Inspection Reports for
Golden Age Care Center

The facility has accepted the allegation of substantial compliance and submitted a Plan of Correction to address deficiencies, with certification of compliance effective December 17, 2025.

The facility failed to keep all medications in a locked medication cart inaccessible to unauthorized staff and residents. An incident was reported where a controlled medication was left unattended and subsequently went missing.

Complaint #2594081-C was investigated and substantiated based on evidence including staff interviews, record reviews, and observation of medication storage and administration practices.

The facility failed to keep all medications in a locked medication cart inaccessible to unauthorized staff and residents, resulting in a medication being left unattended and not administered properly to Resident #1. The investigation included staff interviews, record reviews, and policy reviews, confirming noncompliance with drug storage and administration protocols.

The facility, Golden Age Care Center, is certified in compliance effective August 17, 2025, based on acceptance of the credible allegation of substantial compliance and plan of correction.

The facility failed to provide appropriate pressure ulcer care for one resident and failed to ensure one resident was free from significant medication errors due to omitted insulin doses. Documentation and treatment adherence issues were noted.

The facility was found deficient in multiple areas including medication self-administration documentation, grievance resolution, pressure ulcer care, medication administration errors, pneumococcal vaccination policies, and call light system functionality. Deficiencies were generally of minimal harm and affected few residents.

The survey included investigation of complaints #1767344 and #1767346 which resulted in deficiencies.

The facility was found deficient in several areas including self-administration of medications, grievance handling, pressure ulcer treatment, medication error prevention, immunizations, and resident call system functionality. Deficiencies were supported by clinical record reviews, policy reviews, staff and resident interviews, and observations.

The investigation was complaint-related focusing on Resident #3's lack of restorative therapy and delayed treatment for groin discomfort. Resident #3 expressed frustration about therapy interruptions and inadequate care. The complaint was substantiated based on interviews and record reviews.

The facility failed to provide restorative activities as planned for Resident #3 and did not ensure appropriate assessment and interventions to maintain the resident's optimal health and well-being. Documentation and interviews revealed missed restorative tasks and delayed treatment for groin discomfort.

Complaint #127183-C was substantiated.

The facility was found to have deficiencies related to activities of daily living and quality of care, specifically failing to provide restorative activities and appropriate assessments and interventions for residents, including Resident #3. Complaint #127183-C was substantiated.

The complaint investigation found that the facility did not notify the physician or the resident's power of attorney about the new blistered wound discovered on 7/3/24 and failed to obtain treatment orders. The power of attorney was unaware of the severity of the wound until visiting on 7/13/24.

The facility failed to notify the physician and the resident's power of attorney about a new blister on Resident #1's left foot and did not obtain physician orders for wound treatment. The blister grew over time without proper medical notification or orders, despite staff awareness.

Complaint #122064-C was substantiated based on clinical record review, staff interviews, family interview, and provider interview.

The facility failed to notify the physician and resident's power of attorney (POA) upon discovery of a new blistered area on Resident #1's left foot and failed to obtain treatment orders for the wound. The blister grew in size and treatment orders were not obtained despite wound progression. The ARNP was not initially aware of the wound due to being on vacation. Resident #1 had multiple comorbidities contributing to skin issues.

The complaint investigation was substantiated. Resident #3 expressed embarrassment and humiliation due to being moved to a feeding assistance table without her consent. Staff and the Director of Nursing confirmed the move was made due to feeding difficulties but without resident inclusion or communication.

The facility failed to treat Resident #3 with dignity by moving her abruptly to a feeding assistance table without her consent, causing emotional distress. Interviews and records confirmed the resident's frustration and embarrassment, and staff acknowledged the move was made without resident inclusion or proper communication.

The facility failed to treat a resident with dignity by moving her abruptly to a feeding assist table, failed to complete a criminal background check for one staff member, served inappropriate diet consistency to residents on mechanical soft diets, and did not implement adequate infection control measures including a plan to prevent Legionella growth in water systems.

Complaint #111301-C, #116489-C, #116570-C were substantiated.

The facility was found deficient in multiple areas including failure to treat a resident with dignity, failure to complete a criminal background check for a staff member, failure to serve diets at the appropriate consistency, and failure to implement adequate infection prevention and control measures including Legionella prevention.

Multiple complaints were investigated during the survey period. Several complaints were substantiated including complaints #93591-C, #94454-C, #95328-C, #96284-C, #96427-C, #102676-C, #102677-C, #103884-C, #104928-C, and facility reported incidents #99530-I and #104930-I. Some complaints were not substantiated. The facility lacked documentation for some complaints and investigations.

The facility was found to have multiple deficiencies including failure to treat residents with dignity, protect residents' property, prevent abuse and neglect, properly investigate allegations of abuse, and ensure quality of care including medication administration and PASRR compliance. Several complaints were substantiated. The facility reported a census of 36 residents during the survey.

This visit was complaint-related, triggered by concerns about COVID-19 reporting. The facility was found non-compliant with notification requirements. Substantiation status is not explicitly stated.

The facility was found not to be in compliance with COVID-19 reporting requirements, specifically failing to notify residents, representatives, and families of confirmed COVID-19 cases within the required timeframe. Interviews confirmed the facility did not inform residents or staff testing positive for COVID-19.

Complaints #85762, #88859, and #89169 were investigated and found not substantiated.

The facility failed to provide care consistent with professional standards to prevent pressure ulcers, as evidenced by Resident #3 developing a pressure ulcer. The facility did not implement adequate interventions to prevent the wound and failed to document the wound properly.