Golden Age Operations

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, record review, and interview, the facility failed to develop a comprehensive care plan for of 2 of 3 residents. (Resident (R)22 and R24). Findings include; Record review of the facility policy dated 2025, titled Comprehensive Care Plan revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. Review of R22's Face Sheet revealed R22 was admitted to the facility on [DATE], with diagnoses including but not limited to acute respiratory failure with hypoxia, hydrocephalus, and mild cognitive impairment. Review of R22's Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, record review and interview, the facility failed to complete a dressing change using standards of practice to prevent cross contamination of a pressure ulcer, for 1 of 1 resident, (Resident (R)22), reviewed for pressure ulcers. Findings include: Review of the facility policy dated 2024, titled, Clean Dressing Change stated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and or cross/contamination. Setup clean field on the overbed table with needed supplies .Place a disposable cloth or linen saver on the overbed table. Place only the supplies to be used per wound on the clean field . Use no touch techniques to remove ointments and creams from their containers (i.e. use of tongue blade or applicator). Review of R22's Face Sheet revealed R22 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, hydrocephalus, and mild cognitive impairment.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure 2 of 2 sampled residents (Resident (R)12 and (R)22), received the correct oxygen flow rate per physician's orders. Findings include: Review of the undated facility policy titled, Oxygen Administration revealed, Policy: Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in cases of emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Review of R12's Face Sheet revealed R12 was admitted to the facility on [DATE], with diagnoses including but not limited to: paroximal atrial fibrillation, heart failure, long term (current) use of anticoagulants, acute ischemic heart disease, asthma, bipolar disorder, current episode mixed, mild, presence of automatic (implantable)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observation, record review and interview, the facility failed to ensure proper handwashing and proper precautions utilizing gloves while removing and reapplying a transdermal patch for Resident (R)5, for 1 of 1 residents observed. Findings include: Review of the facility policy titled, Medication Administration, states, Policy: Policy Explanation and Compliance Guidelines: . 4. Wash hands prior to administering medication per facility protocol and product. 14. Remove medication from source, taking care not to touch medication with bare hand. 19. Wash hands using facility protocol and product. During an observation on 03/18/25 at 8:40 AM, during medication administration revealed, R5 was ordered Rivastigmine 4.6mg/24. Apply transdermal patch everyday. Registered Nurse (RN)1 prepared the medications for R5. RN1 signed the Medication Administration Record (MAR) to indicate the medications had been given. RN1 sanitized her hands, collected the medications and knocked on the door of the resident's room. RN1 placed the medications on the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were timely administered for 1 (Resident (R)6) of 3 sampled residents observed for medication administration. Findings included: An undated facility policy titled, Medication Administration, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. On 06/10/2024 at 10:15 AM, the surveyor observed Registered Nurse (RN)1 administer R6 their 8:00 AM dose of oxybutynin chloride and sennosides-docusate sodium. R6's Order Summary Report, with active orders as of 06/10/2024, revealed an order dated 04/11/2024 for oxybutynin chloride oral tablet, give 5 milligrams (mg) by mouth four times a day for overactive bladder and sennosides-docusate sodium oral tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure two staff assisted with a mechanical lift transfer for 1 (Resident (R)4) of 3 sampled residents reviewed for accidents. The failure resulted in R4 sustaining a laceration to the back of their head. Findings included: An undated facility policy titled, Safe Resident Handling/Transfers, with a copyright date of 2023 revealed It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy specified, 10. Two staff members must be utilized when transferring residents with a mechanical lift. An admission Record revealed the facility admitted R4 on 11/13/2023. According to the admission Record, the resident had a medical history that included diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, facility policy review, and interviews, the facility failed to ensure the comprehensive care plan was developed with the participation of the resident and the resident representative for two (Resident (R) 2 and R6) of 33 residents sampled. Findings include: Review of the facility's undated policy titled, Care Planning-Resident Participation revealed, Policy: This facility supports the resident's right to be informed of and participate in his or her care planning and treatment (implementation of care). Policy Explanation and Compliance Guidelines: 1. The facility will inform the resident, in a language he or she can understand, of his or her rights regarding planning and implementing care, including the right to be informed of his or her total health status. 2. The facility will notify the resident and/resident representative, in advance, of the care to be furnished and the type of caregiver or professional that will furnish care, as well as changes to the plan of care. 3. The facility will encourage and assist the resident and or assist the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standard of quality for one (Resident (R) 14) of three residents observed during observations of medication administration. Observations revealed R14's blood sugar was not checked as ordered. Findings include: On 04/18/23 at 8:00 AM, during a medication administration observation in R14's room, Licensed Practical Nurse (LPN)1 did not obtain the resident's fingerstick blood sugar (FSBS) level. A review of R14's care plan indicated the resident was at risk for unstable blood glucose related to stress, sedentary activity level, and lack of adherence to diabetes management due to the resident having diabetes and being insulin dependent. R14's goals indicated the resident would not have any complications related to diabetes through the review date. Interventions included for staff to administer the resident's diabetes medication as ordered by the doctor and to monitor/document for side effects and effectiveness. On 04/20/23 at 9:04 AM, a review of the electronic health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to make good faith attempts to improve performance through its Quality Assurance Committee. The facility failed to provide consistent care plan meetings for its residents and resident representatives dating back to November of 2022. Findings include: Review of an undated facility policy titled, Quality Assurance Performance Improvement, revealed its purpose is to enable the facility to take a proactive approach to continually improve the way care is provided to residents. QAPI is integrated into all care and services with a focus on clinical care, quality of life, resident choice, balance between safety and choice, and evidence based best practices. In an interview with the Minimum Data Set (MDS) consultant on 04/18/2023 at approximately 12:27 PM revealed the facility has been without a full-time MDS coordinator since October of 2022. There is a list of residents that have missed their care plan meetings, and the facility is actively trying to hire a full-time MDS coordinator. The consultant stated a performance improvement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, facility policy review, and interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable disease for two (Resident (R) 14 and R6) of three residents observed during medication administration. Observations during medication administration revealed the nurse did not perform hand hygiene between residents after contact with the residents during medication administration. Findings include: Review of the facility's undated policy titled, Medication Administration, revealed, 16. Wash hands using facility protocol and product. Review of the facility's undated policy titled, Hand Hygiene, revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanations and Compliance Guidelines: 2. Hand Hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Review of the undated Hand Hygiene Table revealed, Use either soap and water or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.