Inspection Reports for
Golden Age Living Center

Complaint 2664063 regarding missing controlled narcotic medication for Resident #1 was substantiated by findings that the facility did not investigate or document the discrepancy as required by policy.

The facility staff failed to complete an investigation related to the missing controlled narcotic medication. Documentation of the investigation was absent, and the Director of Nursing did not follow facility policy for investigating and documenting the medication discrepancy. The administrator was aware of the issue but did not ensure proper follow-up or documentation.

The facility failed to consistently document residents' code status (DNR/Full Code) in care plans and orders for multiple residents. Additionally, the facility did not perform required pre-dialysis assessments and lacked proper communication with the dialysis clinic for one resident.

The facility failed to ensure hazardous area doors were self-closing and smoke resistant, and failed to secure oxygen cylinders properly, posing fire and safety risks. Multiple hazardous areas and oxygen storage deficiencies were identified, with potential impact on all facility occupants.

The facility failed to post required telephone numbers and resident rights information in the secured memory care unit. Additionally, the fire alarm system was out of service for more than four hours without proper procedures in place, posing a risk to all occupants.

The facility was found to have deficiencies related to the fire alarm system being out of service for more than four hours, the sprinkler system being out of service for more than four hours, and improper use and maintenance of electrical extension cords and power strips. Policies and procedures related to fire watch and system impairments were incomplete or missing required elements.

The facility failed to post the telephone number for the Adult Abuse and Neglect Hotline, the name, address, and phone number for the Long-Term Care Ombudsman, and resident rights in a form accessible to residents and visitors on the secured MCU. Interviews with staff and residents confirmed the information was not accessible on the MCU but was located elsewhere in the facility.

The facility failed to conduct comprehensive assessments and care plans for residents as required by regulations. Documentation deficiencies were noted in the Care Area Assessment (CAA) summaries and comprehensive care plans for multiple residents.

The facility failed to document the date and location of supportive CAA documentation for 12 sampled residents and failed to develop and implement complete care plans addressing triggered care areas with measurable goals and time frames for multiple residents. Staff did not document rationales for decisions not to proceed with care plans for triggered areas, and the facility lacked a comprehensive care plan policy.

The facility failed to maintain and test the fire alarm system smoke detectors for sensitivity as required, did not conduct fire drills quarterly on each shift as required, failed to maintain the emergency generator's remote manual stop station, and failed to properly maintain oxygen storage safety measures. These deficiencies have the potential to affect all facility occupants.

The facility failed to ensure residents were free of significant medication errors, as evidenced by a medication error involving Resident #1 who received Lantus insulin not prescribed, resulting in low blood sugar and required emergency treatment. The facility's policies on medication administration and error documentation were reviewed and found deficient.

The facility failed to follow its medication disposal policy when Certified Medication Technician A dropped medications for three residents and did not properly dispose of them. Observations and interviews confirmed multiple instances of improper medication handling and administration.

The facility failed to ensure staff had access to all areas of the building at all times, did not conduct required annual functional tests of emergency lighting and emergency generator systems, and had fire safety deficiencies including door-locking arrangements and emergency lighting.

The facility failed to maintain doors in a means of egress readily accessible at all times, including failure to post exit codes, ensure doors had positive latching hardware, and maintain inspection/testing records for fire doors and electrical receptacles. The facility also failed to provide continuing education on safety guidelines for medical gases and their cylinders.