Golden Age Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to complete a recapitulation (a detailed summary of the resident's stay at the facility) for three of 12 sampled residents (Resident #42, #43 and #44). The facility census was 39. Review of the facility's undated Discharge Summary policy showed:-The facility will communicate necessary information to the resident, continuing care provider, and other authorized persons at the time of a discharge;-The discharging resident must have written discharge summary that includes a recapitulation of the resident's stay.1. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure staff served food to residents in a sanitary manner when Dietary Aide A served three residents their meals after touching unclean surfaces in the dining room with gloved hands without changing gloves or washing hands between each resident. This affected three of 12 sampled residents (Resident #22, #23 and #27). The facility census was 39. The facility did not provide the requested policy on sanitary handling of food served to the residents. 1. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/18/25 showed:- Severe cognitive impairment;- Partial assistance for activities of daily living (ADL)s;- Partial assistance for eating;- Diagnoses included cancer, high blood pressure and heart failure. [...]

Inspectors wroteBased on observation and interview the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections when the facility failed to ensure enhanced barrier precautions (EBP) were used for residents with wounds and/or an indwelling medical devices. This affected two residents (Resident #1, Resident #4) of 12 sampled residents. The facility census was 39. Review of facilities Enhanced Barrier Precautions policy, dated 10/2/2020, showed:-Enhanced Barrier Precautions apply to all residents with any of the following: wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy, or ventilator) regardless of MDRO (multidrug-resistance organisms) colonization status. [...]

Inspectors wroteBased on interview and record review the facility failed to prioritize its improvement activities; measure the success of actions, track performance; regularly review, analyze, and act on data collected regarding the facilities performance improvement plan. This had the potential to effect all residents. The facility census was 39. Review of the facilities Quality Assurance Performance Improvement Program (QAPI) policy, dated 10/31/2024, showed:- Design of the QAPI program will:-gather quality concerns and issues from a variety of data sources;-establish methods to identify quality issues then to correct or show targeted improvement through scheduled monitoring;-develop and implement corrective action and performance improvement programs, and monitor and evaluate the effectiveness of the corrective action/performance improvement activities, revising as needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure on resident, Resident #1 was free from verbal and physical abuse when Certified Nursing Assistant (CNA A) grabbed the resident's arm, jerking him/her back into the wheelchair, while yelling and cursing at the resident. The facility census was 43. Review of the facility's Abuse and Neglect Policy, dated 2/19/2014 showed: -Upon hire, all staff will be trained on the abuse and neglect policy and through on going in-services. -Prevention: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -An employee of this facility shall not knowingly: b. Fail to report an incident or suspected incident of abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to employee a full time Licensed Nursing Home Administrator (LNHA) for the facility who was responsible for operation of the facility. In addition the LNHA was not available on a full time basis in the facility to provide oversight including development of a Facility Assessment or oversee the Quality Assurance program to ensure the residents receive appropriate nursing and medical care. The census was 43. Review of the facility's Assistant Administrator Job Description, dated 3/22/24, showed: -Golden Age Nursing Home requires Administration to maintain a courteous professional manner while interacting and communicating with residents, their families, co-workers, and visitors. This extends to telephone conversations, and written or digital forms of communication. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies as required. This had the potential to affect all of the residents. The sample was 19. The census was 43. Review of the facility's Matrix for Providers, dated 8/28/24, showed a census of 43 and the following resident characteristics: -26 residents with Dementia diagnosis -One resident fed via tube -No residents on dialysis -Three residents with indwelling catheter -11 residents with falls -6 residents on Hospice services During an interview on 8/28/24 at 1:22 P.M. the Administrator said: - She does not work in the facility on a full time basis. -She did not know anything about a facility assessment and does not have one. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a signature from the resident or or resident's legal representative on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms prior to discharging from Medicare services for two residents (Resident #4 and #11) out of three sampled residents. The facility census was 43. Review of form instructions skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) Form CMS-10055, dated 4/8/2014, showed: -Signature and date: The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The skilled nursing facility may fill in the date if the beneficiary needs help. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the walls, hallways, ceilings and floors in a clean and homelike environment. Furthermore the facility failed to ensure furnishings were in good repair. The facility census was 43. The facility did not provide a policy for cleaning, maintenance of the facility and care of furnishings. Observations beginning on 08/28/24 at 11:06 A.M. showed on the 300 hall: -There was a gash in the sheet-rock between rooms [ROOM NUMBERS]; -There were multiple nicks and scratches in the sheet of the lower third of the hallway walls -Ceiling vent was rusted; -Multiple ceiling tiles had water stains; - Water stains on carpets in outpatient therapy room and room between the outpatient therapy and the exit door; -Multiple light fixtures had dead bugs and debris ; -There was water staining around vent outside room [ROOM NUMBER]; [...]

Inspectors wroteBased on interview and record review, the facility failed to check the Family Care Safe Registry (FCSR) prior to employment to ensure all newly hired employees as well as checking the NA Registry to verify that new employees did not have a Federal Indicator (marker given to individuals who have committed abuse/neglect. This affected eight out of eight sampled employees hired since August, 2024. The facility census was 43. Review of the facility's Personnel Policy, dated January 2020., showed no information in regard to the requirement for staff to complete criminal background checks prior to employment. Review of the facility's undated Abuse and Neglect Policy., showed: -No information regarding Family Care Safe Registry verification. -No information regarding all staff to be verified through the NA Registry. Review of new employee hire records in the years 2023 and 2024., showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five randomly sampled nursing staff (Nurse Aide A, Certified Nurse Aid A, B and C and Certified Medication Technician A)had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. The deficient practice potentially effected all residents. The facility census was 43. The facility did not provide a policy on competencies. Review of the employee files showed: -Nurse Aide (NA) A: -date of hire was 9/13/23 -No competency evaluation at the time of hire or within the last 12 months or since hire. -Certified Nurse Aide (CNA) A: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one nurse aide (NA) completed a nurse aide training program within four months of his/her employment in the facility. The census was 43. The facility did not provide a policy on use of Nurse Aides. Review of Nurse Aide (NA) A employee file showed: -Date of hire 9/13/23 -He/She completed an orientation module between 9/18/23 and 10/5/23. During an interview on 08/28/24 04:11 PM NA A said: -He/She began employment while he/she was in high school. -He/She did not attend a Vocational Technical School for Certified Nurse Aide (CNA) training. -He/She was not enrolled in CNA classes. -Administration had not discussed CNA classes with him/her. -He/She was not aware he/she needed to be certified within 4 months of hire. The administrator was not available for interview. During an interview the Director of Nursing said: [...]

Inspectors wroteBased on record review and interview the facility failed to have administrative oversight for the Quality Assurance and Performance Improvement (QAPI) program. This had the potential to effect all residents. The facility census was 43. Review of the facility policy QAPI Program dated 2/13/23 showed: -The Board of Directors and Administration of the facility are responsible and accountable for the ongoing QAPI Program. Review of the facility QAPI meeting minutes for 2024 showed the Administrator did not attend the meetings on: -February 2nd -May 30th -June 21st -August 1st During an interview on 8/27/24 at 3:29 P.M. the Human Resources/QAPI Coordinator said: -Administration is not always at the meetings because of their availability. -The Administrator works 2 days a week. -The Assistant Administrator was in the facility daily. During an interview on 8/28/24 at 2:23P.M. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure quarterly quality assessment committee (QAA) meetings were held with the required members. The facility census was 43. Review of the facility provided policy Quality Assessment and Assurance (QAA) Committee dated 3/3/23 showed: -The facility will maintain a QAA Committee consisting of the following representatives: -Administrator -Medical Director (licensed physician) -Director of Nursing -Infection Preventionist -Clerical staff -Staff members may be assigned for expertise and work perspective in the area under study Review of the facility provided QAA meeting notes showed only the Medical Director and Director of Nursing (DON) were present for meetings: -January 31, 2024 -Apirl 22, 2024 - No meeting in July 2024. -August 24, 2024 During an interview on 08/28/24 at 1:37 P.M. the DON said: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an effective training program for all new and existing staff was in place, when the facility failed to complete a facility assessment to include: Staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. Furthermore, the facility failed to track attendance and hours of training for staff members who required at least 12 hours of education yearly. This had the potential to effect all residents. The facility census was 43. The facility did not provide their Facility Assessment. The facility did not provide a policy on education of staff and competencies. Review of education records showed: - Quality Assurance and Performance Improvement education was completed 1/10/24; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure continued competence of nurse aides when they failed to perform competency evaluations, at least yearly, for 5 randomly sampled nursing staff (Nurse Aide A, Certified Nurse Aid A, B and C and Certified Medication Technician A). This had the potential to effect all residents. The facility census was 43. The facility did not provide a facility assessment or a policy on competency. Review of the employee files showed: -Nurse Aide (NA) A: -date of hire was 9/13/23 -No competency evaluation at the time of hire or within the last 12 months or since hire. -Certified Nurse Aide (CNA) A: -date of hire was 5/17/22 -No competency evaluation at the time of hire nor within the last 12 months -CNA B : -date of hire 9/14/17 -No competency evaluation at the time of hire nor within the last 12 months -CNA C: [...]

Inspectors wroteBased on interview and record review, the facilty failed to follow their abuse and neglect policy when staff failed to immediately intervene and report witnessing two separate incidents of staff to resident physical and verbal abuse to facility administration. The facility census was 43. Review of the facility's Abuse and Neglect Policy, dated 2/19/2014 showed: -Upon hire, all staff will be trained on the abuse and neglect policy and through on going in-services. -Prevention: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -An employee of this facility shall not knowingly: b. Fail to report an incident or suspected incident of abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep one cognitively impaired resident (Resident #1) safe from verbal and physical abuse when Certified Nursing Assistant (CNA A) grabbed the resident's arm, jerking him/her back into the wheelchair, while yelling and cursing at the resident. The facility census was 43. Review of the facility's Abuse and Neglect Policy, dated 2/19/2014 showed: -Upon hire, all staff will be trained on the abuse and neglect policy and through on going in-services. -Prevention: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. -An employee of this facility shall not knowingly: b. Fail to report an incident or suspected incident of abuse. [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia and failed to review it annually. The facility also failed to ensure facility staff were informed of the facility's Water Management Plan. The facility census was 43. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: -Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) and other opportunistic waterborne pathogens (e.g. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they maintained a Department of Health and Senior Services (DHSS) approved surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 43. The facility did not have a policy for surety bonds. Review of the facilities approved surety bond, approved on 12/23/2011 showed an approved amount of $15,000.00. Review of the RTF worksheet on 01/12/2023 showed: -The average monthly balance for the facility's interest bearing account of $18,934.23; -The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 = required bond amount) should be at least $28,500. During an interview on 01/12/23 at 10:20 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure puree food items were prepared according to the recipe to conserve nutritive value, flavor and appearance. This effected the four residents who had orders for puree diet. The facility census was 43. Review of the facility's Puree (texture-modified diet that can be useful for people with chewing difficulties) diet policy, undated showed: - When preparing a pureed diet, measure portions before processing. - When preparing meat, puree with a broth or other liquid. All meat must be moistened and served with low fat sauce or gravy to allow for ease in swallowing. Observation of [NAME] A preparing the puree meal for lunch on 1/11/23 at 11:30 A.M., showed: - Breaded pork chop, white and wild rice, broccoli and apple cobbler on the menu. - He/she placed four breaded pork chops in blender and blended up. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure stored dishes were clean and free from dust and food particles, failed to monitor the chemicals in the dishwasher were reaching proper sanitation, failed to maintain kitchen tiles were in good repair and in sanitary condition to prevent food contamination and failed to maintain the kitchen in a sanitary manner. This has the potential to affect all residents residing in the facility. The facility census was 43. Review of the facility's cleaning policy, undated showed: - Ensure a clean and sanitary dietary environment. - All equipment, food contact surfaces and utensils shall be cleaned. - All food surfaces will be cleaned at the end of each food preparation session. - The floor of the kitchen must be cleaned daily and after each spill or contamination. - Refrigerator units must be cleaned monthly. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI) plan and failed to have a plan that contained all required elements. Facility census was 43. Review of facility policy, QAPI, dated 1/11/23, showed: -The issues and projects addressed at QAPI committee meetings will include both clinical and non-clinical issues for quality assurance or performance improvement. -The QAPI committee will consider all assessments and recommendations reported by audit or analysis, or complaints received and referred by the sub-committee; submit findings of performance improvement projects (PIPs) to the chair person; recommendations will be made for resolutions of issues reported and/or PIPs; and consider/select requests for projects. [...]