Goldwater Care Danville

Inspectors wroteBased on interview and record review, the facility failed to ensure staff used two-person assistance during mechanical lift transfer and failed to inspect mechanical lift slings prior to each use in accordance with facility policy and manufacturer recommendations for one (R1) of three residents reviewed for accidents on a sample list of eight. These failures resulted in R1 falling from a mechanical lift while suspended in the air and sustaining a comminuted, displaced and impacted proximal left humeral fracture (shoulder), and a small subgaleal hematoma (pocket of blood between skull bone and scalp skin). This past non-compliance occurred from 7/1/26 to 7/2/26.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services. This failure has the potential to affect all 72 residents within the facility. The Long Term Care Facility Application for Medicare and Medicaid dated 6/7/26 documents 72 total residents within the facility. On 6/7/26 at 1:15PM, V1 Administrator, stated they do not currently have a dietary manager. V1 stated that a new dietary manager will start 6/8/26. V1 stated they do not have a full time in house dietician. The registered dietician visits once a month. On 6/8/26 at 9:15AM, V1 Administrator, stated that the hired dietary manager did not complete the on boarding paperwork so they can not start until that is completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store food and equipment under sanitary conditions in accordance with professional standards for food service safety. This failure has the potential to affect all 72 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to hold quarterly Quality Assurance Performance Improvement (QAPI) meetings with all required members. 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 assess for the ability to self-administer medications and failed to have physician orders to self-administer medications for three of three residents (R7, R21, R70) reviewed for self-administration of medications in the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements for trust fund accounts for three of three residents (R4, R6, R83) reviewed for personal funds in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) for four (R6, R7, R8, R30) of 18 residents reviewed for ADLs in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe hot water temperatures for 11 of 18 residents (R4, R6, R7, R18, R28, R35, R49, R51, R58, R63, R68) reviewed for accident hazards in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an oxygen concentrator was unobstructed and easily accessible, provide oxygen as ordered, and appropriately store, label and change oxygen tubing/humidification, nebulizer tubing, and Continuous Positive Airway Pressure equipment for four of four residents (R7, R9, R24, R47) reviewed for respiratory care in the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin as ordered resulting in repeated significant medication errors for one of two residents (R63) reviewed for insulin in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered and stored in accordance with professional standards of practice for 3 residents (R22, R44, and R59) reviewed from a sample of 40 residents and during medication storage observations. On [DATE] at approximately 11:09 AM, V13, Licensed Practical Nurse (LPN), administered medications to R59. V13 placed a cup containing R59's prepared medications on R59's bedside table and exited the room prior to observing R59 consume the medications. On [DATE] at approximately 8:37 AM, V19, Licensed Practical Nurse (LPN), placed a cup containing Miralax on R44's bedside table and exited the room prior to observing R44 consume the medication. At approximately 9:02 AM, V19 stated she should have remained with R44 and observed the resident consume the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at preferable temperature for four residents (R3, R6, R8, R30) reviewed for dining on a sample list of 40. On 6/7/26 at 11:50AM R3 stated the food is cold and does not taste good. The Facility Resident Council Minutes dated 3/30/26 document cold food was reviewed in old news and remained a current complaint with residents. The Facility posted meal times observed outside dining room entrance on 6/7/26 document breakfast at 7:00AM, Lunch at 12:00PM and dinner at 5:00PM. On 6/7/26 between the hours of 12:00PM and 1:30PM, room lunch trays were being delivered on an open rolling rack. Plates sat on a warming element and were covered. A dessert item was contained in a disposable bowl covered with clear wrap. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete hand hygiene during medication administration, wear gloves for medication injections and blood glucose monitoring, change soiled gloves during wound treatment and clean a glucometer after use for four residents (R25, R31, R32, and R59) of four residents reviewed for infection control from a sample of 40 residents. The Facility policy, undated, titled Medication Administration General Guidelines documents that individuals administering medications are responsible for adhering to good hand hygiene practices, including washing hands thoroughly before preparing medications, before and after resident contact, and after contact with potentially contaminated surfaces or equipment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to promote dignity during dining for two of 18 residents reviewed (R83, R15) for dignity in the sample list of 40.

Inspectors wroteBased on interview and record review the facility failed to report low blood glucose levels to the provider for one of five residents (R4) reviewed for unnecessary medications in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications by failing to ensure adequate indication for use of an antipsychotic and failing to attempt gradual dose reductions for two of five residents (R83, R52) reviewed for unnecessary medications in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the resident or resident representative with written notice of bed-hold rights upon transfer to the hospital for one (R14) out of two residents reviewed for hospitalization on a sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to submit a discharge due to death Minimum Data Set (MDS) for one (R55) resident of one resident reviewed for assessment on a sample list of 40. R55's Resident Census Sheet dated [DATE] documents R55 admitted to the facility on [DATE] and with a deceased date of [DATE]. R55's Minimum Data Set (MDS) admission Submission List dated [DATE] documents an MDS entry submission completed [DATE], and admission MDS completed [DATE] and a Medicare 5 day MDS completed on [DATE]. This list does not document an MDS submission completed for death in facility or discharge. On [DATE] at 1:58PM V26 [NAME] President of Operations confirmed an MDS should have been completed at the time of R55's death or discharge from the facility. The Facility Assessment of Resident Policy dated [DATE] documents assessments are to be completed within 14 days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for and offer adaptive communication devices or alternative communication methods for one of one resident reviewed (R3) for impaired communication and a weak voice in the sample size of 40.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to follow its bowel monitoring protocol and failed to assess, monitor, and report changes in condition to the physician for one resident (R49) reviewed for constipation in the sample list of 40. B. Based on observation, interview and record review, the facility failed to implement physician's orders for fluid restriction for one of 18 residents (R7) reviewed for physician's orders in the sample list of 40.

Inspectors wroteBased on interview and record review, the facility failed to follow colostomy orders for one resident (R25) out of one reviewed for colostomy care on a sample list of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received tube feeding formula and water flushes as ordered by the physician and dietitian for one of one resident (R3) reviewed for enteral feeding in the sample list of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to enter an order for fluid restrictions for one (R53) out of one residents reviewed for dialysis on a sample list of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were available as ordered, update pharmacy interchanges and accurately record medication administration for two of 18 residents (R63, R25) reviewed for physician's orders in the sample list of 40.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on interview and record review the facility failed to implement diabetic care and follow physician's orders for two of three residents (R1, R3) reviewed for diabetic care in the sample list of four. This failure resulted in R3 being admitted to the intensive care unit for treatment of Diabetic Ketoacidosis. B. Based on observation, interview, and record review the facility failed to timely notify family and physician of a change in condition for one of three residents (R1) reviewed for falls in the sample list of four. This failure resulted in R1 experiencing a delay in treatment of compression fracture following a fall causing R1 increased pain and tearfulness. C. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and care plan fall interventions, accurately complete fall risk assessments, and thoroughly investigate falls for three of three residents (R1, R2, R4) reviewed for falls in the sample list of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders which resulted in repeated significant medication errors for one of three residents (R2) reviewed for medication errors in the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to ensure the security and proper accounting of a controlled substance (Ativan) for R1. This failure affected one of three residents (R1) reviewed for abuse in the sample of three. This past non-compliance occurred from 8/30/25 to 11/24/25. Findings Include:R1's Facility census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Hospice, Hemiplegia and Hemiparesis, Type 2 Diabetes, COPD, Chronic Respiratory Failure with Hypoxia, Cerebrovascular Disease, Major Depressive Disorder, Obstructive and Reflux Uropathy, Retention of Urine, Obesity, Presence of Urogenital Implants, Delusional Disorders, Presence of Cardiac Pacemaker, Mood [Affective] Disorder, Vascular Dementia, HTN, GERD, Heart Disease, Chronic Kidney Disease Stage 3 and Anxiety Disorder. [...]

Inspectors wroteA partial extended survey was conducted. Failures at this level require two separate deficient practice statements. A. Based on observation, interview and record review the facility failed to reposition a resident timely, prevent cross contamination during wound care, provide the correct wound treatment, complete skin assessments timely, update a resident's care plan with pressure sore interventions, provide wound supplements, obtain ordered laboratory tests timely, and implement care plan interventions for pressure sore care and prevention for one (R4) resident of five residents reviewed for pressure sores. These failures resulted in R4 obtaining 18 separate facility acquired Pressure Sores from January 2025 through September 2025. R4 currently has five facility acquired Stage 4 Pressure Sores and two facility acquired Stage 2 Pressure Sores. The immediate jeopardy began on 8/19/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects all 83 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate of less than 5%. A full medication administration observation was completed with three errors out of 28 opportunities resulting in a 10.7% medication error rate. This failure affects one (R11) resident out of seven residents reviewed for medication administration in a sample list of 14 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain Contact Isolation Precautions for one (R4) resident out of four residents reviewed for Infection Control in a sample list of 14 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of neglect and injuries of unknown origin to the administrator and state survey agency for three of five residents (R1, R2, R3) reviewed for resident rights in the sample list of five residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician's orders and complete neurological assessments for three of four residents (R2, R4, R5) reviewed for injuries in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to ensure confidentiality/privacy of resident information for one of five residents (R1) reviewed for resident rights in the sample list of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their abuse policy for reporting, investigating, and documenting injuries of unknown source for one of four residents (R3) reviewed for injuries in the sample list of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate injuries of unknown origin for two of four residents (R2, R3) reviewed for injuries in the sample list of five.

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate a fall to identify the root cause and determine appropriate post fall interventions for one of three residents (R4) reviewed for falls in the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate medical record for one of three residents (R4) reviewed for falls in the sample list of five.

Inspectors wrote2. R12's Census Detail and Medical Diagnoses List, both dated 5/28/25, document R12 was admitted to the facility 6/4/24 with medical diagnoses including Parkinson's Disease, History of Falling, Difficulty Walking, Lack of Coordination, and Dementia. R12's Fall Risk Assessments List dated 5/28/25 documents no Fall Risk Assessment completed from 9/22/24 through 3/1/25. R12's Fall Risk Assessment dates corresponded directly with the falls experienced by R12 documented in R12's Nurses Progress Notes and Initial Fall Occurence Notes dated 6/14/24, 6/26/24, 7/5/24, 8/13/24, 9/22/24, 3/1/25, 4/4/25, and 5/20/25. The facility's Fall Prevention Program policy dated 11/21/17, provided by V2, Director of Nursing, documents fall risk assessments will be completed on admission, at least quarterly, after each fall incident, and with any significant change in status. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer a medication according to manufacturer's directions and failed to utilize PRN (as needed) doses for one resident (R1) of three residents reviewed for medications in a sample list of four residents. This failure caused R1 to receive insufficient dose of medication which lead to increasing signs and symptoms of Parkinson's Disease which caused R1 to be fearful and suffer psychosocial harm. Findings Include: R1's Care Plan updated 4/17/25 includes the following diagnoses: Parkinson's Disease without Dyskinesia, Functional Quadraplegia, Chronic Obstructive Pulmonary Disease, Type II Diabetes Dysphagia, and Dysphasia with a gastrostomy tube. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and is dependent on staff to complete Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to verify placement of a gastric feeding tube prior to instilling flush and medications and failed to flush the tube between medications for one resident (R1) of three residents reviewed for medication administration in a sample list of four. Findings Include: The facility's policy Medication Administration -Gastrostomy or Nasogastric Tube reviewed 8/3/20 states Check tube for proper placement: Aspirate to visually verify stomach contents. Gastric fluid normally appears clear or yellow with mucus or may appear milky if residual remains from previous feeding. Aspirated contents must be returned to the stomach to maintain ph (Acid Base Balance), fluid and electrolyte balance. [...]

Inspectors wroteBased on observation, Interview, and record review the facility failed to implement enhanced barrier precautions (EBP) for one resident (R2) of three residents reviewed for EBP in a sample list of three residents.

Inspectors wroteFailures at this level require more that one deficient practice statement. A. Based on observation, interview and record review, the facility failed to follow their Norovirus policy by failing to restrict symptomatic staff from work and handling food, and by failing to implement and follow isolation and contact precautions during a Norovirus outbreak. These failures resulted in R45 contracting Norovirus and subsequently expiring. R45's documented cause of death is listed as Acute Renal Failure related to Viral Gastroenteritis. These failures have the potential to affect all 79 residents who reside in the facility. The Immediate Jeopardy began on 3/19/25 when the facility failed to restrict V20 Dietary Aide from working with gastrointestinal virus symptoms. V1 Administrator was notified of the Immediate Jeopardy on 4/4/25 at 8:15 AM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement nutritional interventions, timely implement dietitian recommendations, care plan for weight loss, and timely notify the dietitian, physician, and resident representative of significant weight loss for three of four (R38, R72, R36) residents reviewed for nutrition in the sample list of 51. These failures resulted in ongoing and significant weight loss for R38 and R36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the licensed staff maintains a current state license. This failure has a potential to affect all 79 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications timely, as ordered, and in accordance with pharmacy instructions resulting in five medication errors out of 25 opportunities, a 20% medication error rate. This failure affects two of five residents (R14, R47) reviewed for medication administration in the sample list of 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to label insulin vials with opened dates, appropriately store medications and destroy discharged resident medications for four of six residents (R187, R186, R47, R82) reviewed for medication storage in the sample list of 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner and environment that promotes resident's independence and dignity while dining for two (R7, R46) of 18 residents reviewed for residents' rights in a sample size of 51.

Inspectors wroteBased on interview and record review the facility failed to develop an individualized care plan that included interventions for end of life care. This failure has the potential to affect one (R76) of one resident reviewed for Hospice on a sample list of 51.

Inspectors wroteBased on interview and record review the facility failed to review and revise a Care Plan in a timely manner for one (R76) of eighteen residents reviewed for advanced directives on the sample list of 51. 04/01/25 01:21 PM, R76's Care Plan dated 1/9/25 documents that R76 is a full code. On 04/01/25 at 12:48 PM, R76's medical record documents that she signed a code status form on 1/3/25 documenting that R76 doesn't want to be resuscitated. On 4/2/25 at 12:45 PM, V9 Care Plan Coordinator stated that social services usually take care of getting a resident's code status form signed and put into the medical record. V9 stated that she noticed today that R76 was a full code on the care plan. V9 stated the code status should have been updated on the care plan as soon as possible after it was signed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oral care for one (R55) of 24 residents reviewed for ADL (Activities of Daily Living) care in a sample list of 51. Findings Include: The facility's policy Oral Hygiene updated 1/1/14 states: Oral care is an essential part of morning and evening care. Note: Some residents may require oral hygiene after each meal due to inability to rinse out food debris. R55's current diagnosis list includes the following diagnoses: Dysphagia following Cerebral Vascular Accident, Seizures, Anxiety, and Dementia with Behaviors. On 1/31/25 at 10:00AM R55 was lying in bed sleeping. R55 was breathing through R55's mouth with her mouth open. A large amount of crusty gray secretions were noted on R55's lips and oral cavity. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to document assessments and obtain treatment orders for newly identified pressure ulcers, develop a care plan for pressure ulcers, develop and implement pressure relieving interventions, and timely implement treatment orders for one of four residents (R38) reviewed for pressure ulcers in the sample list of 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain physician orders for oxygen use and provide hygienic care and storage of nebulizer equipment for two of two residents (R36, R185) reviewed for respiratory care in the sample list of 51.

Inspectors wroteBased on interview and record review the facility failed to periodically assess psychotropic medication use, identify targeted resident behaviors, attempt nonpharmacological interventions, and avoid duplicate therapy for three residents (R4, R26, R64) of five residents reviewed for unnecessary medications in a sample list of 51.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication and antifungal medication to one resident (R1) of three residents reviewed for significant medication errors in the sample list of eight. These failures resulted in R1 experiencing pain and continued symptoms of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use sanitary practice to handle and administer medications to residents. This failure has the potential to affect all 81 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to acquire and administer medications to meet the needs of residents. This failure affects one resident (R1) out of seven reviewed for medications.

Inspectors wroteBased on interview and record review, the facility failed to complete pressure sore treatments for one resident (R2) of one resident reviewed for infection's in the sample list of six. This failure resulted in R2 developing an infection in R2's pressure wound.

Inspectors wroteBased on interview and record review the facility failed to provide timely emergency airway management and suctioning for a resident in respiratory distress during a medical emergency. This failure affected one of three residents (R1) reviewed for emergency airway management and has the potential to affect all 77 residents residing in the facility. This failure resulted in R1's subsequent death. The Immediate Jeopardy began on 9/19/24 when R1 aspirated and could not maintain adequate oxygenation. Staff could not locate the suctioning equipment, made multiple trips in and out of R1's room getting missing equipment, and could not get the suctioning equipment functioning therefore delaying emergency airway management and respiratory treatment for R1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a full time director of nurses to oversee and coordinate nursing services provided within the facility. This failure has the potential to affect all 77 residents residing in the facility. Findings Include: On 11/20/24 and 11/22/24 there was no staff member in the facility designated as the Director of Nursing (DON) or DON present at the facility. On 11/20/24 at 9:00 AM, V1, [NAME] President of Operations, stated, There is no DON (Director of Nursing) right now. The former DON (V24) resigned as of 11/9/24. We did hire a new DON to replace the former one but then the new one decided not to come work at this facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a full time administrator to oversee and ensure applicable regulations are met in facility and ensure for operations and provision of resident services. This failure has the potential to affect all 77 residents residing in the facility. Findings Include: On 11/20/24 at 9:20 AM, V1, [NAME] President of Operations, stated, The administrator (V25) was in a motorcycle accident back in September and we are not sure if she will be coming back to work. We have considered hiring (V2, Human Resources Manager) as the administrator in training. On 11/20/24 and 11/22/24, there was no full time staff member present in the facility Licensed as a Nursing Home Administrator. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a quality improvement review for an adverse event resulting in a resident's (R1) death. This failure has the potential to affect all 77 residents residing in the facility. Findings Include: On 11/22/24 at 10:45 AM, V1, [NAME] President of Operations, stated, This incident was never reported to any of us (corporate staff), or the regional nurses. The first I heard of it was when you (surveyors) came in 2 days ago. V1 further stated, We would have done staff education and all the things we needed to do at that time (9/19/24). On 11/22/24 at 12:45 PM, V1 stated there had been no QAPI/ QA (Quality Assurance Performance Improvement/ Quality Assurance) reviews or risk management reviews conducted as a result of the aspiration incident involving R1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure nursing staff honored a resident's right for their choice of life-sustaining treatment preferences. This failure affected one of three residents (R1) reviewed for Advance Directives on the sample list of three. Findings Include: The Advance Directive Policy dated [DATE] documents the purpose of the policy is to ensure all residents or resident representatives are informed concenring the right to accept or refuse medical treatment and formulate an Advanced Directive. If a resident or health care representative indicates an Advanced Directive regarding Cardio Pulmonary Resucitation or Scope of Treatment (Practitioner Orders for Life-Sustaining Treatment POLST), the appropriate forms will be completed. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure facility nursing staff had the appropriate competencies and skills required to provide residents with potentially life saving nursing services. This failure affected one of three residents (R1) reviewed for Dysphagia and aspiration risk on the sample list of three. Findings Include: The Facility Assessment, last reviewed on February 2024 documents the facility will ensure staff are educated and have competencies in the areas that are necessary to provide the level and type of support and care needed for their resident population. This includes specialized care such as oxygen administration and suctioning. The same assessment documents the facility on average within an typical month has eight residents requiring oxygen respiratory services and one resident requiring suctioning. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a quarterly financial statement to two of three residents (R7 and R8) reviewed for resident funds on the sample list of 10.

Inspectors wroteBased on interview and record review the facility failed to notify a physician/provider of a significant bruise for one of five residents (R2) reviewed for falls/injury of unknown source in the sample list of 10.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain a wheelchair free of sharp edges to prevent injury during a mechanical lift transfer and failed to implement fall interventions to prevent falls for three of five residents (R2, R9 and R10)reviewed for injury of unknown origin/falls on the sample list of 10.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right (R1) to be free from sexual abuse by another resident (R2) by failing to supervise R2, a resident with a known history of behaviors of inappropriate touching towards other residents (R3, R4, R5, R6, R7, R8, R10, R14). R1-R8, R10, and R14 are nine of 14 residents reviewed for abuse in the sample list of 16. These failures resulted in R2 sexually abusing R1 when R2 was left unsupervised. The Immediate Jeopardy began on 5/24/24 when R1 was sexually abused by R2. V1 Administrator was notified of the Immediate Jeopardy on 6/11/24 at 11:21 AM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure staff were trained in the areas identified in its facility assessment. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct ongoing training in effective resident care communications for all staff. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct ongoing training in Resident Rights for all staff. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct ongoing staff training on the facility's Quality Assurance Performance Improvement (QAPI). This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct ongoing staff training on the facility's Infection Control Program. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs), providing care to residents, received 12 hours of annual in-service training . This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to conduct ongoing behavioral health training for staff providing resident care. This failure has the potential to affect all 67 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to maintain residents' complete and accurate medical records. This failure affects five (R1, R2, R3, R6, R7) of five residents reviewed for physician visits in the sample list of 16.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of resident to resident physical abuse to the state survey agency for two (R8, R9) of 14 residents reviewed for abuse in the sample list of 16.

Inspectors wroteBased on interview and record review the facility failed to have an agreement for outside services for behavioral health needs. This failure affects one (R2) of 14 residents reviewed for abuse in the sample list of

Inspectors wroteBased on interview and record review, the facility failed to protect the resident rights to be free from sexual abuse by another resident. This failure affects four residents (R1, R2, R8, R9) reviewed for abuse in the sample of nine. Findings Include: A Facility Reported Incident dated 2/20/24 and corrected with actual date of 4/7/24 documents R1 asking a visitor (V5) to remove R1 from an area (lounge) and take R1 to an activity. R1 reported to the visitor that R1 was afraid of another resident (R2). V5 reported this immediately to V3 (Activity Aide). V3 spoke with R1 privately and R1 told V3 that R2 had been following R1 around and R2 had rubbed R1's chest. It was reported to V1 (Administrator) right away. R1's Diagnoses Sheet (current) includes the following diagnoses: Insomnia, Urine Retention and Congestive Heart Failure. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement fall prevention interventions according to resident's plans of care. This failure affects one resident (R69) out of five reviewed for accidents and falls on the sample list of 50. This failure resulted in R69 experiencing a femur fracture requiring surgical intervention to repair.

Inspectors wroteBased on observation, interview and record review the facility failed to store medications and biologicals in a locked area, failed to maintain proper temperatures of the medication refrigerator, and failed to ensure only Licensed staff have access to medication room keys. These failures have the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a clinically qualified director of food and nutrition services. This failure has the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food storage to protect food quality and potential for cross contamination. These failures have the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure required personnel attended the required quarterly Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 65 residents residing in the facility. Findings Include: The Quality Assurance Performance Improvement (QAPI) Plan dated 9/15/23 documents the facility Quality Assessment & Assurance (QAA) Committee consists of facility leadership including the Infection Preventionist. The QAA committee should meet at least quarterly and will be responsible for developing and implementing appropriate plans of action to correct identified quality deficiencies. On 2/22/24 V1 Administrator provided four Quality Assessment and Assurance (QAA) committee meeting sign-in sheets for the previous year's worth of QAA meetings. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their Infection Prevention and Control Program policy to investigate and report a facility communicable infectious disease outbreak to the local health department/or state agency. This failure has the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed ensure resident rights were maintained by failing to include five residents in their care plan meetings. This failure affected six of six residents (R9, R16, R30, R42, R45 and R60) reviewed for care planning/resident rights on the sample list of 50.

Inspectors wroteBased on observation and interview, the facility failed to protect resident dignity by serving residents seated at the same dining table at different times. This failure affects two residents (R12 and R23) out of 22 reviewed for dining on the sample list of 50.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's medical record to reflect a resident's wishes for life sustaining treatment including cardio-pulmonary resuscitation. This failure affects one resident (R26) out of one reviewed for advanced directives on the sample list of 50.

Inspectors wroteBased on interview and record review the facility failed to recognize and report injuries of unknown origin for one (R41) out of two residents reviewed for injuries of unknown origin in a sample of 50 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and monitor an injured Left Foot for one resident (R9) out of one resident reviewed for skin/injuries in a sample list of 50 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications per physician order for two of five residents (R30, R12) reviewed for medication administration on the sample list of 50 residents. The facility had four medication errors out of 25 opportunities for error resulting in a 16% medication error rate.

Inspectors wroteBased on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one (R9) resident out of two residents reviewed for Antibiotic Stewardship in a sample list of 50 residents.

Inspectors wroteBased on interview and record review, the facility failed to educate residents about the risks and benefits of receiving a pneumonia vaccine and failed to offer the vaccine to residents. This failure affects two residents (R26 and R40) out of five reviewed for immunizations on the sample list of 50.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident's (R1) representative was notified in a timely manner, of retention of urine that required an invasive device insertion to relieve pain from excessive urine retention, and critical laboratory results. This failure affected one of three residents (R1) reviewed for notification of change in condition on the sample list of five.

Inspectors wroteBased on record review and interview, the facility failed to accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding falls. This failure affects one of three residents (R1) reviewed for falls/resident assessments on the sample of five.

Inspectors wroteBased on observation, record review, and interview the facility failed to implement targeted fall intervention for a two resident (R1 and R4) at risk for falls, with a history of falls. R1 and R4 are two of three residents reviewed for falls on the sample list of five.

Inspectors wroteBased on interview and record review the facility failed to maintain a complete and accurate medical record for one of five residents (R4) reviewed for accuracy of medical records on the sample list of five.