Inspection Reports for
Golden Horizons

The complaint alleged the Housing Manager treated staff and tenants rudely and disrespectfully, making threatening statements. The investigation included interviews with staff and tenants, observations of interactions, and review of records. The complaint was partially substantiated with findings of rude and disrespectful behavior and failure to promote tenant autonomy, but no regulatory insufficiency was found for the rule violation related to tenant rights.

The investigation found a deviation from the requirements of the rules but did not meet the standards for a regulatory insufficiency. Multiple tenants and staff reported rude and disrespectful interactions involving the Housing Manager, including use of profanity and heated arguments, but no physical threats or intimidation were substantiated. The Housing Manager failed to promote tenant autonomy by involving a Power of Attorney without tenant permission. Additionally, a regulatory insufficiency was identified related to the evaluation of a tenant's cognitive status.

Complaint intake #41148-CR2 triggered the investigation. The complaint/incident investigator made observations related to occupancy agreements, service plans, nurse review, staffing, medications, policies and procedures, record checks, and compliance with the plan of correction. The complaint was substantiated with findings of regulatory insufficiencies in occupancy agreements and failure to follow the plan of correction.

The program failed to comply with regulatory requirements in occupancy agreements and compliance with the plan of correction. Several occupancy agreements were incomplete with blank spaces and missing information. The program also failed to follow the previously submitted plan of correction. No regulatory insufficiencies were noted in evaluation, nurse review, medications, policies and procedures, or record checks during the revisit. Staff demonstrated training on medications and hand washing. A $500 civil penalty was assessed.

Complaint/incident investigation conducted on March 4 and 5, 2013, substantiated repeated regulatory insufficiencies in service plans, nurse review, staffing, medications, policies and procedures, and record checks.

The program failed to comply with regulatory requirements in multiple areas including individualized service plans, nurse reviews, staff training, medication administration, and occupancy agreements. A $3,000 civil penalty was assessed due to repeated regulatory insufficiencies.

The complaint investigation was related to alleged medication errors due to untrained staff members. The investigation confirmed medication errors and deficiencies in staff training and medication administration procedures.

The report identified regulatory insufficiencies in tenant evaluations, service plans, nurse reviews, staffing, medication administration, policies and procedures, and record checks. Medication errors were documented, and staff training and documentation were found lacking. The program failed to comply with regulatory requirements, resulting in a civil penalty.

Complaint investigation was substantiated with findings of regulatory insufficiencies in multiple areas including medications, nurse review, food service, staffing, transportation, structural requirements, and background checks.

The investigation found multiple regulatory insufficiencies including improper medication administration, incomplete nurse reviews, inadequate food service documentation, insufficient staff training and nurse delegation, transportation safety issues, and incomplete background checks. The program was assessed a $500 civil penalty and submitted a Plan of Correction.