documentation or interventions related to the sexual abuse incident. The resident involved in the incident had a diagnosis of vascular dementia and was noted to have intact cognition with a BIMS score of 14. Despite this, the resident exhibited impulsivity and behaviors that could lead to unsafe situations. The care plan included instructions for staff to provide redirection and reorientation, but it did not address the specific risk of sexual abuse towards other residents. The facility's records showed multiple instances of inappropriate behavior by the resident, yet there was no comprehensive plan to address these behaviors or protect other residents. Interviews with staff revealed that there was a lack of awareness and documentation regarding the resident's inappropriate behaviors towards other residents. Some staff members were unaware of the incident, and others confirmed that the care plan did not include interventions for sexual abuse. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to update the care plan and take appropriate measures to prevent further incidents.
Removal Plan
- R2 was placed on a one on one and would remain a one on one until alternative living arrangements can be made and/or medication can be implemented to decrease sexual urges.
- To ensure the psychosocial well-being of R1, a follow-up interview was conducted. During the interview conducted by Administrative Nurse B and Administrative Nurse C, R1 denied being afraid of R2 or that she was fearful of living across the hall from him. R1 reported she felt safe living at facility and had no complaints.
Resident Safety Compromised During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident during two separate transfer incidents. The first incident occurred when staff used a shower chair to transport the resident, resulting in the chair's wheel breaking and the resident falling forward, sustaining a fractured tibia. The resident's medical history included chronic obstructive pulmonary disease, diabetes, polyneuropathy, and a right above-knee amputation, which made him dependent on staff for transfers and increased his risk for difficult transfers. In the second incident, the facility staff did not ensure a safe transfer of the resident into his electric wheelchair, which had exposed metal, while using a mechanical lift. This resulted in a laceration on the resident's anterior lower leg that required sutures. The resident's care plan was not updated to include the use of a controlled ankle movement boot, which was ordered by a physician for protection after the removal of a cast. The facility's policies and procedures were not adequately followed, as evidenced by the lack of maintenance documentation for the shower chair prior to the incident and the failure to apply the CAM boot before transferring the resident. Interviews with staff revealed that the resident's wheelchair lacked proper padding, contributing to the injury during the transfer. The facility's policy for resident showers and accident prevention was not effectively implemented, leading to these safety deficiencies.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to foodborne illnesses among residents. During an observation, a sealed 10-pound bag of macaroni was found without an opened date in the dry goods pantry. Additionally, a half meat sandwich in a zip lock bag lacked a date, and a sealed zip lock bag contained four half-emptied squeeze bags of icing dated several months prior, with no expiration dates noted. Dietary Staff BB confirmed these concerns during an interview. Furthermore, an open garbage can full of garbage was observed near the food preparation station, which Dietary Staff B acknowledged should have been closed at all times. During an environmental tour, several unsanitary conditions were noted in the kitchen. The top oven had areas of bubbled burned food debris, and two large fry pans had multiple scratches on their cooking surfaces. A large white cutting board was found with multiple scratches and gouges on both sides, and two white rubber spatulas had cracks and chips on their outer surfaces. Dietary Staff BB confirmed these issues during an interview. The facility also failed to provide a policy on food storage, further contributing to the unsanitary conditions observed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for at least eight continuous hours on 29 specific days between August 2023 and January 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) and Daily Staff Postings, which confirmed the absence of RN coverage on the specified dates. The facility reported a census of 48 residents, and the lack of RN coverage placed these residents at risk for unsupervised nursing care and services. Administrative Staff A confirmed the absence of RN coverage on the days indicated in the PBJ report. The facility utilized the Facility Assessment to determine the required RN coverage but failed to ensure compliance with the eight-hour requirement.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report 24-hour Licensed Nurse (LN) coverage for 16 specific dates between April 1, 2023, and March 31, 2024. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for the fiscal year, Quarter 3 of 2023, which revealed gaps in LN coverage on several weekends in April, May, and June 2023. During an interview on July 11, 2024, Administrative Staff A acknowledged that the PBJ data was inaccurate regarding the 24-hour LN coverage for the specified dates. The facility relied on its Facility Assessment policy for completing the PBJ, but this did not ensure accurate reporting. The failure to provide complete and accurate staffing information in a uniform format as specified by CMS constitutes a deficiency in the facility's compliance with federal requirements.
Facility Fails to Maintain Sanitary Environment and Fall Mat Maintenance
Penalty
Summary
The facility failed to provide a clean, home-like, and sanitary environment for residents in the special care unit. During an environmental tour, a pervasive odor of urine was detected throughout the unit and extended into the main hallway. Maintenance Director U attributed the odor to a resident who urinated in random places, and despite multiple interventions by nursing staff since September 2022, the issue persisted. Administrative Nurse E confirmed that the odor compromised the sanitary and home-like environment for the 11 residents in the special care unit. The facility did not have a policy related to the elimination of urine odors. Additionally, the facility failed to maintain sanitary conditions for two residents who had cracked and worn fall mats in their rooms. During an initial tour, it was observed that one resident had a fall mat with multiple cracks and worn surfaces, while another resident had two fall mats with similar issues. Administrative Nurse E confirmed that the condition of the fall mats made sanitation difficult and reduced their effectiveness. The facility lacked a policy for fall mat maintenance, contributing to the unsanitary and unsafe environment for these residents.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to uncommunicated care needs. For one resident, the MDS inaccurately documented the use of antiplatelet medication as an anticoagulant, despite physician orders and medication administration records indicating the use of aspirin, an antiplatelet medication. This discrepancy was confirmed by the Administrative Nurse, who acknowledged it as a clerical error and noted the absence of a facility policy for MDS completion. Another resident's MDS also incorrectly documented the use of anticoagulant medication instead of antiplatelet medication. The resident's care plan and medication records showed the administration of aspirin, but there was no documentation of anticoagulant use. The Administrative Nurse confirmed this error, attributing it to clerical mistakes and the lack of a specific MDS completion policy. Additionally, the MDS for a third resident failed to document contractures as impairments, despite the resident having a right-hand contracture and using a hand splint and carrot splint. Observations noted inconsistencies in the application of these splints, and staff reported that care sheets lacked information about the splints. The Administrative Nurse confirmed the oversight in the MDS documentation, again highlighting the absence of a facility policy for MDS completion.
Failure to Develop Timely Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R47, within the required timeframe. R47 was admitted with diagnoses including Alzheimer's disease, anxiety, and dementia, and had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Despite these conditions, the care plan was not completed within 21 days of admission, as required by the facility's policy. The policy mandates that a comprehensive care plan be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS). Observations and interviews revealed that R47's care plan lacked staff interventions to provide person-centered care. The resident was noted to be anxious, wringing her hands, and moving around her room, indicating potential unmet needs. The facility's policy, dated 03/28/24, emphasizes the importance of developing a care plan that includes measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. However, the facility did not adhere to this policy, resulting in a deficiency that could negatively impact the resident's well-being.
Failure to Update Care Plan for CAM Boot Use
Penalty
Summary
The facility failed to review and revise the care plan for a resident, identified as R30, to include the use of a controlled ankle movement (CAM) boot as ordered by the physician. The resident had a history of chronic obstructive pulmonary disease, diabetes, polyneuropathy, and a right above-knee amputation, and was dependent on staff for transfers and mobility. Despite a physician's order dated 05/23/24 for the CAM boot to be worn except during skin checks and range of motion exercises, the care plan was not updated to reflect this requirement. This oversight led to an incident where the resident sustained a laceration on his left lower extremity due to contact with an exposed piece of metal on his wheelchair during a transfer without the CAM boot being applied. Observations and interviews revealed that staff did not apply the CAM boot prior to transferring the resident, which was contrary to the physician's order and the facility's policy on accidents and supervision. The resident reported a previous incident where a shower chair wheel broke, resulting in a fall and a subsequent fracture, which required a cast and later a CAM boot. The facility's policy required changes in a resident's condition to be reflected in the care plan, but this was not done for R30, leading to inadequate protection during transfers and resulting in injury.
Failure to Apply Sheepskin Padding to Wheelchair Arm Rests
Penalty
Summary
The facility failed to apply sheepskin padding to the arm rests of Resident 34's wheelchair, as required by the care plan. Resident 34 had a history of arthritis and anxiety, with severely impaired cognition as indicated by a BIMS score of five on the Annual MDS. The care plan, dated July 4, 2024, specified the application of sheepskin padding due to a skin tear obtained on the same day. However, the physician orders dated July 10, 2024, did not document the need for sheepskin padding, and observations on July 10, 2024, confirmed the absence of sheepskin on the wheelchair arm rests. Certified Nurse Aide M verified the lack of sheepskin padding and stated she had never seen it on the resident's wheelchair. Administrative Nurse E expressed that the charge nurse responsible for the intervention should have ensured its completion according to the care plan. The facility's policy on accidents and supervision emphasized maintaining a hazard-free environment and implementing necessary interventions to prevent accidents. The failure to apply the sheepskin padding potentially increased the risk of additional skin injuries for Resident 34.
Failure to Implement Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to develop and implement trauma-informed and person-centered care for a resident with a history of personal trauma. The resident, who had diagnoses including Alzheimer's disease, anxiety, and dementia, was found to have a history of childhood sexual abuse and domestic violence. Despite this, the resident's care plan lacked interventions to address past trauma, adjustment difficulties, or indications of distress. The care plan did not include strategies to assist the resident in reaching and maintaining their highest level of mental and psychosocial well-being. Observations and interviews revealed that the resident exhibited signs of anxiety, such as hand-wringing and restlessness, yet the care plan did not reflect any trauma-informed interventions. Staff members, including CNAs and administrative staff, were unaware of any training on PTSD or the resident's trauma history. The facility's policy on Trauma Informed Care emphasized the importance of culturally competent care that minimizes triggers and re-traumatization, but this was not reflected in the care provided to the resident.
Sanitary Environment Deficiency in Soiled Utility Room
Penalty
Summary
The facility failed to maintain a sanitary environment in the soiled utility room on the 400-hall, as observed during an environmental tour. A trash can in this room was found without a liner and a lid, which is against the facility's standard practice. The Maintenance Director confirmed that all trash containers should have liners and lids, and that trash and soiled linen containers are to be washed out at the end of every shift. However, the facility did not provide a policy related to the requirement for lids or coverings on trash cans, indicating a lapse in maintaining sanitary conditions.
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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) |
|---|---|---|---|---|
| El Dorado Care And Rehab | 30 mi | — | 22 | 0 |
| Yates Operator, Llc | 30.3 mi | — | 0 | 0 |
| Lakepoint El Dorado, Llc | 31.2 mi | — | 0 | 0 |
| Lakepoint Augusta, Llc | 38 mi | — | 0 | 0 |
| Chase County Care And Rehab | 39.3 mi | — | 19 | 0 |
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