Golden Age Nursing Home

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's grievances related to missing property were investigated and resolved. This deficient practice was identified for three (3) of seven (7) residents reviewed for grievances (Residents #1, #2, and #3)

Inspectors wroteBased on resident and staff interviews, record review and facility policy review, the facility failed to ensure residents were free from misappropriation of property for one (1) of four (4) residents reviewed (Resident #1).

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure that allegations of abuse and misappropriation were reported immediately to the State Agency within required timeframes. This deficient practice was identified for two (2) of seven (7) residents reviewed for reporting of allegations (Residents #1 and #4).

Inspectors wroteBased on staff interviews, record reviews, and facility policy reviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment was coded accurately for three (3) of twenty-one sampled residents. Residents #18, #54, and #81.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to follow nursing standards of practice as evidenced by administering a resident's medication by the wrong route for eight (8) of 38 medication opportunities observed. Resident #30 Findings Include: Cross Reference F759 Review of the facility policy titled, Medication Administration -General Guidelines unrevised, revealed under, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices . Also revealed under, A. Preparation . 4) Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to implement interventions to maintain nutritional status for one (1) of eight (8) residents reviewed for nutritional status. Resident # 20.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure an as-needed (PRN) psychotropic medication had a stop date for two (2) of five (5) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was not five (5) percent (%) or greater for eight (8) of 38 medication opportunities. The medication error rate was 21.05%. Resident #30 Findings Include: Cross Reference F658 Review of the facility policy titled, Medication Administration -General Guidelines unrevised, revealed under, A. Preparation . 4) Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away .B. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to use enhanced barrier precautions (EBP) during wound care for one (1) of five (5) resident direct care opportunities during the survey. Resident #59 Findings Include: Review of the facility policy titled, Enhanced Barrier Precautions with a revision date of 5/24 revealed under, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .2. Initiation of Enhanced Barrier Precautions: An order for enhanced barrier precautions will be obtained for residents with any of the following: i. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, freezers, and dry storage room were dated, labeled, and discarded by the expiration date for one (1) of two (2) kitchen tours.

Inspectors wroteBased on staff interview ,record review, and facility policy review, the facility failed to accurately code antipsychotic medication for two (2) of 18 Minimum Data Set (MDS) assessments reviewed. Resident #61 and #62.

Inspectors wroteBased on observations, resident and staff interview, record review and facility policy review the facility failed to implement a care plan for removing facial hair on a resident that was dependent on staff for Activities of Daily Living (ADL) [Resident #28], and failed to develop a care plan for positioning of right arm and positioning of a urine catheter bag [Resident #228] for three (3) of 18 care plans reviewed.

Inspectors wroteBased on observations, staff and resident interview, record review and facility policy review the facility failed to remove facial hair on a resident that was dependent on staff for their Activities of Daily Living (ADL) for one (1) of 18 resident's reviewed for ADL's. Resident #28. Findings Include: Review of the facility policy titled, ADL Basic Care with a revision date of 4/25/17 revealed, A. All residents are given or are assisted with their bathing, showering or bed bath . An observation on 07/24/23 at 3:53 PM, revealed that Resident #28 had dark hair approximately 1/8 of an inch long above her lip with a patch of black hair 1/8 of an inch wide and long on either side of her mouth and black hair stubble approximately 1/8 inch long covering her chin. An observation on 07/25/23 at 09:13 AM, revealed that the hair above Resident #28's lips and on her chin remained as it was yesterday. [...]

Inspectors wroteBased on observations, resident and staff interview, record review and facility policy review, the facility failed to provide treatment and care to address a resident's positioning needs that were in accordance with professional standards of practice for one (1) of (18) residents reviewed on sample.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to maintain a urinary catheter drainage bag below the bladder to prevent the potential of infection for one (1) of two (2) residents with a urinary catheter in the facility.

Inspectors wroteBased on staff interview, record and policy review the facility failed to ensure residents were free from unnecessary medications as evidenced by no documented monitoring for side effects of psychotropic medications for two (2) of five (5) residents reviewed for unnecessary medications. Resident #61 and Resident #62.