Goldwater Care Marseilles

Inspectors wroteBased on interview and record review the facility failed to use two staff members when assisting a resident with bed mobility/daily care. This failure resulted in the resident falling off the side of the bed, elevated to high position, landing on the floor and sustaining a left hip fracture on 5/29/26. This applies to 1 of 3 residents (R4) reviewed for accidents/falls in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered as ordered by the physician. This applies to 1 of 3 residents (R6) reviewed for medication administration in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was served the correct consistency diet. This applies to 1 of 3 residents (R3) reviewed for choking in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to identify a pressure injury on a resident's left heel until it was a stage 3. This failure resulted in R5 being found with an open area with devitalized tissue on her left heel on 4/18/26. The facility also failed to complete accurate weekly wound assessments for residents with pressure injuries. This applies to 2 of 2 residents (R5, R6) reviewed for pressure injuries in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their menu was followed. This failure has the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure there was sufficient nursing staff to meet the resident needs and ensure resident safety. This applies to 4 of 4 (R3, R5, R6 and R2) residents reviewed for staffing in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms had doors which close without obstruction in order to provide privacy for 1 of 3 residents (R1) in the sample of 14 reviewed for privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete accurate weekly assessments of a resident's venous stasis wound. The facility also failed to ensure that a resident's breast biopsy procedure was scheduled and failed to ensure transportation for a dermatology appointment was arranged for a resident. This applies to 3 of 14 residents (R6, R2 and R3) reviewed for necessary care and services in the sample of 14.

Inspectors wroteBased on interview and record review the facility failed to transfer a resident using a mechanical lift in a safe manner for 1 of 3 residents (R2) reviewed for safety in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure meal preferences and allergies were accommodated for 2 of 3 residents (R1 and R9) reviewed for resident food preferences and allergies in the sample of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's dressing to a surgical wound with a history of infections was changed per physician's orders. This applies to 1 of 3 residents (R2) reviewed for wound care in the sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to protect it's residents from misappropriation. This applies to three of three residents (R1, R3, R4) in the sample of nine reviewed for trust funds.

Inspectors wroteBased on interview and record review the facility failed to update a resident's physician regarding a change in resident's pressure injury to 1 of 3 residents (R2) reviewed for pressure injury in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to carry out treatment orders for an antibiotic ointment and failed to promptly notify a physician after the deterioration of a non pressure wound. These failures contributed to a delay in R1 missing 9 days of an antibiotic ointment and a delay in a physician assessing R1's left heel arterial ulcer. This applies to 1 of 3 residents reviewed for quality of care in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident (R5) with a metastatic brain neoplasm and prevent an injury for one (R2) of two residents reviewed for accidents in a sample of five. This deficiency resulted in R2 going to the hospital, sustaining a fracture to his right knee, and ongoing pain requiring pain medication.

Inspectors wroteBased on observation, interview and record review, facility staff failed to operate the facility van, with a resident aboard, in a safe manner to prevent an accident, for one of three residents (R1), reviewed for accidents. This failure resulted in R1 sustaining a nondisplaced fracture of the left patella, unspecified fracture.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident (R1) from sexual abuse by (R2). This applies to 1 of 3 residents reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to report potential allegations of theft to the Abuse Coordinator and local law enforcement for 12 (R1 through R10 and R12 through R13) of 12 residents reviewed for misappropriation of resident property in the sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered per the physician's order and facility policy for two (R1 and R5) of nine residents reviewed during medication administration and two (R2 and R4) of four residents reviewed for medications in a sample of five.

Inspectors wroteBased on interview and record review the facility failed to transcribe and administer medication per physician order for one of three residents (R1) reviewed for medications in a sample of three.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff knocked prior to entry to a resident room for one resident (R40) and failed to ensure call lights were responded to in a timely manner for four (R5, R34, R45, R48) of 16 residents reviewed for call light timeliness in a sample of 31. Findings Include: Facility's Resident Rights Policy dated 8/23/17 documents: Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. Facility's Residents' Rights for People in Long Term Care Facilities, Ombudsman Program revised 11/2018, documents: Your rights to dignity and respect; your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff report a resident's change of condition to a medical doctor for one resident (R54-who was having chest pain) of 19 residents reviewed for medical doctor notification in a total sample 31.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop a hand brace care plan for one resident (R20) of 19 residents reviewed for Care Plan in a sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living for two (R73 and R12) of two residents reviewed for activities of daily living in the sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing was changed and dated weekly and ensure cylinder oxygen tanks were stored securely for one (R21) of one resident reviewed for oxygen use in the sample of 31.

Inspectors wroteBased on observation, record review and interview, the facility failed to assure medications were not left at the bedside for one resident (R43) out of 27 residents reviewed for medication administration pass in a sample of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a physician order for change in resident condition for one (R2) of five residents reviewed for change in condition in the sample of six. These failures resulted in the delay of treatment for R2 resulting in continued decline for R2 and R2 being admitted to the local hospital's intensive care unit with multiple comorbidities.

Inspectors wroteBased on observation, interview and record review the facility failed to follow facility dialysis policy and procedures for the care and monitoring of six (R1, R2, R3, R4, R5, and R6) of six residents reviewed for dialysis in the sample of six.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of resident to resident physical contact as potential abuse to the Administrator/Abuse Coordinator for one (R4) resident reviewed for abuse in a sample of five.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise one resident (R7) who requires supervision during meals of three residents reviewed for supervision during meals in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to provide showers to a resident dependent on assistance with showering for one of three residents (R1) reviewed for ADLs (Activities of Daily Living) in the sample of four.

Inspectors wroteBased on interview and record review, the facility failed to immediately have an experienced pest control service address a report of suspected bed bugs in the facility. This failure has the potential to affect all 75 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor oxygen saturation levels according to physician orders and failed to ensure oxygen delivery equipment was properly set up to deliver humidified oxygen for three residents (R1, R2, R3) of three residents reviewed for oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to maintain sufficient working hot water heaters to produce hot water to three of the four facility showers in order to meet the needs of the resident showers for three residents (R2, R4, R5) out of four residents reviewed for showers in a sample of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident call device was within reach for one (R1) resident reviewed for accessibility to call light system; and failed to transport residents in a timely manner from dialysis to their rooms for two (R1 and R2) residents reviewed for transport, in a sample of six.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and assistance for two of six residents (R68 and R23) reviewed for falls in a sample of 29. This failure resulted in R68 being sent to the hospital for pain and a fractured femur requiring surgery.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the doctor, implement/develop non-pharmacological pain techniques, and administer prescribed pain medication per order for one (R10) of one reviewed for pain in a sample of 29. These failures resulted in R10 having an increase in pain to where he was unable to get out of bed, and was transferred to the hospital for pain control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were wearing name (identification) tags and were treating residents with respect. This has the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident call devices were responded to in a timely and polite manner for two (R39 and R20) of 18 residents reviewed for call devices in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident prior to allowing the resident to self-administer medication for one resident (R7) out of eight residents reviewed for medication in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to allow a resident to choose when to get out of bed for one resident (R20) out of 18 residents reviewed for choices in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for a two residents (R19 and R71) out of 18 residents reviewed for care plans in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident Care Plans were revised for two (R39 and R70) of 18 residents reviewed for Care Plans in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide showers per facility policy for one (R27) of two residents reviewed for Activities of Daily Living in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to have an order for hospice for one (R14) of one residents reviewed for hospice in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change gloves and perform hand hygiene during incontinence care for one (R39) of one residents reviewed for incontinence in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to label IV (intravenous) tubing and medication solution with a start date and time and failed administer medications as ordered by the physician for one resident (R71) out of eight residents reviewed for medication administration in sample or 29.

Inspectors wroteBased on interview and record review, the facility failed to act on a pharmacists medication regimen review for one (R14) of five residents reviewed for pharmacist Medication Regimen Review (MRR) in a sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete psychotropic assessments, failed to complete the required Abnormal Involuntary Movement Scales (AIMS), failed to complete consents, failed to identify an appropriate indication for use, failed to identify and monitor specific target behaviors, and failed to attempt gradual dose reductions, to warrant the use of psychotropic medications for two (R68 and R229) of four residents reviewed for psychotropic medications in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to obtain and have on hand a pain medication (Hydrocodone) for one (R10) of one residents reviewed for pain medication in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident/resident representative and the Long Term Care Ombudsman of the reason for transfer in writing for four (R8, R19, R68, R70) of seven residents reviewed for emergency hospital transfer in a sample of 29.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for five ( R8, R19, R68, R70, R77) of seven residents reviewed for emergent transfer in the sample of 29.

Inspectors wroteNoncompliance resulted in two deficient practice statements: A. Based on observation, interview, and record review, the facility failed to monitor the placement and function of personal alarm bracelets for four of five residents (R33, R57, R69, R176) and failed to ensure appropriate interventions were implemented for a resident assessed as high risk for wandering, provide supervision when a daily wandering, cognitively impaired resident exited the building, failed to ensure that the South East exit door's alarm was enabled and in working condition, failed to recognize the incident of elopement as an elopement and failed to report the elopement occurrence to State Agency, for one of five residents (R43), reviewed for elopement, in a sample of 36. These failures resulted in R43 not being adequately supervised and exiting from the facility on 2/17/22 around 2:00 P.M. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to answer call lights in a timely manner for two residents (R26 and R125) of 18 reviewed for call lights in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to test water temperatures regularly thus failing to ensure hot water temperature for resident showers/bathing for two (R8 and R53) of two residents reviewed for Activities of Daily Living/ADLs in a sample of 36.

Inspectors wroteBased on interview and record review the facility failed to include psychotropic medication monitoring on a resident Care Plan for one resident (R33) of 20 residents reviewed for Care Plans in a sample of 36.

Inspectors wroteF684 Based on observation, interview and record review, facility staff failed to failed to ensure policies and procedures regarding hand hygiene were followed during wound care, for one of one residents (R29), reviewed for skin treatments, in a sample of 36. The facility policy, Hand Hygiene/Handwashing, dated (revised) 1/5/22 directs staff, Hand hygiene means cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub. Perform hand hygiene after glove removal. R29's current Physician Order Sheet, dated April 2022 documents the following diagnoses: Type 2 Diabetes Mellitus, Cellulitis of Left Lower Limb. This same document includes the following physician orders: [...]

Inspectors wroteBased on interview and record review the facility failed to provide rationale for continued use of as needed (PRN) psychotropic medications for one (R33) of eight residents reviewed for psychotropic medications in a sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to limit as needed (PRN) psychotropic medication orders to 14 days and failed to document a medical indication and consistent behaviors that warrant the use of antipsychotic medications for three of eight residents (R11, R33, and R46) reviewed for psychotropic medications in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to code the use of a personal alarm on a Resident Assessment for one resident (R33) of 20 residents reviewed for Resident Assessment in a sample of 36.