Goldwater Care Roseville

Inspectors wroteBased on observation, interview, and record review the facility failed to successfully develop a plan and implement an accessible call system for all residents once an electronic call system became inoperable. These failures resulted in R1 being admitted from the hospital into a bed without a working call system on [DATE]. R1 was admitted with the diagnoses of Atrial Fibrillation, Repeated Falls, Acute and Chronic Right Heart Failure, Morbid Obesity, Hypertension, and Venous Insufficiency, and on [DATE] R1 was experiencing chest pain for over two hours without access to a working call system or staff response. These failures affect all 40 residents residing within the facility and resulted in R1 experiencing fear, chest pain, and shortness of breath for over two hours without staff intervention and R1 requiring emergency services for the treatment of a new onset of atrial fibrillation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the cooling/heating vent located in the dining room was free of debris, and residents' bathroom walls, cove base, caulking around the toilets, and air conditioner vent were clean, maintained, and in good repair. These failures have the potential to affect all 40 residents who reside within the facility.

Inspectors wroteBased on record review and interview the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to all employees. This failure has the potential to affect all 40 residents residing within the facility.

Inspectors wroteBased on record review and interview the facility failed to provide training regarding the facility's Compliance and Ethics Program to all employees. This failure has the potential to affect all 40 residents residing within the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a functioning nurse call system in resident bathrooms for all facility residents. This failure resulted in four of four residents (R1, R2, R3 and R4) expressing fear and anxiety during toileting in their rooms due to a non-functioning nurse call system.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a functioning bathroom nurse call light system. This failure has the potential to affect all 44 current facility residents.

Inspectors wroteBased on observation, record review and interview the facility failed to assess for the risk of entrapment from side rails for five residents (R3, R8, R11, R31 and R38) of thirteen residents reviewed for siderails in a total sample of 28. Findings Include: The Facility's Side Rails/Bed Rails Policy dated 10/24/22 documents before bed rails are installed, the facility should: Check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible, since most bed rails and mattresses are purchased separately from the bed frame. Rails should be selected and placed to discourage climbing over rails to get in and out of bed, which could lead to falling over bed rails. When installing and using bed rails, the facility should: Ensure that the bed's dimensions are appropriate for the resident; [...]

Inspectors wroteBased on record review and interview the facility failed to obtain a Level Two PASRR (Preadmission Screening and Resident Review) for one resident (R12) of three residents reviewed for PASRR in a total sample of 28. Findings Include: R12's PASRR Level I Form dated 08/01/2023 documents Reason for screening: This nursing facility resident has never had a PASRR Level I screen. R12's PASRR Level I dated 08/01/2023 documents Mental Health Diagnoses: Schizophrenia suspected; Major depression current, Anxiety current. R12's Notice of PASRR Outcome Explanation; Notice of PASRR Level II Onsite Evaluation Required. Your health care professional and (Company) completed a Preadmission Screening and Resident Review (PASRR) Level I screen for you. This screen shows that you need a face-to-face Level II evaluation. PASRR Level I screens, and Level II evaluations are required by Federal law, 42 U.S.C. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a resident for indwelling urinary catheter removal for one of four residents (R45) reviewed for an indwelling urinary catheter in a sample of 28.

Inspectors wroteBased on record review and interview the facility failed to weigh one resident as recommended (R8) of three residents reviewed for weight loss in a total sample of 28. Findings Include: The Facility's Dietary policy dated 10/17/19 documents Residents identified at nutritional risk may be weighed weekly or bi-weekly as per physician order or Interdisciplinary Team recommendation. R12's Medical Record documents R12's weight on 01/09/25 was 237 pounds. R12's Medical Record documents R12's weight on 2/11/25 was 222 pounds. R12's Weight Progress Note dated 2/17/25 documents Dietitian weight review weight 222 pounds (-6.3%) noted in one month. Please change diet to: (due to) weight loss for 1 month resident to have weekly weights (for) four weeks. R12's Medical Record did not have any documentation of any weights after the 2/11/25, 222 pounds weight. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an appropriate indication for use of antipsychotic medications for one of five (R47) residents reviewed for unnecessary medications in a sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate and follow Enhanced Barrier Precautions for one resident of thirteen residents (R26) reviewed for infection control in a sample of 28.

Inspectors wroteBased on interview, observation, and record review the facility failed to report alleged verbal, mental, and physical abuse to the State Agency for one of three residents (R3) reviewed for abuse in the sample of four.

Inspectors wroteBased on interview, and record review, the facility failed to investigate allegations of potential physical, mental, and verbal abuse and ensure the alleged victim was protected from further abuse during the investigation for one of three residents (R3) reviewed for abuse in the sample of four.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff had hair and facial hair fully restrained during food production and clean-up activities. This failure has the potential to affect all 43 residents currently residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to implement Contact Isolation Precautions and Enhanced Barrier Precautions to contain the potential spread of Multi Drug-Resistant Organisms. This failure has the potential to affect all 43 residents currently residing in the facility.

Inspectors wroteBased on Interview and Record Review, the facility failed to provide a minimum of twelve hours of nurse aide training over a twelve month period. This failure has the potential to affect all 43 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) level I re-screening for one of two residents (R4) reviewed for PASARR screening, in the sample of 20. Findings Include: R4's Face sheet documents R4 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder, Depression, and Post-Traumatic Stress Disorder. R4's OBRA-I (Omnibus Budget Reconciliation Act) Initial Screen (dated 01/22/20) documents R4 was evaluated on 01/20/20. This form documents, Screening is valid for 90 days from date of screening. R4's current medical record does not include a PASARR (Preadmission Screening and Resident Review) level I, or any additional screenings. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to update a plan of care for three residents (R4, R32 and R35) of three residents reviewed for care plan accuracy, in a sample of 20. Findings Include: The facility's policy, Comprehensive Care Planning, dated (revised) 7/20/22 directs staff, It is the (facility) policy to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care .The care plan shall be reviewed and revised as necessary to reflect the resident's current medical, nursing and mental and psychological needs as identified. 1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement interventions to reduce a resident's risk of a fall (R32, R41) and failed to provide adequate supervision to prevent falls for resident (R23), for three of three residents reviewed for falls in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an indwelling urinary catheter was secured with a securement device for one of three residents (R33) reviewed for indwelling urinary catheters in the sample of 20. Findings Include: The facility's Catheterizations (Indwelling) Catheter Insertion policy (revised 02/2018) documents: Secure the catheter to the thigh and attach drainage collection unit. R33's current medical record documents R33's diagnoses to include: Neuromuscular Dysfunction of Bladder. On 04/15/24 at 10:30 AM, R33 was reclined in a recliner operating her tablet. R33 stated she currently has an indwelling urinary catheter. R33's indwelling urinary catheter drainage bag was secured to the lower aspect of her wheelchair and was draining clear, yellow urine. On 04/17/24 at 11:30 AM, R33 was lying in bed covered with a blanket. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a dementia plan of care for one of three residents (R32) reviewed for dementia care, in the sample of 20. Findings Include: R32's electronic diagnoses dated 3/6/24, document that R32 has a diagnosis of Alzheimer's Dementia. R32's current Care Plan, dated 2/28/24, has no documentation of a comprehensive care plan addressing R32's diagnosis of Alzheimer's Dementia. On 4/17/24 at 12:56 P.M., V17/Care Plan Coordinator) confirmed there is no dementia plan of care for R32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the physician evaluated and documented the rationale for the continued use of a PRN (as needed) psychotropic medication for one of three residents (R24) in a sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were implemented for laboratory tests for one of one resident (R33) reviewed for Insulin in the sample of 20. Findings Include: R33's current Physician's Orders document the following medication order: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Inject 35 unit subcutaneously two times a day related to Type 2 Diabetes Mellitus without Complications. R33's current Physician's Orders document the following order: Hemoglobin A1C every 3 Months. R33's medical record does not document any Hemoglobin A1C results since her date of admission to the facility (7/12/23). On 04/17/24 11:15 AM, V2 (Director of Nursing) stated a Hemoglobin A1C has not been completed on R33 since she was admitted to the facility, It was missed. We should have been monitoring this.

Inspectors wroteBased on interview and record review, the facility failed to ensure a quarterly statement of the resident's financial record was provided. This failure has the potential to affect all 43 residents currently residing in the facility. Findings Include: The facility's Resident Right Manual, provided to all residents at time of admission, documents the following: Your rights regarding your money. You have the right to manage your own money. The facility must not require you to let them manage your money or be your Social Security representative payee. If you ask the facility to manage your money, it may only spend your money with your permission. It must give you a current, itemized written statement at least once every three months, and it must put your money in a bank account that earns interest for you. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of any surveys, certifications, and complaint investigations conducted during the past three years were available for review. This has the potential to affect all 43 residents currently residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect a vulnerable resident (R1) from physical abuse that resulted in bodily harm; R1 was found to be bloodied and battered on [DATE]. This affected one of four residents reviewed for abuse in a sample of four. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 while the facility continues to monitor and adjust the implemented procedures.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to ensure the kitchen ceiling was kept clean, dry and without damage, a ceiling exhaust vent was cleaned and without debris and the ice machine scoop was kept in a separate drainage compartment. This deficiency has the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a resident's toileting preferences were met for one of 16 residents (R34) reviewed for accommodation of needs in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and document a resident's skin condition on the Resident Assessment Instrument and failed to accurately assess and document a resident's falls for three of 16 residents (R7, R13, R36) reviewed for accuracy of assessments, in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to update a plan of care to include fall interventions for one resident (R13) of three residents reviewed for falls, in sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a pressure ulcer risk assessment was conducted as per facility policy, failed to properly assess a wound to include a wound description with the correct pressure ulcer stage, provide a wound treatment for a newly acquired wound, and perform hand hygiene during a dressing change for three of six residents (R36, R38, R40) reviewed for pressure ulcers in a sample of 25.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for one of two residents (R34) reviewed for limited range of motion in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to ensure the placement and function of a physician ordered fall intervention for one of three residents (R13) reviewed for falls, in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to document a clinical rationale for duplicative antidepressant therapy for one of three residents (R34) reviewed for psychotropic medications in the sample of 25.