Golden View Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that 3 allegations of neglect were reported timely to the Administrator of the facility and the State Survey Agency (SSA) for 3 of 8 residents reviewed for Abuse or Neglect. (Resident identifiers are #3, #4, and #5.)

Inspectors wroteBased on interview and record review, the facility failed to maintain evidence demonstrating the result of all grievances and ensure that all written decisions include the necessary elements for 2 out of 2 grievances reviewed.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement infection control policies for 1 of 3 residents reviewed for Transmission Based Precautions (TBP) and failed to implement water management control measures, potentially exposing 72 residents to waterborne pathogens. (Resident identifier is #12.)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure sanitization of dishware and failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchens and 2 of 2 kitchenettes observed. Findings Include: Refrigerator Temperatures Review on 11/4/24 of the Main Kitchen refrigerator/freezer temperature logs, Cascade/Retreat refrigerator/freezer temperature logs, and the third floor refrigerator/freezer temperature logs for October and November 2024 revealed no logs were available for November 2024 (11/1, 11/2, and 11/3), and missing temperatures for 10/2, 10/22, 10/24, 10/28, 10/29, and 10/31. Observation on 11/4/24 of the third floor refrigerator revealed no thermometer for taking temperatures. Interview on 11/4/24 8:00 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) to prevent the spread of infections for 4 out of 8 residents reviewed for EBP in a final sample of 15 residents (Resident Identifiers are #12, #16, #23, and #39).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow procedures in place for self-administration of medications for 2 residents out of 4 residents reviewed for choices in a final survey sample of 16 residents (Resident Identifiers are #38 and #28).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that licensed staff had infection control competencies in skills and techniques necessary to care for residents' needs for 6 of 6 staff reviewed (Staff Identifier's are A, B, C, M, N, and O).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate less than 5 percent for 3 of 29 medications observed during medication administration (Resident Identifiers are #22, #47 and #25).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to accurately code Minimum Data Set (MDS) assessments for 4 residents in a final sample of 15 residents (Resident Identifiers are #15, #3, #24, #27). Findings Include: Resident #15 Review on 11/5/24 of Resident #15's Preadmission Screening and Resident Review (PASARR) Determination Summary Level II, due to mental illness, dated 5/5/23, revealed that Resident #15 was approved for Nursing Facility Services. Review on 11/5/24 of Resident #15's Annual MDS with an Assessment Reference Date (ARD) of 7/15/24 revealed Section A 1500 was coded as No for Level II PASARR.Resident #3 Review on 11/5/24 of Resident #3's Significant Change in Status MDS with an ARD of 10/24/24 revealed under section N0415 Medications: High-Risk Drug Classes: Use and Indication E. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to notify the physician of medications not administered to the resident for 3 residents in a final sample of 18 residents (Resident Identifiers are #17, #23 and #30).

Inspectors wroteBased on interview, record review, policy review, and manufacturer's instructions, it was determined that the facility failed to inform the resident or resident's representative of the risks and benefits of Antipychotic medication for 2 out of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident Identifiers are #25 and #42).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a discharge summary that contains all the necessary elements for 1 out of 1 residents reviewed for discharge (Resident Identifier is #62).

Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide a stop date for an as needed (PRN) psychotropic medication for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident identifier is #59).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to promptly notify the ordering practitioner of abnormal laboratory (lab) results according to the facility's policies and procedures for notification for 1 of 1 resident reviewed for lab results in a final survey sample of 18 residents (Resident identifier is #23).

Inspectors wroteBased on observation and interview, the facility failed to use facial hair restraints when serving food from the steam table for 2 of 3 units observed for meal service (Units Observed: The Pines Unit and The Cascade Unit).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to send a copy of a written notice of transfer/discharge to the Office of the State Long Term Care Ombudsman (OLTCO) for 1 of 1 residents reviewed for discharge and 1 of 1 residents reviewed for hospitalizations in a final sample of 18 residents (Resident identifiers are #16 and #62).