Golden Years Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established national guidelines, were prepared in advance and were followed for 1-of -1 reviewed for menus. 1. The facility failed to ensure current, accurate menus were provided and visible to residents for one dining area 2. The facility failed to ensure residents were offered individual menus for meal which is not a homelike environment. These deficient practices could place at risk of not getting food that they want or like.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure that expired foods were discarded. 2. The facility failed to ensure the food processor was sanitized between each food item. 3. The facility failed to ensure food items were labeled and dated. 4. The facility failed to ensure that serving utensils and dishes were not stored dirty. These failures could place residents at risk for foodborne illness, causing the residents to get sick in 1 of 1 kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the medical record was complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to document nursing progress notes, assessments, or transfer documents when Resident #1 was transferred to the acute care hospital on [DATE]. This failure could place residents at risk for not receiving appropriate care due to incomplete information in the chart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility for 1 of 1 full recertification survey (Survey A) reviewed for survey results. The facility failed to post the results of Survey A dated 04/27/23 in a public area for all residents and visitors to view on 07/01/24. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care based on the comprehensive assessment of a resident and in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 16 Residents reviewed for quality of care The facility failed to perform Resident #33's left fifth toe wound treatment as ordered on 07/01/24. This failure placed residents at risk of worsening infection, sepsis, and amputation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 05/21/2024. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 5/21/2024 and ended on 5/22/2024 The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of 1 of 3 (Resident # 2) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident's #2's Ativan 0.5 mg, 60 tablets (an anti-anxiety medication) received from the pharmacy on 5/22/2024 at 12:17 am and reported missing 5/22/2024 during the day shift. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. The non-compliance was identified as Past non-compliance, the facility had corrected the non-compliance before the survey began.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates for 1of 2 medication rooms and 2 of 4 medication carts reviewed for medication storage. -The facility failed to date a multi-use product (eye drops) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts and medication rooms. -The facility failed to ensure medications were stored in a clean, safe, and sanitary manner. These failures place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for one (Resident #2) of 15 residents reviewed for care plans. The facility failed to identify Resident #2's preference for wearing a hospital gown daily instead of her personal clothing. This failure put residents at risk for their preferences not to be honored and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of one resident reviewed for catheter care (Resident #11). The facility failed to ensure Resident #11's catheter was secured to his body with a catheter secure device. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a therapeutic diet as prescribed by the attending physician for one (Resident #15) of eight residents reviewed for therapeutic diet. The facility failed to provide Resident #15 with the therapeutic diet as prescribed by her attending physician when she was provided a meal with extra carbohydrate portions when she was prescribed a consistent carbohydrate diet order. This failure put residents at risk for health complications related to in adherence to diet order, increased blood sugar and decreased quality of life.