Inspection Reports for Golden Crest Nursing Centre

Deficiencies were identified in multiple areas including Freedom from Abuse and Neglect, ADL Care for Dependent Residents, Activities to Meet Resident Needs, Treatment and Services to Prevent Pressure Ulcers, Resident Records, and Fire Drills. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.

The survey included complaint investigations with intake reference numbers 2637102, 2688992, and 2635642.

Deficiencies were identified in multiple areas including freedom from abuse and neglect, ADL care for dependent residents, activities to meet resident needs, prevention and treatment of pressure ulcers, and maintenance of resident medical records. Additionally, a Life Safety Code deficiency was found related to fire drills not being conducted quarterly on all shifts.

The complaint was substantiated based on findings that Resident ID #1 had a witnessed fall on 2024-07-08 resulting in a hospital evaluation, and the facility failed to provide adequate care plans and interventions to prevent such incidents.

The facility failed to develop and implement individualized care plans with measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs related to Activities of Daily Living for 5 of 5 residents reviewed. Care plans lacked person-specific approaches and did not adequately describe the level of staff assistance required. Staff interviews revealed reliance on verbal communication rather than care plans to direct resident care.

The facility failed to store lidocaine patches in accordance with accepted professional principles for one resident, as the patches were found stored in the resident's room without an assessment for self-administration and should have been stored in the medication cart.

The facility was found deficient in multiple areas including failure to notify physicians of medication refusals, inadequate pressure ulcer care, failure to monitor significant weight gain, pharmacist failure to report medication irregularities, medication errors exceeding 5%, improper storage and labeling of medications, and failure to maintain infection prevention and control related to BIPAP equipment cleaning.

The facility failed to provide person-centered care by not ensuring the call light was within reach of Resident ID #67 as specified in the care plan. The call light was tied to the opposite side of the bed, out of the resident's sight and reach, which was acknowledged by staff and corrected during the survey.

The complaint alleged that Resident ID #1 lost 20 pounds over a month and did not receive prescribed nutritional supplements as ordered. The complaint investigation confirmed missed supplement doses due to back order. The fall risk deficiencies were identified through surveyor observation and interviews.

The facility failed to ensure Resident ID #1 received prescribed nutritional supplements due to unavailability, resulting in missed doses. Additionally, the facility failed to keep call lights within reach for Residents ID #2 and #3, posing fall risk hazards.

The complaint investigation was substantiated with findings of abuse and neglect related to a resident's behavioral contract restricting coffee and activities, which was not properly implemented or agreed upon by all parties. Multiple interviews and observations confirmed failure to protect the resident from abuse and neglect.

Deficiencies were cited at a scope and severity level H, constituting substandard quality of care. Key issues included failure to protect residents from abuse, failure to complete timely MDS assessments, failure to meet professional standards in care, inadequate treatment of pressure ulcers, failure to provide necessary ADL services, and failure to maintain accurate and confidential resident records.

The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 2 residents, failed to ensure the environment was free from accident hazards by not providing adequate supervision while eating for 1 resident, and failed to document wound measurements and treatment orders as required. Staff did not consistently follow care plans or physician orders, and supervision during meals was inadequate.

The facility was found deficient in multiple areas including failure to protect a resident from abuse related to restrictive behavioral contracts, failure to complete timely Minimum Data Set (MDS) assessments, failure to meet professional standards for abdominal girth measurements, inadequate assistance with activities of daily living, insufficient pressure ulcer care and documentation, lack of adequate supervision during meals, failure to provide appropriate nephrostomy care, and failure to follow infection control precautions during wound care.

The facility was determined not to be in compliance with requirements related to professional standards of care and treatment, including failure to ensure nursing staff followed physician's orders for pain medication and failure to provide necessary treatment and services to prevent and heal pressure ulcers for several residents.

The complaint investigation found substantiated deficiencies related to medication errors and pressure ulcer care failures affecting multiple residents.

The facility failed to ensure proper administration of pain medication for one resident and failed to provide appropriate pressure ulcer care and prevention for four residents. Deficiencies included incorrect medication dosing, failure to discontinue wound treatment as recommended, failure to ensure use of prescribed medical devices, and inadequate documentation and communication of care plans.