Goldwater Pontiac Nursing Home

In the surveyor’s words

From the most serious findings on record at Goldwater Pontiac Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 25, 2022

  Based on observation, interview and record review, the facility failed to thoroughly assess a resident's risk for falls, implement appropriate safety interventions to prevent further falls, provide a safe, non-hazardous shower environment, failed to follow the facility policy for bathing, and failed to use an appropriate chair for transporting/moving a resident from one location to another for one of six residents (R2) reviewed for falls on the sample list of six. Theses facility failures resulted in R2 falling out of a shower chair while being relocated, while in the shower chair, to a dry/non-slick environment. […]

• Actual harm, isolatedF740May 16, 2024

  Based on observation, interview and record review, the facility failed to provide behavioral health services to maintain the highest practicable mental well-being for a resident diagnosed with major depression. This failure affects one of two residents (R53) reviewed for behavioral health services on the sample list of 30. This failure resulted in R53 being tearful, visibly shaking, and expressing despair. Findings Include: R53's ongoing diagnosis listing documents the following diagnoses: Vascular Dementia without Behaviors, Anxiety Disorder and Major Depression. […]

• Actual harm, isolatedF689Sep 23, 2021

  Based on observation, interview and record review, the facility failed to ensure post fall interventions were in place for one of three residents (R2) reviewed for falls on the sample list of five. This failure resulted in R2 having a fall that resulted in a 3 centimeter forehead laceration that required sutures. Findings Include: R2's Fall Risk assessment dated [DATE] and 6/21/21 both document R2 is at high risk for falls. R2's MDS (Minimum Data Set) dated 6/21/21 documents a BIMS (Brief Interview for Mental Status) as a 7, which indicated severe cognitive impairments. This MDS documents R2 is independent with bed mobility and requires supervision for transfers. R2's Progress Notes dated 2/8/21 documents at 8:00 am, R2 ambulated to nurses desk, reporting I (R2) need a band-aid. […]

• Actual harm, isolatedF689Jun 4, 2021

  A. Based on record review and interview, the facility failed to apply foot pedals to a wheelchair, to provide a safe transport of a resident (R25) when leaving the facility in the facility van. This failure resulted in R25 sustaining a right distal femur and patella fracture, which required emergency treatment, overnight hospitalization and a leg cast. R25 is one of four residents reviewed for accidents/falls on the sample list of 35. B. Based on observation, interview and record review the facility failed to provide supervision to prevent a resident from wandering, impacting six of eight residents (R30, R38, R24, R29, R50 and R13) reviewed for resident to resident altercations on the sample list of 35 residents. Findings include: A. […]

• Actual harm, isolatedF686Mar 25, 2021

  Based on observation, interview and record review, the facility failed to complete pressure ulcer treatments as ordered, prevent cross contamination of the pressure ulcer, assess and measure the pressure ulcer weekly, implement pressure relieving interventions and failed to notify the Physician and Registered Dietician of worsening pressure ulcers for two of three residents (R1 and R4) reviewed for pressure ulcers. This failure resulted in R1 and R4's wounds doubling in size and progressing to an unstageable pressure ulcer. […]