Goldwater Care Marseilles

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 29, 2022

  Noncompliance 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. […]

• Immediate jeopardy, isolatedF684May 2, 2024

  Based 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. Findings include: These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 4/1/24 at 4:15 pm when the facility failed to follow a physician order to send R2 to the local hospital for an evaluation resulting in delay of R2 treatment and being admitted to the local hospital's intensive care unit with multiple comorbidities. […]

• Actual harm, isolatedF686Aug 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure weekly skin assessments were completed, failed to timely identify and assess skin breakdown, failed to implement ordered pressure relieving interventions, and failed to ensure prescribed wound treatments were consistently completed to 1 of 3 residents (R1) reviewed for pressure injury in the sample of 3. These failures resulted in a facility acquired pressure injury to R1's left heel which was identified at a stage 3 pressure injury. The findings include:R1's Physician Order Sheet (POS)dated 8/26 shows R1 had diagnoses that include polyneuropathy and diabetes mellitus. […]

• Actual harm, isolatedF684Jul 15, 2026

  Based on observation, interview and record review the facility failed to provide dressing changes to a scalp wound. This failure resulted in the wound increasing in size. The facility failed to follow physician treatment orders for a resident's non-pressure wound and failed to follow physician orders to schedule an orthopedic appointment for 3 of 37 residents (R50, R53, R59) reviewed for quality of care in the sample of 37. The findings include: 1.On 07/14/26 at 9:24 AM, R50 was sitting in his wheelchair in the dining room. R50 said he had a sore on his head. R50 removed his ball cap to reveal a foam dressing that was dated 7/9/2026. The dressing had visible dried drainage and was rolling on the edges. […]

• Actual harm, isolatedF686Jul 15, 2026

  Based on observation, interview and record review the facility failed to have pressure ulcer prevention intervention in place and failed to follow pressure ulcer treatment orders for 2 of 5 residents (R50 and R53) reviewed for pressure ulcers in the sample of 37. This failure resulted in R53 developing pressure ulcers to his bilateral heels. The findings include:1.On 7/13/26 at 9:36 AM, R53 was lying in bed. R53's knees were bent and unable to be extend and his toes were pressing up against the foot board. R53's heels were pressing firmly into the mattress. R53's right heel was red/purple in color. R53 said that he is six feet tall and his bed is too small for him making it impossible to extend his legs straight. […]