Goldwater Care Spring Valley

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689May 24, 2023

  Facility Failures resulted in two deficient practice statements. A. Based on observation, interview and record review, the facility failed to serve hot cereal at a safe temperature to prevent a resident's second-degree burn (R1) and failed to notify the facility Administration so an investigation could be conducted, which resulted in another resident (R2) suffering a second-degree scalding burn after facility kitchen staff served a scalding hot beverage without performing the required safe temperature check prior to serving. R1 sustained a 4.0 CM (centimeter) X 1.4 CM X 0.1 CM second degree, blistered, painful wound to the left anterior thigh on 11/29/22 when she was served a bowl of hot cereal. […]

• Immediate jeopardy, isolatedF886Mar 24, 2023

  Based on observation, interview and record review, the facility failed to conduct COVID-19 testing on residents that displayed COVID-19 like symptoms for five residents (R2, R7, R15, R16 and R17) out of 16 residents reviewed for COVID-19 testing in a sample of 24. The facility also failed to perform COVID-19 testing on employees that displayed COVID-19 like symptoms prior to providing direct care and services to residents in the facility. This failure has the potential to cause COVID-19 infection to all 80 residents residing in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/6/23 when the facility failed to conduct COVID-19 testing on R16 after R16 started displaying COVID-19 like symptoms. […]

• Immediate jeopardy, isolatedF689Nov 16, 2022

  Based on interview and record review, the facility failed to directly supervise a resident (R1) who required supervision and assistance while eating. This failure resulted in R1, who has a history of dysphagia, is on a mechanically altered diet, is impulsive with eating and needs verbal cuing to eat slowly and take small bites, being served a lunch meal tray within R1's reach without staff members directly present. R1 subsequently choked on food items from R1's lunch tray. R1 required the [MEDICATION(S)] Maneuver, Cardiopulmonary Resuscitation efforts and transfer to the local area hospital where R1 expired. […]

• Actual harm, isolatedF684Feb 16, 2022

  Based on interview, and record review, the facility failed to routinely assess a pressure wound and failed to follow physician's orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in the disruption of surgical skin grafts, resulting in a delay of healing to R1's wounds. FINDINGS INCLUDE: The facility policy, Skin Condition Assessment and Monitoring- Pressure and Non-Pressure, dated (revised) 6/8/2018 directs staff, To establish guidelines for assessing, monitoring and documenting the presents of skin breakdown, pressure injuries and other non-pressure skin conditions and assuring interventions are implemented. Pressure and other ulcers will be assessed and measured at least weekly by licensed nurses and documented in the resident's clinical record. […]

• No harm, potential for more than minimal, widespreadF812Mar 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure the ice scoop, for the ice machine, was stored on the outside of the ice machine. This failure has the potential to affect all 79 residents residing in the facility. Findings include: Facility Policy, entitled Cleaning Instructions: Ice Machine and Equipment, dated 2010, document, 10. Store the ice scoop outside the machine in a separate, sanitized container that allows the water to drain and not collect around the scoop. On 03/26/2024, at 9:35 a.m., during the initial kitchen tour, with V6/Dietary Manager, the ice scoop, for the ice machine, was inside of the ice machine and full of ice. […]