Inspection Reports for
Golden Age Healthcare and Rehabilitation Center
27090 HWY 16, DENHAM SPRINGS, LA, 70726
Back to Facility Profile8 Reports
Inspection Report — Aug 27, 2025
Complaint Investigation CMS
Date: Aug 27, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that staff failed to treat Resident #5 with respect and dignity during care.
Complaint Details
The complaint was substantiated. Interviews with Resident #5, staff members S3CNA, S4CNA, S2LPN, and the Director of Nursing confirmed that S3CNA was rough and disrespectful to Resident #5 during care on 08/08/2025.
Findings
The facility failed to ensure Resident #5 was treated with respect and dignity. Staff member S3CNA was observed and reported to have been rough and disrespectful when assisting Resident #5, which was confirmed by interviews and the Director of Nursing.
Deficiencies (1)
F 0550: The facility failed to honor the resident's right to a dignified existence and respect. Staff member S3CNA was rough and disrespectful to Resident #5 during care, which was confirmed by multiple staff and the Director of Nursing.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3CNA | Named in finding for rough and disrespectful care to Resident #5. | |
| S4CNA | Witnessed interactions between S3CNA and Resident #5. | |
| S2LPN | Licensed Practical Nurse | Confirmed inappropriate behavior of S3CNA and intervened during care. |
| S1DON | Director of Nursing | Confirmed staff should treat residents with dignity and respect and that S3CNA's behavior was inappropriate. |
Inspection Report — Apr 1, 2025
Complaint Investigation CMS
Date: Apr 1, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging sexual abuse of a resident by a visitor at the facility.
Complaint Details
The complaint was substantiated. Resident #2 reported sexual abuse by a visitor on 02/11/2025, which was confirmed by interviews, clinical records, and law enforcement. The accused was arrested on 03/28/2025 for first degree rape/oral.
Findings
The facility failed to protect Resident #2 from sexual abuse by a visitor who forced his penis into her mouth on 02/11/2025. Corrective actions were implemented prior to the State Agency's investigation, including banning the accused visitor and providing counseling and increased monitoring for the resident.
Deficiencies (1)
F 0600: The facility failed to protect residents from sexual abuse, resulting in actual psychological harm to Resident #2 when a visitor sexually assaulted her on 02/11/2025. The facility implemented corrective actions prior to the investigation.
Report Facts
Residents Affected: 1
Visitor log time in: 13.34
Visitor log time out: 14.2
BIMS score: 15
Date of arrest: Mar 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Interviewed regarding the incident, reporting, and corrective actions. |
| S3SW | Social Worker | Interviewed Resident #2 and reported the abuse to administration and police. |
| S4CNA | Certified Nursing Assistant | Assigned to Resident #2 on the day of the incident and interviewed about observations. |
| S5LPN | Licensed Practical Nurse | Assigned to Resident #2 on the day of the incident and interviewed about observations. |
Inspection Report — Feb 19, 2025
CMS
Date: Feb 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident assessments and the administration of intravenous fluids.
Findings
The facility failed to ensure accurate coding of hospice care for one resident and failed to properly monitor, flush, and replace the saline lock IV access site for another resident, resulting in minimal harm or potential for harm.
Deficiencies (2)
F0641: The facility failed to ensure the MDS assessment accurately reflected hospice status for Resident #23, who was not coded correctly for hospice care in two quarterly assessments.
F0694: The facility failed to administer IV fluids according to professional standards for Resident #57 by not monitoring, flushing, or replacing the peripheral IV site as required.
Report Facts
Residents reviewed for hospice: 3
Residents reviewed for IV fluid therapy: 1
Physician orders for IV fluids: 2
Inspection Report — Feb 19, 2025
Routine CMS
Date: Feb 19, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, assessments, and safety at Golden Age Healthcare and Rehabilitation Center.
Findings
The facility was found deficient in maintaining a sanitary environment, accurate resident assessments, coordination of PASRR Level II recommendations, provision of scheduled showers, safe administration of IV fluids, and proper food storage in unit refrigerators. All deficiencies were associated with minimal harm and affected a few residents.
Deficiencies (6)
F 0584: The facility failed to maintain a sanitary environment for Resident #163 by not cleaning dried stool on the floor and bed sheets promptly.
F 0641: The facility failed to ensure the MDS assessment accurately reflected hospice status for Resident #23, with incorrect coding on two quarterly assessments.
F 0644: The facility failed to incorporate PASRR Level II determination and recommendations into Resident #167's care plan as required.
F 0677: The facility failed to provide scheduled showers for Resident #56, resulting in missed showers for a week without documentation or refusal.
F 0694: The facility failed to administer IV fluids properly for Resident #57 by not monitoring, flushing, or changing the peripheral IV site according to standards.
F 0812: The facility failed to store food under sanitary conditions by not labeling food items with resident names and dates in the unit refrigerator, potentially affecting 81 residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7CNA | Confirmed failure to clean stool in Resident #163's room | |
| S1ADM | Confirmed responsibility of nursing staff to maintain sanitary environment | |
| S4MDS | Confirmed inaccurate MDS hospice coding for Resident #23 and failure to incorporate PASRR Level II for Resident #167 | |
| S2DON | Confirmed inaccurate MDS hospice coding for Resident #23, failure to incorporate PASRR Level II for Resident #167, and improper IV site care for Resident #57 | |
| S6SSD | Verified PASRR Level II recommendations not incorporated into Resident #167's care plan | |
| S5MDS | Responsible for Resident #167's care plan; confirmed PASRR Level II not incorporated | |
| S12CNA | Confirmed Resident #56 missed showers during vacation period | |
| S14SUP | Confirmed hall CNAs assist with showers when shower aide is off | |
| S11CNA | Confirmed responsibility to shower Resident #56 and lack of documentation for showers | |
| S10CNA | Confirmed no showers given to Resident #56 in February 2025 | |
| S13ADON | Confirmed no documentation of showers for Resident #56 on 02/08/2025 | |
| S8LPN | Confirmed lack of IV site assessment and flushing for Resident #57 |
Inspection Report — Oct 9, 2024
Routine CMS
Date: Oct 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including communication of significant changes in condition, implementation of physician orders, and accident prevention.
Findings
The facility failed to ensure nursing staff communicated a resident's significant change in condition to the physician, failed to implement physician orders for wheelchair alarms and TED hose for two residents, and failed to implement fall prevention interventions after a resident's fall.
Deficiencies (3)
F 0580: The facility failed to ensure nursing staff communicated a resident's significant change in condition to the physician when a deformity in a resident's leg was identified but not reported.
F 0656: The facility failed to implement physician orders for Resident #6's wheelchair alarm and visual cue to wheelchair brakes and Resident #7's TED hose as ordered.
F 0689: The facility failed to ensure the resident's environment remained free from accident hazards by not implementing a chair alarm intervention after a fall for Resident #6.
Report Facts
Residents reviewed for injury: 1
Residents reviewed for comprehensive care plans: 6
Residents reviewed for accidents: 3
BIMS score: 6
BIMS score: 13
Incident date: Sep 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Nurse who failed to report Resident #3's leg deformity | |
| S5NP | Nurse Practitioner | Confirmed failure to report Resident #3's leg deformity |
| S2DON | Director of Nursing | Confirmed expectations for reporting and implementation of orders |
| S6LPN | Licensed Practical Nurse | Confirmed failure to implement wheelchair alarm and visual cues for Resident #6 |
| S7ADON | Assistant Director of Nursing | Confirmed failure to implement wheelchair alarm and TED hose orders |
| S9LPN | Licensed Practical Nurse | Confirmed Resident #7 did not have TED hose as ordered |
| S10CNA | Certified Nursing Assistant | Reported Resident #6 fall and lack of wheelchair alarm |
| S8CNA | Certified Nursing Assistant | Confirmed Resident #7 was not wearing TED hose |
Inspection Report — Jun 26, 2024
Routine CMS
Date: Jun 26, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living and infection prevention and control at the nursing home.
Findings
The facility failed to ensure a resident received scheduled bathing care and failed to maintain proper hand hygiene and cleaning techniques during incontinence care, posing minimal harm or potential for actual harm to residents.
Deficiencies (2)
F 0677: The facility failed to provide scheduled bathing care to Resident #3 on 05/20/2024 despite care plans and policies requiring assistance with activities of daily living.
F 0880: The facility failed to maintain an infection control program by not ensuring staff performed proper hand hygiene and glove changes during incontinence care for Resident #1.
Report Facts
Residents reviewed for Activities of Daily Living: 3
Residents reviewed for incontinent care: 2
Residents affected: 1
Residents affected: 1
Inspection Report — Mar 6, 2024
Complaint Investigation CMS
Date: Mar 6, 2024
Visit Reason
The inspection was conducted based on complaints regarding resident care, including failure to resolve grievances, inaccurate assessments, failure to follow physician orders, inadequate assistance with activities of daily living, improper medication storage, unsafe food temperatures, and inaccurate medical record documentation.
Complaint Details
The complaint investigation was triggered by reports that Resident #44 was not receiving scheduled baths, was left dirty, and that grievances were not properly filed or resolved. Additional complaints included inaccurate resident assessments, failure to follow physician orders, improper medication storage, unsafe food temperatures, and inaccurate documentation of resident care.
Findings
The facility failed to document and resolve grievances, ensure accurate MDS assessments, follow physician orders for nutrition, provide adequate personal hygiene care, secure medications properly, maintain safe food temperatures, and accurately document resident care activities.
Deficiencies (7)
F 0585: The facility failed to document and make prompt efforts to resolve grievances for Resident #44, who reported not receiving scheduled baths and being left dirty with unclean clothes.
F 0641: The facility failed to ensure accurate MDS assessments for Residents #8 and #149 by not coding the use of a chair alarm and dialysis services respectively.
F 0656: The facility failed to implement a person-centered care plan by not providing ice cream with lunch and dinner as ordered for Resident #43.
F 0677: The facility failed to provide necessary personal hygiene care to Resident #44, who missed multiple scheduled baths and was observed unclean with soiled clothes and foul odor in her room.
F 0761: The facility failed to ensure medications were stored properly during administration; medications were left unattended on an unlocked medication cart.
F 0812: The facility failed to maintain milk at safe temperatures (41°F or below) prior to serving, with observed temperatures up to 47°F.
F 0842: The facility failed to maintain accurate medical records for Residents #63 and #93 by not documenting scheduled baths and showers as required.
Report Facts
Residents reviewed for grievances: 3
Residents sampled for MDS assessment accuracy: 34
Residents reviewed for nutrition: 3
Residents reviewed for ADLs: 4
Milk temperature readings: 47
Baths not given: 12
Baths not given: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S15LPN | Licensed Practical Nurse | Named in medication storage deficiency for leaving medications unattended on medication cart |
| S1DON | Director of Nursing | Interviewed regarding multiple deficiencies including grievance process, medication storage, and documentation |
| S13LPN | Licensed Practical Nurse | Interviewed regarding Resident #44's bath schedule and documentation |
| S9CNA | Certified Nursing Assistant | Reported Resident #44 was not receiving scheduled baths and observed poor hygiene |
| S11CNA | Certified Nursing Assistant | Responsible for bathing Resident #44 but confirmed not giving baths as scheduled |
| S7CS | Staff | Observed milk temperature above safe range during food service |
| S8KC | Staff | Observed milk temperature above safe range during food service |
| S18CNA | Certified Nursing Assistant | Interviewed about documentation of baths for Resident #63 |
| S6CNA | Certified Nursing Assistant | Interviewed about showering Resident #93 and documentation responsibilities |
| S4CNA | CNA Supervisor | Verified shower documentation deficiencies for Resident #93 |
Inspection Report — Mar 16, 2023
Complaint Investigation CMS
Date: Mar 16, 2023
Visit Reason
Investigation of an allegation of physical abuse reported by Resident #165 and his family, and review of other resident care concerns including care plan implementation, medication administration, staffing, medication storage, and food safety.
Complaint Details
The complaint investigation was triggered by an allegation from Resident #165 and his family that a staff member hit him in the head. The facility did not report this allegation to the state agency and conducted a limited investigation, stopping after family indicated no concern. The allegation was not substantiated due to lack of evidence and resident cognitive impairment.
Findings
The facility failed to report an allegation of physical abuse to the state agency and did not conduct a thorough investigation. The facility also failed to implement residents' care plans, ensure proper medication administration and storage, maintain adequate staffing levels, and document kitchen sanitation and temperature checks.
Deficiencies (8)
F609: The facility failed to timely report suspected abuse and report investigation results to proper authorities for Resident #165.
F610: The facility failed to thoroughly investigate an alleged physical abuse incident involving Resident #165, stopping the investigation prematurely based on family input.
F656: The facility failed to implement comprehensive care plans for 3 residents, including incorrect diet for Resident #2, wound vac not continuously operating for Resident #168, and missing anti-roll backs and chair alarm on Resident #223's wheelchair.
F658: The facility failed to ensure staff observed residents taking medications, as pills were found partially dissolved in hand rails.
F725: The facility failed to provide sufficient Certified Nursing Assistant staffing to meet resident needs, resulting in residents waiting long periods for care and some care needs unmet.
F761: The facility failed to ensure medications and supplies were stored and labeled properly, including leaving medications unattended on carts, unlocked medication carts, expired medications available for use, and unlabeled insulin pens.
F812: The facility failed to maintain documentation of daily chemical sanitation checks for the dishwasher and temperature logs for freezers and coolers.
F835: The facility failed to administer in a manner that enabled effective use of resources by not reporting an allegation of physical abuse and not completing a thorough investigation.
Report Facts
Residents screened for abuse: 34
Residents affected by abuse reporting deficiency: 1
Residents reviewed for care plan implementation: 10
Residents affected by care plan deficiency: 3
Medication pills found partially dissolved: 10
Staffing hours short: 11
Residents assigned per CNA: 20
Medication carts reviewed: 5
Expired medications found: 3
Unlabeled insulin pens found: 2
Missing temperature logs: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1ADM | Administrator | Confirmed limited abuse investigation and non-reporting to state agency |
| S2DON | Director of Nursing | Confirmed abuse investigation details, medication administration and storage deficiencies, staffing issues, and medication cart checks |
| S7LPN | Licensed Practical Nurse | Observed leaving medications unattended and unlocked medication cart |
| S12CNAS | CNA Staffing Coordinator | Verified staffing shortages and assignment logs |
| S16CNA | Certified Nursing Assistant | Reported working alone on hall with 20 residents and staffing shortages |
| S17DS | Dietary Supervisor | Confirmed missing dishwasher chemical sanitation logs and temperature logs |
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