The Golden Rule Home

Inspectors wroteBased on interview and facility document review, the facility failed to ensure that the designated director of food service met the minimum required qualifications. Specifically, the facility did not employ a full-time Registered Dietitian (RD), and the facility Dietary Manager (DM) was not a certified dietary manager or certified food service manager, nor did she have an associate's degree or higher in food service management. This failed practice had the potential to affect 52 residents who received meals from the kitchen (total census: 56).

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to follow the planned, written menu for 1 of 2 meals observed. Specifically, the facility served incorrect portion sizes for the lunch meal on 06/09/2026. This failure had the potential to affect 52 residents who received meals from the kitchen (total census: 56).

Inspectors wroteBased on interview and facility document and policy review, the facility failed to ensure the Medical Director participated in the facility's Quality Assurance and Performance Improvement (QAPI) Committee meetings as required for 13 of 13 reviewed QAPI meetings held during the timeframe from 05/30/2025 through 05/29/2026.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed on a quarterly basis and submitted within the required timeframe for 17 (Residents #33, #12, #16, #17, #18, #22, #23, #3, #35, #38, #40, #43, #44, #45, #5, #54, and #8) of 18 residents reviewed for resident assessments.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess smoking safety prior to allowing residents to smoke unsupervised, failed to supervise residents who required supervision with smoking, and failed to ensure residents who smoked did so in accordance with the facility's smoking policy. Failed practices were identified for 3 (Residents #68, #50, and #55) of 3 residents reviewed for smoking. The failed practices had the potential to affect 14 residents who smoked, according to a list provided by the facility. Specifically, the facility failed to:- reassess smoking safety and need for supervision for Resident #68 after the resident was observed in the smoking area with oxygen in use on two occasions;- assess Resident #50 for safety while smoking; [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was assessed for the ability to safely self-administer medication and failed to obtain a physician's order prior to allowing the resident to self-administer medication for 1 (Resident #33) of 8 sampled residents reviewed for self-administration of medications.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure a certified nursing assistant (CNA) immediately reported an allegation of suspected abuse in a manner consistent with the process outlined in the facility's abuse policy for an incident involving 1 (Resident #20) of 4 sampled residents reviewed for abuse. Specifically, CNA #11 notified the off-duty Assistant Director of Nursing (ADON) of suspected abuse by way of text message instead of notifying a supervisor on-duty or the facility's Abuse Coordinator directly as specified in the facility's abuse policy, which resulted in a delayed initial report submission to the state survey agency (SSA).

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure medication administration was accurately documented in the medical record for 1 (Resident #73) of 22 residents whose medical records were reviewed.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure the proper storage of respiratory equipment for 1 (Resident #33) of 2 sampled residents reviewed for respiratory care, and failed to ensure staff used personal protective equipment (PPE) during the care of a resident on Enhanced Barrier Precautions (EBPs) for 1 (Resident #7) of 1 sampled resident reviewed for EBP. Specifically, Resident #33's nebulizer mouthpiece was not stored in a bag or closed container when not in use to prevent potential contamination, and staff performed wound and incontinence care for Resident #7 without donning the appropriate PPE.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the right to formulate an advance directive for two (#24 and #25) of three sampled residents reviewed for advance directives. The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/01/24, documented 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure careplans were updated quarterly for three (#14, 26, and #27) of 14 sampled residents reviewed for careplans. The DON identified 34 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to conduct thorough skin assessments weekly for one (#138) of one sampled resident reviewed for non-pressure related skin conditions. The DON identified 34 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff properly utilized hair nets for one (Cook #1) of three sampled employees observed for kitchen sanitation. The DON identified 34 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a) turn and reposition a resident with pressure ulcers for one (Res #2) of three sampled residents reviewed for pressure ulcers, b) obtain orders for treatment of pressure ulcers upon admission for one (Res #2) of three sampled residents reviewed for pressure ulcers, and c) complete weekly wound assessments for one (Res #3) of three sampled residents reviewed for pressure ulcers. The ED identified 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide hydration to a resident each shift for one (Res #2) of three residents reviewed for hydration and nutrition. The ED identified 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to provide adequate supervision to prevent elopement which resulted in a past noncompliance immediate jeopardy (IJ) situation effective from 05/28/23 to 05/30/23 for one (#15). Res #15 eloped from the facility on 05/24/23 and was found 300 yards away on a county road. The facility put interventions in place up through 05/28/23. The resident eloped again on 05/30/30 and was found in a nearby field. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician responded to the pharmacy medication regimen review recommendations in a timely manner and failed to have a policy which included time frames for the different steps in the process for two (#25 and #15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who received psychotropic medications received a gradual dose reduction for an antidepressant medication in a timely manner for one (#25) and an acceptable diagnoses/indication for the use of an antipsychotic medication for one (#15) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form, documented 22 residents received psychoactive medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5% for three (#2, 6, and #14) of eight residents observed during medication pass. A total of 36 opportunities were observed with 21 errors. Total error rate was 58.33%. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate coding of MDS assessments for indwelling catheters and anticoagulant use for two (#3 and #10) of 16 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a new serious mental illness to OHCA for a level II evaluation for one (#11) of one residents sampled for PASRR level II evaluations. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure a comprehensive care plan was developed for dementia for one (#15) of 16 sampled resident whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plans were updated related to accidents for one (#25) of three residents reviewed for accidents. The Resident Census and Conditions of Residents form documented 36 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. provide nail care for a resident who was unable to carry out activities of daily living for one (#13) of 16 sampled residents. b. provide showers per the plan of care and/or resident preference for one (#18) of three residents sampled for activities of daily living. The Resident Census and Conditions of Residents form documented 31 residents required the assistance of staff with ADLs.