Goldwater Care Bloomington

Inspectors wroteBased on interview and record review, the facility failed to report a fall with injury to the state agency for one (R4) of three residents reviewed for falls in a sample list of six.

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services in accordance with physician orders for ordered daily weights, failed to implement and document ordered blood glucose monitoring and diabetic management, and failed to assess, monitor, and provide ordered wound care following hospitalization and/or fall-related injuries for four (R10, R12, R80, R88) of four residents reviewed for post-hospitalization on a sample list of 39 residents.

Inspectors wroteA. Based on observation, interview, and record review the facility failed to provide proper transport and privacy while transporting a resident to the shower room for one resident (R5) of four residents reviewed for quality of care in a sample of 16. B. Based on observation, interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for three residents (R7, R8, and R14) of four residents reviewed for quality of care in a sample of 16. Findings Include: A. On 04/06/26 at 09:50AM V3, Certified Nursing Assistant (CNA), was observed transporting R5 from the shower room to R5's room using a shower chair with R5 wrapped in a top sheet. During the transport R5 was heard exclaiming to V3 I am cold, slow down V3 responded by saying I am going slow, R5 then stated No you're not, you always go to fast. I am cold. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered and central line dressings were changed according to physician orders for two (R4 and R6) of three residents reviewed for quality of care, in a total sample of 16. Findings Include: 1. R4's Medical Record documents R4 discharged from the facility on 3/7/26. R4's Medication Administration Record dated 2/13/2026 printed on 4/7/2026 documents Vancomycin HCI-Sodium Chloride (antibiotic) 200 milliliters (ml) intravenously every 48 hours at 9:30 AM related to subacute osteomyelitis, left ankle and foot per physician's order. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to maintain the resident hallways and resident common seating area carpet, in a clean, sanitary, odor free condition. This failure affects all 76 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to assist one (R1) resident while eating causing R1 to spill hot coffee on her left hip and left thigh out of three residents reviewed for Accidents in a sample list of three residents. R1 obtained four separate blisters which required treatment from a Wound Physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a fall by failing to ensure fall precautions were in place and failed to minimize the risk of injury from a fall by failing to ensure interventions to reduce the risk of injury were in place. The facility also failed to ensure fall precautions and interventions were in place after a fall with injury for one (R1) of three residents reviewed for falls on the sample list of four. This immediate jeopardy began on [DATE] at 8:00 PM when this failure resulted in R1 having a high impact fall on [DATE] from an elevated bed onto the floor. This fall resulted in R1 sustaining a right leg fracture with shattered and displaced bone fragments. This fall contributed to R1's death five days later [DATE]. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 10:23 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely medical treatment for one (R4) of three residents reviewed for change in condition on a sample list of 6. This failure resulted in R4 having an acute ischemic stroke resulting in receptive aphasia. The facility's Physician-Family Notification-Change in Condition Policy dated 11/13/2018 documents that the facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: B) a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). [...]

Inspectors wroteBased on interview and record review the facility failed to conduct a comprehensive pain assessment after a fall with injury, failed to administer as needed pain medications as ordered by the physician when signs of symptoms of excruciating pain were present, and failed to notify the family and physician when a change in the level of pain was identified for one (R1) of three residents reviewed for pain on a sample size of four. This failure resulted in R1 suffering excruciating pain in which R1 was observed with facial grimacing, yelling and screaming for four days after sustaining a right leg fracture. R1's Progress Note dated [DATE] documents that on [DATE] at 8:00 p.m., R1 was found on floor next to bed on his back after V13, Certified Nursing Assistant (CNA) heard his screams while V13 was in another resident room. [...]

Inspectors wroteBased on interview and record review the facility failed to employ a registered nurse, eight hours a day, seven days a week. This failure has the potential to affect all 88 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to assess, monitor, implement careplan interventions, obtain treatment orders and failed to prevent cross contamination during wound care for one (R63) resident's facility acquired Left Heel Pressure Ulcer. This failure resulted in R63's Left Heel Pressure Ulcer deteriorating leading to surgical debridement and infection requiring two antibiotic therapies.

Inspectors wroteBased on interview and record review the facility failed to provide timely call light response for six (R7, R11, R22, R26, R35, R226) of nine residents reviewed for call light response times in the sample list of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure four residents (R19, R65, R24, R226) had physician orders for medications which were in residents rooms out of four residents reviewed for qualified persons in a sample of 41 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for four (R66, R28, R33, R49) of four residents reviewed for infection control in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed for self-administration of medication. This failure affects two (R24 and R36) of two residents reviewed for self-administration of medication on the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms were equipped with call lights and failed to provide an appropriate call light for three (R7, R11, R66) of three residents reviewed for accommodations of needs in the sample list of 41.

Inspectors wroteBased on interview and record review the facility failed to complete a discharge summary for one resident (R75) out of one resident reviewed for discharge in a sample list of 41 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to address a decline in walking and transfer ability for one (R42) of 24 residents in the sample of 41.

Inspectors wroteBased on interview and record review the facility failed to provide showers as scheduled for one (R35) of two residents reviewed for showers in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and implement activities of interest for one (R42) of 24 residents reviewed for activities in the sample list of 41.

Inspectors wroteBased on interview and record review the facility failed to provide supervision to prevent falls and thoroughly investigate falls for one (R42) of one resident reviewed for falls in the sample list of 41.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care and urinary catheter care, failed to have physician's orders for catheters and catheter care, and failed to provide appropriate catheter care for three (R66, R28, R63) of four residents reviewed for urinary care in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess pain for one (R66) of two residents reviewed for pain in the sample list of 41.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of the deterioration of a wound and failed to provide wound care as ordered by the physician for one (R1) of three residents reviewed for wounds on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to have an operational Legionella water management plan. This failure has the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure water temperatures were at comfortable levels. This failure has the potential to affect all 72 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide showers/bathing assistance for two of six residents (R8, R9) reviewed for showers in the sample list of 11 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide fingernail care for one (R1) of five residents reviewed for hygiene in the sample list of five.

Inspectors wroteBased on observation, interview and record review the facility failed to have physician orders for urinary catheters and document and report changes in urinary condition for two (R1, R5) of three residents reviewed for urinary catheters in the sample list of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to have physician orders and care plans for oxygen, and monitor oxygen saturation levels for three (R1, R2, R4) of three residents reviewed for oxygen in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to provide timely toileting for one (R4) resident resulting in an incontinence episode out of four residents reviewed for timeliness of cares in a sample list of four residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions for a resident with a known history of falling, complete thorough fall investigations, complete accurate fall risk assessments and obtain complete neurological checks for residents with head injury post fall. These multiple failures affect two (R1, R2) residents reviewed for accidents on a sample list of three residents. Findings Include: 1. R2's Facility Census documents R2 was admitted to the facility on [DATE] and includes the following medical diagnoses; Cerebellar Stroke Syndrome, Aphasia, Asthma, Lack of Coordination, Abnormal Posture, Repeated Falls, Need for Assistance with Personal Care, Ataxic and Abnormalities of Gait and Mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to a resident requesting to be put to bed in a timely manner. This failure affected one (R1) out of three residents reviewed for falls in a sample list of six residents, resulting in R1 falling and sustaining a left rib fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure narcotic pain medication was obtained to be given as ordered resulting in R5 experiencing uncontrolled pain for 24 hours. The facility also failed to timely administer requested pain pain medication for one (R5) of five residents reviewed for medications in the sample list of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff nurses and Certified Nursing Assistants for 10 (R1, R2, R3, R4, R5, R6, R7, R9, R10, R11) of 11 residents reviewed for staffing in the sample list of 11. This failure has the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a severely cognitively impaired resident (R6) did not exit the facility unnoticed (elopement). The facility failed to ensure staff were trained on exit door alarms and identifying residents at risk for elopement, supervise R6, assess elopement/wandering risk, develop and implement a care plan and interventions for wandering/exit seeking behaviors, identify triggers for exit seeking behaviors, and monitor departure alert device placement for three (R6, R7, R8) of three residents reviewed for elopement in the sample list of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered timely as ordered resulting in repeated significant medication errors for two (R2, and R5) of five residents reviewed for medications in the sample list of 11.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's Power of Attorney (POA) of a fall with injury for one of three residents (R1) reviewed for notifications on the sample list of three.

Inspectors wroteBased on interview and record review the facility failed to implement fall prevention interventions and complete a thorough fall investigation for one (R1) resident out of three residents reviewed for falls in a sample list of three residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and maintain caustic cleaning chemicals in a manner to prevent access by an ambulatory resident diagnosed with dementia. This failure has the potential to affect one resident (R1) out of five reviewed for safety on the sample of five.

Inspectors wroteBased on interview and record review the facility failed to notify a resident and resident representative in writing of an involuntary facility-initiated discharge. This failure affects one of five residents (R1) reviewed for involuntary discharge in a sample list of five residents. Findings Include: The facility's policy Bed Hold and Return to the Facility reviewed 9/16/17 states: Medicaid-eligible residents who are on therapeutic leave or are hospitalized beyond the State's bed-hold policy must be readmitted to the first available bed even if the residents have outstanding Medicaid balances. Once readmitted , however, these residents may be transferred if the facility can demonstrate that non- payment of charges exists and documentation and notice requirements are followed. R1's Care Plan updated 3/7/24 includes the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to allow a hospitalized resident to return to the facility. This failure affects one of five residents (R1) reviewed for involuntary discharge in a sample list of five. Findings Include: R1's Care Plan updated 3/7/24 includes the following diagnoses: Alcoholic Cirrhosis of the Liver, Chronic Atrial Fibrillation, Long Term Use of Anticoagulant, Anemia, Depression, Aseptic Necrosis of Bilateral Femurs, Dysphagia, [NAME] Matter Disease,and Amyotropic Lateral Sclerosis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, but unable to complete Brief Inventory of Mental Status (BIMS). R1's Progress notes from 1/2/24 to 4/2/24 document R1 refused offers to go to the dining room to be fed at least 94 times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance for oral care for one of three residents (R2) reviewed for oral care on the sample of three. Findings Include: R2's March 2024 Medical Diagnoses List documents R2 is diagnosed with Amyotrophic Lateral Sclerosis, Alcoholic Necrosis of Liver, [NAME] Matter Disease, Depression, Anemia, and Difficulty Walking. R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact. R2's Care Plan, dated 1/14/24, documents R2 is at risk for Activities of Daily Living Deficit and requires the assistance of one staff member for oral care. R2's February 2024- 3/6/24 Task Documentation for Oral Care documents eight days with no oral care and multiple days where oral care was only provided once per day. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a wound intervention and complete wound treatments for one of three residents (R2) reviewed for wounds on the sample of three. Findings Include: The facility's Pressure Ulcer Prevention Policy, dated 1/15/18, documents specialty mattresses such as low air loss or alternating pressure may be used as determined clinically appropriate. The facility's Skin Condition Assessment and Monitoring: Pressure and Non-Pressure policy, dated 6/8/18, documents the purpose of the policy is to establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries, and other non-pressure skin conditions and assuring interventions are implemented. The resident's Care Plan will be revised as appropriate to reflect alteration of skin integrity, approaches, and goal for care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide showers to a dependent resident. This failure affected one of three residents (R56) reviewed for showers on the sample list of 31. Findings Include: The facility's Bathing Policy, dated 11/28/12, documents showers must be offered per resident preference at least twice per week and documented in the resident's Electronic Medical Record (EMR) when completed. R56's Medical Diagnoses, dated February 2024, documents R56 is diagnosed with Diabetes, Spinal Stenosis, Asthma, and Arthropathy. R56's Minimum Data Set, dated [DATE], documents R56 is completely cognitively intact and requires substantial maximum assistance for showering. The undated [NAME] Wing Shower Schedule documents R56 is to receive showers on Sundays and Wednesdays. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and monitor weights, failed to complete nutritional assessments, and failed to monitor nutritional status for residents. This failure affects two (R10, R22) of three residents reviewed for body weight in a sample list of 32 residents. These failures resulted in R10 experiencing an unintended unmonitored significant weight loss of over 40 lbs.(pounds) in 3 months, placing R10 at risk for multiple clinical issues and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe handrails. This failure has the potential to affect all 69 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity was maintained by speaking to a resident in a derogatory manner (R29), and failing to provide timely incontinence care and meet resident hygiene needs (R25, R41 and R40). (R25, R29, R41 and R40) are four of four residents reviewed for dignity in the sample of 32.

Inspectors wroteBased on observation, record review, and interview, the facility failed to properly store medications by leaving medication cart unlocked and by leaving medications at the bedside for three (R22, R43 and R56) residents out of three residents reviewed for medication storage in a sample list of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to offer and/or document refusals of Pneumococcal Polysaccharide Vaccination (PPSV) 23 and/or Pneumococcal Conjugate Vaccine (PCV) 13, 15 or 20 to four residents (R25, R41, R43, R48) out of five residents reviewed for immunizations in a sample list of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to invite residents and/or resident representatives to care plan meetings for two of two residents (R22, R48) reviewed for care plans in a sample list of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the Physician and resident/resident representative of changes and monitoring issues with residents weights. This failure affects two (R10, R22) residents out of three residents reviewed for notification of changes in a sample list of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to include a nutritional plan of care in the comprehensive care plan for a resident with significant weight loss for one of three residents (R10) reviewed for care plans in a sample list of 32 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a recapitulation of stay post discharge for one of (R79) of two residents reviewed for discharge summaries in a sample list of 32 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide timely showers for one (R22) resident out of three residents reviewed for bathing in a sample list of 32 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a dressing to a stage four pressure sore for one of three residents (R29) reviewed for pressure sores in a sample list of 32 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe mechanical lift transfers, failed to thoroughly investigate mechanical lift transfer incidents, and failed to implement fall interventions for three of six residents (R45, R51, and R48) reviewed for accident/falls on the sample list of 32.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents indwelling urinary catheter tubing was secured to prevent pain or discomfort. This failure affects two (R43, R29) residents out of three residents reviewed for incontinence care in a sample list of 32 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen humidifier bottle once depleted, and change oxygen nasal cannula, oxygen tubing, and humidifier bottle according to physician order and facility policy. This failure affected one of one resident ( R29) reviewed for respiratory on the sample list of 32.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete hand hygiene during incontinence care for one (R41) out of four residents reviewed for Infection Control in a sample list of 32 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to address a residents malfunctioning call light. This failure affects one (R64) out of two residents reviewed for call lights in a sample list of 32 residents.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to assess a resident with previous medical history of Respiratory illness and hospitalizations who was in acute respiratory distress, and failed to notify the Physician timely of a change in respiratory condition for a resident. These failures resulted in R17 experiencing respiratory distress for a period of 15 hours, with a low oxygen level, and yelling out to staff of being unable to breathe before R17 was transferred to a local hospital in respiratory distress. This failure affects one (R17) of three residents reviewed for a change in condition. R17 experienced respiratory distress for a period of 15 hours, with a low oxygen level and yelling out to staff being unable to breathe. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents right to be free from mental, verbal, and physical abuse by other residents. This failure affects six of six residents (R8, R19, R20, R23, R18 and R19) reviewed for abuse in a sample list of 23 residents. Ths failure resulted in R18 verbally and mentally abusing R8, and R8 experiencing fear and tearfulness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to prevent worsening of a residents (R3) pressure ulcer. The facility also failed to assess, monitor, and follow physician orders for resident's wounds. These failures affect two (R3, R14) out of four residents reviewed for Pressure Ulcers in a sample list of 23 residents. These failures resulted in a deterioration R3's Stage IV Sacral Pressure Ulcer with grey tissue, foul odor and substantial amount of drainage from the wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to a residents call light in a timely manner; failed to thoroughly investigate and provide increased supervision to prevent a residents fall; failed to complete fall risk assessments and implement fall interventions; failed to timely report a fall with head injury to the physician; failed to complete post fall assessments; and failed to complete post fall neurological assessments for a resident. These failures affects three (R3, R7, R21) out of four residents reviewed for falls in a sample list of 23 residents, resulting in R3 falling and sustaining a femur fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident after an allegation of resident to resident abuse, failed to thoroughly investigate abuse allegations, and failed to maintain thorough documentation of abuse allegations for six residents (R8, R9, R18, R19, R20, R23) out of six residents reviewed for abuse in a sample list of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to document/monitor/track resident behaviors, report behaviors to the physician, and develop/implement behavioral care plans. This failure affects five (R9, R20, R22, R23, R18) of six residents reviewed for abuse in the sample list of 23.

Inspectors wroteBased on interview and record review, the facility failed to timely report allegations of abuse to the State Survey Agency and Administrator for three (R20, R9, R23) of six residents reviewed for abuse in the sample list of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide weekly showers for two (R3, R4) residents out of eight residents reviewed for Activities of Daily Living in a sample list of 23 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care and/or urinary catheter care for three residents (R3, R5, R19) out of three residents reviewed for incontinence care in a sample list of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide timely Physician visits for two (R7, R20) residents out of four residents reviewed for Physician Visits in a sample list of 23 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination during wound care of Pressure Ulcers for two (R3, R14) residents out of three residents reviewed for Infection Control in a sample list of 23 residents.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents (R2, R3) rights to be free from verbal and physical abuse from a staff member for two (R2, R3) residents out of three residents reviewed for abuse in a sample list of five residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse prevention policy by failing to report allegations of staff to resident verbal and physical abuse to the Abuse Coordinator. This failure affects two (R2, R3) of three residents reviewed for abuse in a sample list of five residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement IDT (Inter-Disciplinary Team) and fall care planned fall interventions, failed to update the fall care plan after a fall, and failed to ensure a call light and personal belongings were within reach for one of three residents (R1) reviewed for falls with injury in the sample of three. These findings resulted in R1 falling face forward out of her wheelchair, resulting in R1 experiencing increased pain and fracturing her left femur which required surgical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to deliver meals to residents in a timely manner and at a palatable temperature. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change and label oxygen tubing and humidification bottles (R9, R2, R35, R38), failed to clean CPAP (Continuous Positive Airway Pressure) mask, tubing, and humidifier (R275), and failed to obtain physician orders for changing oxygen tubing, changing humidification bottles and cleaning of the CPAP mask, tubing and humidifier for five of five residents (R275, R9, R2, R35, R38) reviewed for oxygen in the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to complete Quarterly Psychotropic Medication Assessments for four of six residents (R8, R28, R36, R44) reviewed for Psychotropic Medications on the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent to increase the dosage of a prescribed psychotropic anti-anxiety medication for one of six residents (R8) reviewed for psychotropic medications on the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to initiate a Care Plan including resident centered interventions for three residents (R28, R36, R2) of 21 residents reviewed for Care Plans in a sample list of 40 residents. Findings Include: 1. R28's progress notes, printed [DATE], includes the following diagnoses: Dementia, Psychotic Disturbance, and Anxiety. R28's Care Plan, with a review date of [DATE], documents R28 experiences wandering and delusions, in which R28 believes R28's deceased (spouse) is coming to get R28 and their children. There are no Dementia specific resident centered interventions included in R28's Care plan to address R28's Dementia care. 2. R36's electronic medical record documents a current Physician's Order, dated [DATE], Please call Hospice with any concerns regarding (R28) including change of condition, falls, and death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program for group activities in order to support psychosocial well-being for one of one resident (R61) reviewed for Activities on the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to identify the root cause for a fall or initiate resident centered interventions to prevent a fall for one resident (R28) of five residents reviewed for accidents in a sample list of 40 residents. Findings Include: R28's progress notes, printed 1/28/23, includes the following diagnoses: Diabetes with Neuropathy, Chronic Obstructive Pulmonary Disease, Macular Degeneration, Congestive Heart Failure, Difficulty Walking, Muscle Atrophy, Weakness, History of Falling, Dementia, Psychotic Disturbance, and Anxiety. R28's Care Plan includes a problem, initiated 3/1/22, documenting, (R28) is at risk for falling due to dementia; macular degeneration; and weakness. R28's Minimum Data Set (MDS), dated [DATE], documents R28 requires extensive assistance of two or more staff to transfer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for one of three residents (R18) reviewed for medication administration in the sample list of 40. The facility had 2 medication errors out of 32 opportunities resulting in a 6.25% medication error rate.

Inspectors wroteBased on observation and interview, the facility failed to maintain visual control of medications, and failed to prepare only one residents medication at a time for two of two residents (R21, R61) reviewed for medication storage in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe appropriate Contact Droplet Precautions for one known COVID (Human Coronavirus) positive resident. In addition, the facility failed to utilize staff Personal Protective Equipment correctly during one observation. This failure affects one (R43) of five residents reviewed for COVID in a sample list of 40 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide full visual privacy for one of 20 residents (R32) reviewed for privacy in the sample list of 40.