Goldwater Care Princeton

Inspectors wroteBased on interview and record review the facility failed to notify the power of attorney for a resident with dementia of an incident for 1 of 3 residents (R3) reviewed for notification in the sample of 5.

Inspectors wroteBased on interview, and record review the facility failed to prevent resident to resident abuse for 2 of 3 residents with dementia (R1 & R2) reviewed for abuse in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dementia care for a resident with dementia and behaviors for 1 of 3 residents (R1) reviewed for dementia care in the sample of 5.

Inspectors wroteBased on observation, interview and record review the Facility failed to staff a full-time Director of Nursing. This failure has the potential to affect all 76 Residents residing in the Facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to assess each resident for risk of entrapment and only use bed rails after trying other alternatives for five of five residents (R4, R5, R9, R46, R64) and explain the risks and benefits to the resident or the resident's representative for one of five residents (R4) in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered as ordered for one of three residents (R4) in a sample 35.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from resident-to-resident physical abuse for two of three residents (R1, R2) reviewed for physical abuse in a sample of three.

Inspectors wroteBased on interview and record review the facility failed to provide snacks at bedtime for all residents. This failure has the potential to affect all facility residents. The facility policy, Snacks, undated, documents Policy: Between meal snacks are available to residents per the planned menu or resident preference. Purpose: Too offer additional nourishment between meals. Procedure: 1. The Food and Nutrition Department will send snacks to the nursing stations at the appropriated times .3. Bedtime snacks will be sent to the nursing station(s) in bulk. These snack items are to be offered to each resident. Per facility policy, acceptance or refusals of snacks are to be documented. The facility's Certified Nursing Assistant (CNA) Job Description documents Essential Duties and Responsibilities: Provide assistance with serving meals and feeding; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement a cleaning procedures and schedule for the kitchen and failed to use appropriate utensils while plating lunch. This has the potential to affect 66 residents residing in the facility.

Inspectors wroteFacility failures resulted in two deficient practices. A.) Based on record review and interviews the facility failed to follow their policy on Water Management Program for Prevention of Legionella Growth, and perform preventative maintenance to stop the growth and spread of Legionella. This has the potential to affect all 66 residents that reside at the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have knowledge of who the Grievance Official is, how to file a Grievance and where the forms are located for four (R11, R22, R54, and R60) of four residents reviewed for Grievances in a sample of 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored and labeled correctly. This failure has the potential to affect all 28 residents (R3, R10, R14-17, R26, R27, R29, R31, R33, R35, R36, R38-R40, R44, R46-R49, R52, R53, R57, R59, R65, R68 and R121) currently residing in the facility Safe Unit.

Inspectors wroteBased on observation, interview and record review the facility failed to provide for personal dignity during a transfer for one (R19) of 17 residents reviewed for dignity in a sample of 49.

Inspectors wroteBased on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R59 and R61) reviewed for PASARR screening, in the sample of 49.

Inspectors wroteBased on interview and record review the facility failed to perform physician ordered daily weights for one of one resident (R19) reviewed for daily weights in a sample of 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to reduce a residents' risk of a fall and safety interventions for transfer for two of five residents (R3, R26) and failed to follow their elopement policy, failed to document the testing of the elopement device and doors and failed to ensure an elopement device was in place for one (R31) of one residents reviewed for elopement in a sample of 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ordered nutritional drink for a resident with weight loss was offered for one (R26) of one resident reviewed for nutrition in a sample of 49.

Inspectors wroteBased on interview and record review, the facility failed to perform an ongoing assessment of the resident's respiratory status for one resident of one resident (R44) reviewed for oxygen therapy, in a sample of 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's dialysis fistula as ordered for one of one residents (R51) reviewed for dialysis, in a sample of 49.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents on Psychotropic medications have supporting diagnoses and identified targeted behaviors with monitoring for three (R26, R33 and R44) of three residents reviewed for Psychotropic medications in a sample of 49.

Inspectors wroteBased on record review and interview the facility failed to conduct a quarterly care plan meeting since admission for one of 6 (R1) residents reviewed for care plans in a sample of 6. Findings Include: The facility policy named, Comprehensive care plan, dated 11/17/2017, documents, The resident and/or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone, or video conference (if available) at least quarterly. R1's Nurses Notes, documents R1 was admitted on [DATE]. R1's Minimum Data Set progress note, dated 5/19/2023, documents, R1's invite to a care plan meeting. On 10/13/2023 at 2:20PM V6/Care Plan Coordinator stated, I have been in this role since March of this year. I did invite V9/R1's daughter to the care plan meeting for R1 on 5/19/2023 for the yearly review. [...]

Inspectors wroteBased on interview and record review the facility failed to administer medications safely for one of three residents reviewed (R3), in a sample of six. This failure resulted in R3 ingesting R2's medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate an allegation of a potential misappropriation of resident property for one (R9) of three residents reviewed for criminal activity in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop interventions to address wandering on resident Care Plans for two (R1 and R2) of three reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete Elopement Risk assessment, failed to include two residents identified as at risk for Elopement in the Elopement Risk Protocol and in the facility's Elopement risk binder for two residents (R1 and R2)

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents were informed regarding the facility Grievance process. This failure has the potential to affect all 66 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review the Facility failed to staff a Certified Dietary Manager. This failure has the potential to affect all 66 Residents residing in the Facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve meals at the scheduled mealtime. This failure has the potential to affect all 66 Residents residing in the facility. The facility also failed to provide bedtime snacks for five residents (R10, R15, R38, R45, R56) of six residents reviewed for bedtime snacks in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain required safe serving/holding food temperatures for Resident meals. This failure has the potential to affect all 66 Residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to promptly act upon recommendations of the resident council group residents and failed to demonstrate the facility response to group recommendations for six residents (R10, R15, R38, R45, R56, R123) in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to revise resident care plans for two of 20 residents (R19 and R59) reviewed for care plans in the sample of 33.

Inspectors wroteBased on observation, interview, and record review the Facility failed to perform hand hygiene and follow a Physician order during skin care for one (R26) of three Residents reviewed for skin care in a sample of 33.