Goldwater Pontiac Nursing Home

Inspectors wroteBased on interview and record review the facility failed to promptly refund an overpayment of monthly charges for one resident (R2) of three residents reviewed for management of funds in a sample list of six. Findings Include: The facility's census documents R2 was admitted to the facility on [DATE]. At that time R2 was admitted to a private room with a shared bath. R2's signed contract with the facility dated 6/10/22 documents R2 was being charged for a semiprivate room with a shared bath. On 2/28/24 R2's representative paid $12,650.00 for R2's room and board. R2's Transaction Report documents R2's room and board was billed for that month at $9,920.00. The facility also provided a cancelled check signed by V13, R2's representative in the amount of $12,650.00. This supports the information on the Transaction report as above. This constituted an overpayment of $2,720.00. On 6/17/26 at 10: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely post-fall assessment and physician notification, and failed to follow a physician order to obtain a post fall x-ray for two of six residents (R1 and R3) reviewed for falls on the sample of six.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate falls and document a root cause for two of six (R1, R3) residents reviewed for falls in a sample size of six.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from misappropriation of money for one of 10 residents (R86) reviewed for misappropriation of property in the sample list of 38. On 8/18/2025 at 10:40 AM, R86 stated R86 thought her money was in her purse, but when she went to get her hair done there were only singles left, and the large bills were gone, which was $80. R86 stated R86 had gotten $40-$50 from V10 Business Office Manager and had some money left over from a prior withdrawal. R86 stated R86 keeps her purse in her room and does not leave her room, so the only time someone could have taken it was during the night when R86 was asleep. R86 stated the facility replaced the $80. On 8/19/25 at 9:30 AM R86 stated R86 is unsure what happened to her missing $80 but is certain R86 did not misplace it. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a thorough investigation of an allegation of misappropriation of funds for one of ten residents (R86) reviewed for misappropriation of property in the sample list of 38. On 8/18/2025 at 10:40 AM R86 stated R86 thought her money was in her purse, but when she went to get her hair done there were only singles left, and the large bills were gone, which was $80. R86 stated R86 had gotten $40-$50 from V10 Business Office Manager and had some money left over from a prior withdrawal. R86 stated R86 keeps her purse in her room and does not leave her room, so the only time someone could have taken it was during the night when R86 was asleep. R86 stated the facility replaced the $80. On 8/19/25 at 9:30 AM R86 stated R86 is unsure what happened to her missing $80 but is certain R86 did not misplace it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for the use and care of a CPAP (continuous positive airway pressure) for one of two residents (R6) reviewed for respiratory care on the sample list of 38. On 8/18/2025 at 10:08 AM there was a CPAP machine on R6's desk in R6's room. R6 stated R6 is suppose to use it, but has had problems getting parts for it. R6 removed the filter from the machine to show the filter was dirty, covered in gray debris/dust. R6 stated R6 has talked to facility staff about needing parts for the machine. R6's Minimum Data Set, dated [DATE] documents R6 has severe cognitive impairment. R6's active physician orders and active care plan do not document the use or care of R6's CPAP machine as of 8/18/25. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent further abuse from occurring by allowing employees (V4 and V5 Certified Nursing Assistants) unrestricted access to residents following an abuse allegation. This failure has the potential to affect 36 residents (R1, R3, R4, R5, R7-R38) of 38 residents reviewed for abuse in the sample list of 38.

Inspectors wroteBased on interview and record review the facility failed to timely notify a resident representative and physician of an allegation of abuse for one (R1) of 38 residents reviewed for abuse in the sample list of 38.

Inspectors wroteBased on interview and record review the facility failed to timely notify the administrator, state survey agency, and local law enforcement of an allegation of abuse for one (R1) of 38 residents reviewed for abuse in the sample list of 38.

Inspectors wroteBased on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections and conduct infection surveillance. These failures affects one resident (R13) and has the potential to affect all 80 residents residing at the facility. Findings Include: 1. The facility Infection Surveillance, Tracking and QA (Quality Assurance) Reporting Policy dated 2/14/18 documents the facility will identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: review of laboratory/microbiology reports and results, observing for trends and monitoring to ensure appropriate precautions were initiated as appropriate. Infection Tracking includes but is not limited to: [...]

Inspectors wrote2. R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has severe cognitive impairment. On 5/13/24 at 12:35 PM, R43 was sitting in the lounge area eating lunch, by R43's self, away from all other residents who were in the dining area. At this time, V3 ADON (Assistant Director of Nursing) / Licensed Practical Nurse stated V3 is unsure why R43 is in the lounge area by R43's self other than the fact that R43 likes to tool around and take food off of other resident trays. R43's Care Plan dated 4/23/24 does not document that R43 takes food from other residents and is to sit by R43's self. Based on observation, interview and record review the facility failed to ensure that residents are treated with respect and dignity. This failure affects three (R76, R43, & R66) of twenty four residents reviewed for dignity on the sample list of 30.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to complete a self-administration of medication assessment for one of one resident (R29), reviewed for self-administration of medication. Findings Include: 05/15/24 09:15 AM R29 was observed with a medication cup on the bedside table with several unidentified medications still inside. R29 was observed with eyes closed resting in a recliner at this time. 05/15/24 09:20 AM R29 room door under constant observation from 09:15 AM until V12 (Registered Nurse) returned to nurses station at 09:20 AM. V12 then accompanied this surveyor to R29's room. V12 looked at the medication cup located on bedside table and picked it up from the bedside table concealing it in her left hand. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report allegations of abuse to the Abuse Coordinator for one of three residents (R44) reviewed for abuse on the sample list of 30. Findings Include: R44's MDS (Minimum Data Set) dated 3/14/24 documents R44 has severe cognitive impairments. R44's Nursing Progress Notes document the following: 5/11/24 at 3:34 am by V27 RN (Registered Nurse) - R44 expresses frustration toward staff members, refusing care, and accusing CNAs (Certified Nursing Assistant's) of punching R44 in the gut. Upon inspection, R44 had no bruising or redness to indicate a punch to the gut. 4/27/24 by V28 LPN (Licensed Practical Nurse) - R44 was sitting out in the living room on the wing. There was another resident (unidentified) talking to a stuffed animal. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set for three of 24 residents (R29, R43, R53) reviewed for Assessments on the sample list of 30. Findings Include: 1) R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has limited ROM (Range of Motion) to both bilateral upper and lower extremities. R43's Care Plan dated 4/23/24 does not document any limited ROM. On 5/13/24 at 1:57 PM, V3 ADON (Assistant Director of Nursing) / LPN (Licensed Practical Nurse) stated R43 does not have any limited ROM. On 5/14/24 at 3:05 PM, V5 LPN stated R43 has full ROM to all extremities but does have some weakness in the legs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assist with shaving and nail care for two (R12, R69) of twenty four residents reviewed for activities of daily living on the sample list of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a pressure ulcer wound treatments was completed as ordered, implement pressure relieving interventions and prevent potential cross contamination of the wound for two of five residents (R13, R51) reviewed for pressure ulcers on the sample list of 30. Findings Include: The facility's Pressure Ulcer Prevention Policy dated 1/15/18 documents specialty mattresses such as a low air loss, alternating pressure, etc mattress may be used as determined clinically appropriate. Specialty mattresses are typically used for resident who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds, and use a pressure reducing pad in chairs of all types to protect bony prominence's for residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration for two of six residents (R36, R71) reviewed for medication administration on the sample list of 30 . The facility had two errors out of 34 opportunities for a medication error rate of 5.88%. Findings Include: 1. On 5/14/24 at 3:23 pm, V30 RN (Registered Nurse) entered R36's room to check R36's blood glucose level, which was 156. At this time, V30 stated V30 was only checking R36's blood glucose level and would be giving R36 the ordered insulin, which will be 5 units per the sliding scale orders and other ordered medications at 4:00 pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free of significant medication errors, by administering a residents intravenous antibiotic medications without consulting the physician due to critical lab values. This failure affects one (R71) resident out of a sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure employees with symptoms of COVID-19 were tested for COVID-19 and excluded from resident contact while symptomatic. This failure had the potential to affect eight (R6, R7, R8, R9, R10, R11, R12, and R13) of thirteen residents reviewed for COVID-19 on the sample list of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain sanitary food processing equipment, free of grease-like substance, metal fragments, rust and exposed metal. These failures have the potential to affect all 78 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections, conduct infection surveillance, and review their policy annually. This failure has the potential to affect all 78 residents residing at the facility. Findings Include: The facility policy Infection Prevention and Control Program dated 11/28/17 and last reviewed on 1/7/19 documents the facility is to comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an Infection Preventionist. This failure has the potential to affect all 78 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an air mattress is safe operable condition, ensure bed brakes were locked, and follow the facility Fall Prevention Program guidelines, which resulted in R57 falling from bed. The facility also failed to ensure a safe environment according to the plan of care, free from trip hazards for one resident (R17) at risk for falls. These four failures affect two of eight residents (R57 and R17) reviewed for falls/accident hazards on the sample list 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician's order for oxygen administration and failed to store oxygen tubing in a sanitary manner for one of two residents (R63) reviewed for oxygen in the sample list of 28. Findings Include: The Oxygen and Respiratory Equipment policy dated 1/7/19 documents oxygen nasal cannula tubing should be stored in a clear plastic bag when not in use. R63's Medical Diagnoses List dated July 2023 documents R63 is diagnosed with Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, and Congestive Heart Failure. R63's Physician Order Sheet (POS) dated July 2023 documents R63 is prescribed oxygen at two liters via nasal cannula for mild Dyspnea or oxygen saturation less than 88 percent. This order was not added until 7/28/23. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain a physician order for dialysis treatment and failed repeatedly to monitor the dialysis catheter site and dressings for two of two residents (R29, and R58) reviewed for Dialysis on the sample list of 28. Findings Include: The Dialysis Monitoring and Observation policy dated 2/13/18 documents if the resident has a catheter for dialysis the nurse should assess the catheter site for any signs of drainage and assess the condition of the catheter dressing every shift. 1. R29's Medical Diagnoses list dated July 2023 documents R29 is diagnosed with End Stage Renal Disease. R29's July 2023 Physician Order Sheet (POS) does not include an order for Hemodialysis or an order for staff to monitor the dialysis catheter site/dressing. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary behavioral health care services for one of one residents (R48) reviewed for behavioral health on the sample list of 28.

Inspectors wroteBased on interview and record review, the facility failed to administer immunizations according to resident wishes for two of five residents (R7 and R63) reviewed for immunizations on the sample list of 28.

Inspectors wroteBased on observation, and interview the facility failed to prevent the potential for cross-contamination and foodborne illness by failing to dispose of expired refrigerated food, failed to date and label open refrigerated food, failing to maintain a can opener and mixer in a sanitary operable condition. 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 document appropriate rationale for extended use of as needed (PRN) psychotropic medication, failed to evaluate the need for continued use of PRN psychotropic medication, and failed to obtain and document consent for psychotropic medication. These failures affect four (R25, R51, R55, R57) of six residents residents reviewed for unnecessary medications on the sample list of 36.

Inspectors wroteBased on record review, observation and interview the facility failed to lock bed wheels and provide adequate staff assistance to prevent a fall for R57. The facility also failed to maintain a safe environment, free of tripping hazards in R44 bedroom and bathroom. R44 and R57 are two of six residents reviewed for falls on the sample list of 36.