Golden Age Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for 2 of 2 (#5 and #58) residents reviewed for environment. Resident #5 Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Idiopathic Peripheral Autonomic Neuropathy, Chronic Ischemic Heart Disease, Morbid Severe Obesity due to Excess Calories, and Acute on Chronic Diastolic Congestive Heart Failure. Review of Resident #5's Quarterly MDS with an ARD of 03/04/2026 revealed a BIMS of 13, which indicated the resident was cognitively intact. An observation was made on 03/15/2026 at 1:26 p.m. of Resident #5's room. Behind her bed was a brown substance splattered on the wall. An interview was conducted on 03/15/2026 at 1:27 p.m. with Resident #5. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services provided as outlined in the comprehensive care plan met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 3 (#12, #129, and #144) of 5 residents reviewed for insulin administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 3 (#7, #98, and #144) of 3 residents reviewed for ADLs. The facility failed to ensure: Resident #7 and #144 received their shower as scheduled; and Resident #98 was dressed in clean attire daily.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and plans of care. The facility failed to ensure nursing staff had competencies and skill sets to:Accurately administer insulin via insulin pens for 3 (#12, #129, and #144) of 5 residents reviewed for insulin administration; andProperly clean a non-invasive mechanical ventilation mask and tubing for 1 (#10) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice and the comprehensive care plan by failing to properly clean non-invasive mechanical ventilation equipment for 1 (#10) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff:1. Properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care for 2 (#6 and #45) of 3 residents observed who required EBP; and2. Performed appropriate Standard PPE glove precautions during incontinence care for 1 of 1 (#45) residents observed for urinary catheter care. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for dignity. The facility failed to ensure staff treated Resident #5 with respect and dignity. Review of Resident #5's Medical Record revealed the resident was admitted to the facility on [DATE] with diagnosis of Unspecified Dementia. Review of Resident #5's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/25/2025 revealed Resident #5 had a BIMS (Brief Interview for Mental Status) of 11, which indicated the resident had moderately impaired cognition. Further review revealed Resident #5 required substantial assistance for ADLs. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse and psychological harm for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for sexual abuse. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in actual psychological harm on 02/11/2025, when Resident #2, a cognitively intact resident, stated a visitor of the facility showed her unwanted pictures of his penis and then later forced his penis into Resident #2's mouth. Resident #2 reported the incident to the facility on [DATE] and stated she did not report it sooner because she was embarrassed. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a sanitary environment for 1 (#163) of 3 (#56, #59, and #163) residents reviewed for environment in the final sample.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#23) of 3 (#23, #75, and #135) residents reviewed for hospice. The facility failed to ensure Resident #23 was coded correctly for hospice.

Inspectors wroteBased on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate a PASRR Level II determination and recommendations into a resident's care plan for 1 (#167) of 4 (#23, #50, #108, and #167) residents reviewed for PASRR.

Inspectors wroteBased on interviews and record review the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled showers for 1 (#56) of 4 (#56, #57, # 63, and #110) residents reviewed for ADLs.

Inspectors wroteBased on observation, interviews and record review the facility failed to administer parenteral fluids consistent with professional standards of practice for 1(#57) of 1(#57) residents reviewed for IV (Intravenous) fluid therapy. The facility failed to monitor, flush, and replace the saline lock IV access site according to professional standards.

Inspectors wroteBased on observations and interviews, the facility failed to store food under sanitary conditions by failing to ensure food was properly labeled and stored in unit refrigerators. This deficient practice had the potential to affect 81 residents who were able to store and consume food in the facility's unit refrigerator.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staff communicated a resident's significant change in condition to the physician when a nurse identified a deformity in a resident's leg for 1 of 1 (#3) residents reviewed for an injury of unknown origin.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 2 (#6 and #7) of 6 (#1, #2, #3, #6, #7, and #8) residents reviewed for comprehensive care plans. The facility failed to ensure the following Physician Orders were implemented: 1. Resident #6's wheelchair alarm and visual cue to wheelchair brakes; and 2. Resident #7's TED hose.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible by failing to implement an intervention after a fall for 1 (#6) of 3 (#1, #3, and #6) residents reviewed for accidents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident received the necessary services to maintain personal hygiene for 1(#3) of 3(#1, #2, and #3) residents reviewed for Activities of Daily Living.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 1 (#1) of 2 (#1 and #2) residents reviewed for incontinent care.

Inspectors wrote677 Based on observations, interviews, and record reviews, the facility failed to ensure residents, who were unable to carry out ADLs, received the necessary services to maintain personal hygiene for 1 (#44) of 4 (#44, #63, #78 and #93) residents reviewed for ADLs.

Inspectors wroteBased on observations, record review and interviews, the facility failed serve food in accordance with professional standards for food service safety. The facility failed to ensure milk was held at a safe temperature for consumption of 41 degrees Fahrenheit or below prior to being served to residents. This had the potential to effect all 169 residents who were served meals from the kitchen.

Inspectors wroteBased on record reviews and interview, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 2 (#63 and #93) of 4 (#44, #63, #78, and #93) sampled residents reviewed for ADL Care.

Inspectors wroteBased on record reviews and interviews, the facility failed to document and make prompt efforts to resolve grievances for 1 (#44) of 3 (#43, #44, and #151) residents reviewed for grievances.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#8 and #149) residents out of a total of 34 sampled residents by failing to ensure: 1. Resident #8 was coded correctly for the use of a chair alarm; and 2. Resident #149 was coded correctly for dialysis services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a person-centered plan of care by failing to follow Physician's Orders for 1 (#43) of 3 (#36, #43, and #149) residents reviewed for nutrition. The facility failed to ensure Resident #43 received ice cream with lunch and dinner as ordered.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure medications were stored properly in accordance with current accepted professional principles during medication administration for 1 (Cart A) of 3 (Cart A, Cart B, and Cart C) Medications Carts observed during medication administration. The facility failed to ensure: 1. Medications were not left unattended on top of Cart A; and 2. Cart A was locked while unattended.