Goldwater Care Roseville

In the surveyor’s words

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

• Immediate jeopardy, widespreadF919Sep 10, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF600Nov 15, 2023

  Based 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. Findings include: The document Abuse Prevention Program dated [DATE], states, The facility reserves the right of our residents to be free from abuse. This facility prohibits abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. […]

• Actual harm, patternF919Jun 3, 2025

  Based 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. Findings include: The facility policy, Call Lights, dated (revised) 2/2/18 documents, Purpose: To respond to resident's requests and needs in a timely and courteous manner. Resident call lights will be answered in (a) timely manner. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. […]

• Actual harm, isolatedF692Jul 27, 2023

  Based on observation, interview, and record review, the facility failed to monitor weights upon admission, complete physician ordered daily weights, and document intakes for a resident dependent of gastrostomy tube feedings for three of three residents (R1) reviewed for g-tubes (gastrostomy tube) in the sample of four. These failures resulted in R1 being admitted to the hospital with the diagnosis of dehydration. Findings include: The facility's Enteral Feedings policy, dated 2/08, documents, It is the policy of the facility to provide commercially prepared products for enteral feedings via a nasogastric, g-tube, jejunostomy tube, or PEG tube when it is has been determined that oral feedings are not sufficient to meet physical requirements. […]

• No harm, potential for more than minimal, widespreadF584Sep 10, 2025

  Based 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.Findings include:The facility's Census Report dated 9/3/25 documents 40 residents reside within the facility.The facility's Housekeeping Director's Job Description dated 3/23/17 documents, Essential Duties and Responsibilities: Clean, wash, sanitize, and/or polish fixtures, ledges, room heating/cooling units, bathroom fixtures, etc. […]