Goldwater Care Bloomington

In the surveyor’s words

From the most serious findings on record at Goldwater Care Bloomington, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 20, 2021

  Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to follow their infection control policy to prevent the spread of a highly contagious disease COVID-19 (Human Coronavirus) to residents and staff. The facility allowed symptomatic staff to work with residents affecting two (R4, R5) of 15 residents sampled for COVID-19. These failures have the potential to affect seven additional residents (R2, R8-R12, R16) and multiple staff. […]

• Immediate jeopardy, isolatedF689Jul 28, 2025

  Based on observation, interview, and record review the facility failed to prevent a fall by failing to ensure fall precautions were in place and failed to minimize the risk of injury from a fall by failing to ensure interventions to reduce the risk of injury were in place. The facility also failed to ensure fall precautions and interventions were in place after a fall with injury for one (R1) of three residents reviewed for falls on the sample list of four. This immediate jeopardy began on [DATE] at 8:00 PM when this failure resulted in R1 having a high impact fall on [DATE] from an elevated bed onto the floor. This fall resulted in R1 sustaining a right leg fracture with shattered and displaced bone fragments. This fall contributed to R1's death five days later [DATE]. […]

• Immediate jeopardy, isolatedF684Jan 23, 2024

  Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to assess a resident with previous medical history of Respiratory illness and hospitalization s who was in acute respiratory distress, and failed to notify the Physician timely of a change in respiratory condition for a resident. These failures resulted in R17 experiencing respiratory distress for a period of 15 hours, with a low oxygen level, and yelling out to staff of being unable to breathe before R17 was transferred to a local hospital in respiratory distress. This failure affects one (R17) of three residents reviewed for a change in condition. […]

• Actual harm, isolatedF689Aug 17, 2025

  Based on observation, interview and record review the facility failed to assist one (R1) resident while eating causing R1 to spill hot coffee on her left hip and left thigh out of three residents reviewed for Accidents in a sample list of three residents. R1 obtained four separate blisters which required treatment from a Wound Physician. Findings include:R1's Electronic Medical Record (EMR) documents medical diagnoses as Hemiplegia and Hemiparesis following Cerebrovascular Disease affecting Right dominant side, Disorders of the Brain, Morbid Severe Obesity due to excess calories, Epilepsy, Traumatic Brain Injury, Colostomy, Chronic pain due to trauma and Legal Blindness. R1's care plan intervention dated 5/2/25 documents R1 is usually provided with one assist by staff to eat. […]

• Actual harm, isolatedF684Jul 28, 2025

  Based on interview and record review the facility failed to ensure timely medical treatment for one (R4) of three residents reviewed for change in condition on a sample list of 6. This failure resulted in R4 having an acute ischemic stroke resulting in receptive aphasia. The facility's Physician-Family Notification-Change in Condition Policy dated 11/13/2018 documents that the facility will inform the resident; consult with the resident's physician or authorized designee such as Nurse Practitioner; and if known, notify the resident's legal representative or an interested family member when there is: B) a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or… […]