Golden Acres Manor

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 1 closed record (Resident #65) with pressure ulcers. Failure to ensure adequate monitoring and assessment by a provider resulted in the worsening of a facility acquired pressure ulcer. Findings Include: Review of the facility policy titled Pressure Injury Prevention and Management occurred on 07/29/26. The policy, dated 02/23/18 stated, . Golden Acres Manor shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate . [...]

Inspectors wroteBased on record review, review of the facility reported incident (FRI) investigations, observations, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 5 of 5 sampled residents (Resident #2, #3, #4, #5, #6) who were subjected to verbal and physical abuse by Resident #1. Failure to protect residents from verbal and physical abuse may result in injury, fear, anxiety, mental anguish, emotional distress and resulted in retaliatory abuse to Resident #1.

Inspectors wroteBased on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 kitchen and 1 of 1 refrigerator on a nursing unit (Prairie Unit). Failure to clean fans in areas where food is stored and prepared, failure to ensure sanitizer test strips are not expired, and failure to store resident cold packs in an area separate from food has the potential for contamination of food and may result in a foodborne illness. Findings Include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3 Food, Section 3-305 Preventing Contamination From the Premises, Section 3-305.11 states, A. Food shall be protected from contamination by storing the food: . 2) Where it is not exposed to . dust, or other contamination. [...]

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 15 sampled residents (#16, #20, #32, and #40) and 1 supplemental resident (Resident #45) observed during personal cares. Failure to practice infection control standards related to hand hygiene, glove use, and disinfecting equipment has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of a facility reported incident (FRI), policy review, and staff interview, the facility failed to ensure residents remained free from misappropriation of funds for 1 of 1 closed record (Resident #52). Failure to protect residents from misappropriation of funds may result in anxiety, mental anguish, and financial loss. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the residents' current status for 1 of 15 sampled residents (Resident #24). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident.

Inspectors wroteBased on observation, review of professional reference, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed standards of practice for 2 of 9 supplemental residents (Residents #13 and #39) observed during medication administration. Failure to clarify, accurately transcribe, and reconcile new physician's orders (Resident #13) may result in residents receiving the wrong medication and failure to correctly prime an insulin pen (Resident #39) may result in residents receiving an inaccurate dose of insulin, and/or result in adverse health consequences.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to assess residents with a history of trauma and identify known triggers for 1 of 2 sampled residents (Resident #16) reviewed for Post-Traumatic Stress Disorder (PTSD). Failure to ensure staff assess residents with PTSD upon admission, identify known triggers, and provide appropriate person-centered treatment/services may result in re-traumatization.

Inspectors wroteBased on observation, review of facility policy/procedure, review of professional reference, review of food temperature logs, and staff interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 kitchen used to prepare food for all residents, staff and visitors. Failure to ensure food was cooled properly, and failure to label food taken out of the original container has the potential to result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on record review, review of professional reference and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 sampled resident (Resident #10) reviewed for pressure ulcers. Failure to follow physician's orders for pressure ulcer treatment may result in delayed healing and/or worsening of the pressure ulcer.

Inspectors wroteBased observation, record review, review of professional reference, and resident and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 2 sampled residents (Resident #36) receiving continuous oxygen. Failure to ensure portable oxygen tanks remain secured to resident wheelchairs and educate residents on oxygen tank safety placed all residents, staff, and visitors at risk for injury.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 8 sampled residents (Resident #1, #4, and #10) observed during personal cares, transfers, and wound treatment/dressing change. Failure to follow infection control practices regarding hand hygiene and wound treatments has the potential for transmission of communicable diseases and infections to residents, staff, and visitors.