Golden Age Care Center

Inspectors wroteBased on observation, staff interviews, record review and the facility policy review the facility failed to keep all medications in a locked medication cart, inaccessible to unauthorized staff and residents. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, resident and staff interview, the facility failed to offer the pneumococcal vaccine to 4 of 5 sampled residents reviewed for immunizations (Residents #4, #5, 26 and #27). The facility reported a census of 40 residents. On 7/31/2025 at 8:49AM, the Director of Nursing (DON) reported she had been in her role as the DON and Infection Preventionist (IP) since May 2023. The DON reported they should check the immunization status of residents upon admission and residents should be offered immunizations at that time. The DON reported she followed the Center for Disease Control and Prevention (CDC) guidelines for offering residents the pneumococcal vaccine. The DON reported being aware that there were residents eligible for the vaccine who had not been offered. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure thorough documentation of an assessment of a resident's ability to self-administer insulin (an injectable medication used to lower blood sugar) for 1 of 1 residents reviewed for medication self-administration (Resident #35). The facility reported a census of 40 residents. The Minimum Data Set (MDS) assessment tool, dated 5/6/25, listed diagnoses for Resident #35 which included diabetes, hypertension, and Parkinson's disease (a disease that caused difficulty with mobility). The MDS stated the resident took insulin and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. [...]

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to make prompt efforts to resolve concerns for 1 of 1 resident reviewed for grievances (Resident #34). The facility reported a census of 34 residents. The Minimum Data Set (MDS) assessment tool, dated 5/6/25, listed diagnoses for Resident #35 which included diabetes, hypertension, and Parkinson's disease (a disease that caused difficulty with mobility). The MDS stated the resident received insulin (an injectable medication used to lower blood sugars) and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. The facility Resident Grievance Policy revised 3/31/23, stated the facility had a grievance system to resolve issues and respond to grievances as soon as possible. [...]

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to carry out interventions and ordered treatments to treat a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #45). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure 1 of 6 residents (Resident #35) reviewed for medications was free of a significant medication error due to the omission of insulin (an injectable medication used to lower blood sugar). The facility reported a census of 40 residents. The Minimum Data Set (MDS) assessment tool, dated 5/6/25, listed diagnoses for Resident #35 which included diabetes, hypertension, and Parkinson's disease (a disease that causes difficulty with mobility). The MDS stated the resident took insulin and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 12/5/24 Care Plan entry stated the resident had diabetes and was dependent on insulin. [...]

Inspectors wroteBased on observation, staff interviews, resident interviews and policy review, the facility failed to provide a proper functioning call system to ensure resident timely access to staff for 2 of 16 residents reviewed (Resident #3, Resident #22). The facility reported a census of 40.

Inspectors wroteBased on staff and resident interview and clinical record review, the facility failed to provide restorative activity as planned for 1 of 1 resident reviewed. (Resident #3) The facility reported census was 38.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure residents are appropriately assessed and provided interventions to maintain their optimal health and well-being for 1 of 3 residents reviewed. (Resident #3) The facility reported census was 38.

Inspectors wroteBased on clinical record review, staff interviews, family interview and provider interview, the facility failed to notify a physician and family representative upon discovery of a blistered area on a resident's left foot. (Resident #1) The facility reported census was 38.

Inspectors wroteBased on clinical record review, staff interviews, and provider interview the facility failed to obtain treatment orders for a resident identified with new wounds. (Resident #1) The facility reported census was 38.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to carry out infection control measures for 1 of 7 residents observed during the medication pass (Resident #21). The facility also failed to develop and implement a plan to prevent the growth of Legionella(a bacteria) in water systems. The facility reported a census of 37 residents. Findings Include: 1. The Infection Prevention and Control Program policy, reviewed 5/19/22, stated the facility would provide a safe environment to help prevent the development and transmission of disease and infection and stated the facility would ensure compliance with State and Federal Regulations. The Minimum Data Set(MDS) assessment tool, dated 1/8/24, listed diagnoses for Resident #21 which included heart failure, urinary tract infection, and pain. [...]

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to serve diets at the appropriate consistency for 5 of 5 residents receiving a mechanical soft diet (a soft diet consisting of finely chopped, blended, or ground foods). The residents received diced chicken instead of ground chicken at a meal. The facility reported a census of 37 residents.

Inspectors wroteBased on observation, interviews, and records review the facility failed to treat resident with dignity for 1 of 8 reviewed for dignity (Resident #3). Resident #3 was moved to the feeding table for assistance abruptly, expressed embarrassment and humiliation with being fed at the feeder table. The facility reported a census of 37 residents.

Inspectors wroteBased on employee file review, policy review, and staff interview, the facility failed to complete a criminal background check to include a record check evaluation for 1 of 6 staff members reviewed (Staff A). The facility reported a census of 37 residents.