Inspection Report
Renewal
Deficiencies: 8
Dec 28, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Golden Options facility to assess compliance with regulatory standards and licensing requirements.
Findings
The inspection identified multiple deficiencies including life safety code violations with locked exit doors, lack of annual disaster plan review documentation, missing administrator continuing education hours, absent resident admission weight records, no current monthly activities calendar, improper medication storage practices, and outdated fire inspection documentation.
Deficiencies (8)
| Description |
|---|
| Two hallway doors leading to a wing of the facility had deadbolt locks, violating life safety code requiring egress doors to not require keys or special knowledge to open. |
| No documentation of annual Disaster Plan review with staff. |
| Administrator's employee file lacked evidence of 16 contact hours of annual continued education for 2022. |
| No documentation of weight taken on admission for Residents #1, #2, and #3; repeat deficiency from prior surveys. |
| No developed or posted monthly group activities calendar; no record of current or past three months' activities. |
| Medications were pre-dispensed into portion cups ahead of time and not stored in pharmacy-dispensed containers. |
| Administrator signs out medications on MARs and places them in portion cups ahead of time for staff to dispense. |
| Last documented annual fire inspection was conducted on 11/13/2020; repeat deficiency from prior survey. |
Report Facts
Facility License Number: 31522
Survey Date: Dec 28, 2022
Response Due Date: Jan 7, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kris Miller | Administrator | Named as Administrator and Staff #1 in findings related to continuing education and medication administration |
| Noelle Markland | Survey Team Leader | Lead surveyor for the renewal inspection |
Inspection Report
Renewal
Deficiencies: 10
Dec 13, 2019
Visit Reason
The inspection was conducted as a renewal inspection of the Golden Options facility to assess compliance with licensing and regulatory requirements.
Findings
The survey identified multiple deficiencies including unsigned policy and procedure manuals, incomplete resident service plans, lack of documentation for incident notifications to providers, inoperable call light systems, unsecured medication storage, missing oxygen use signage, housekeeping issues, excessively high water temperatures, and missing fire inspection documentation for 2019.
Deficiencies (10)
| Description |
|---|
| Policy and Procedure manual has not been signed/dated as reviewed for any date. |
| Resident service plans do not indicate self-administration of medication or medication stored in resident rooms as observed. |
| Resident service plans were not signed by resident, responsible party, or administrator and lacked evidence of review or copy given. |
| Incident reports lacked documentation for notification to resident’s provider or provider’s response. |
| Call light strings in resident room and main shower room were wrapped or knotted, rendering call systems inoperable. |
| Resident medications stored in unlocked and open bathrooms; residents do not close or lock doors when absent. |
| Resident using oxygen did not have a 'No Smoking, Oxygen in Use' sign posted to room. |
| Trash can in laundry room did not have a lid. |
| Hot water temperatures in rooms 12 and 13 were excessively high at 130 and 126.5 degrees respectively. |
| Administrator unable to locate fire inspection for 2019; last documented fire inspection was on 7/21/18. |
Report Facts
Water temperature: 130
Water temperature: 126.5
Incident report dates: 3
Inspection Report
Renewal
Deficiencies: 5
Dec 4, 2018
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
Multiple deficiencies were identified including missing employee files for the administrator and owner, incomplete resident file documentation for a deceased resident, lack of documentation for flame resistant window treatments, missed scheduled medications for a resident, and missing signature pages on medication administration records.
Deficiencies (5)
| Description |
|---|
| Administrator and owner, currently working as direct caregivers, do not have employee files. |
| Resident file for deceased resident missing circumstances of final transfer, notice to responsible parties, and disposition of personal possessions and medications. |
| No documentation noted for flame resistant window treatments. |
| Resident number two had not received scheduled 8AM medications by time of survey; administrator left facility with medication keys prior to survey. |
| Medication administration records are missing signature page of staff members giving medications. |
Report Facts
Missed medications: 3
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