Inspection Reports for
Golden Years Homestead

This finding relates to Intake 2652223.3.1 - 37 (a). The complaint involved failure to monitor opioid side effects and notify the resident's POA of medication changes. The complaint was substantiated based on the investigation.

The facility failed to monitor for adverse side effects of opioid medications with increased doses for one of three residents reviewed for pain management. The resident's power of attorney was not notified of medication changes, and monitoring documentation was incomplete prior to the resident's death.

The facility failed to accurately assess mobility for 1 of 4 residents reviewed. Resident 35's assessment did not reflect impairments observed during the inspection, and the Minimum Data Set (MDS) assessment was incomplete regarding upper extremity impairments.

This citation relates to Complaint 1229505. The complaint involved allegations of verbal and physical abuse by CNA 5 towards Residents B, D, and H. The allegations were substantiated by interviews and record reviews, but the facility failed to report them timely to the Administrator and state agency as required.

The facility failed to timely report allegations of verbal abuse and mistreatment involving three residents to the Administrator and state agency. Multiple interviews and record reviews confirmed incidents of CNA 5 yelling at residents, turning off call lights, and not providing care as required. The Director of Nursing and Administrator were not notified as required by policy.

Complaint IN00457494 and IN00457512 involved allegations of medication errors and inappropriate touching behaviors. Complaint IN00458000 had no deficiencies cited.

The facility failed to ensure proper medication administration for one resident and failed to identify, intervene, and document inappropriate touching behaviors for two residents. Additionally, the facility did not maintain complete and accurate medical records related to these incidents.

This inspection relates to Complaints IN00457494 and IN00457512 involving medication errors and failure to manage and document inappropriate resident behaviors.

The facility failed to discontinue a medication as ordered for one resident, resulting in medication errors. Additionally, the facility failed to identify, intervene, and document inappropriate touching behaviors by a resident toward others, and failed to maintain complete and accurate medical records for involved residents.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to have emergency preparedness policies for LTC roles under a waiver, failure to conduct required emergency plan exercises, deficiencies in kitchen hood extinguishing system appliance placement, fire alarm system time accuracy, sprinkler system inspection documentation and maintenance, fire door annual inspection, and improper use of multiplug power strips in resident rooms and offices.

The investigation was complaint-driven, focusing on trauma-informed care failures, medication storage and labeling issues, and infection control lapses. The complaint was substantiated with findings of minimal harm or potential for harm.

The facility failed to implement trauma-informed care interventions for a resident triggered by another resident's uninvited room entries. Medications were not properly dated when opened or destroyed when expired in multiple medication carts. Infection control measures were inadequate for oxygen tank tubing storage, with no current facility policy in place.

Complaint IN00440828 was unsubstantiated due to lack of evidence. Complaint IN00442467 was unsubstantiated due to lack of evidence. Complaint IN00443361 was substantiated with citation F600 related to physical abuse.

The facility was found to have deficiencies including substantiated physical abuse of a resident by a staff member, failure to implement trauma-informed care interventions for a resident, failure to date and discard expired medications on medication carts, and failure to maintain infection control measures for oxygen tubing. Some complaints were unsubstantiated due to lack of evidence.

This Federal Citation is related to complaint IN00443361. The complaint involved abuse of Resident 26 by QMA 6, substantiated by video evidence and staff statements.

The facility failed to ensure Resident 26 was free from abuse. Video evidence showed QMA 6 pushing Resident 26 against a wall and onto the floor. The facility conducted interviews and investigations, and disciplinary action was taken against QMA 6.

This tag relates to Complaint IN00431247. The complaint involved failure to report injuries of unknown origin for a resident, which was substantiated by the findings.

The facility failed to report an injury of unknown origin for one resident. Documentation showed swelling and bruising on the resident's face over multiple dates without investigation or reporting to proper authorities.

Complaint IN00431247 was substantiated with federal/state deficiencies cited at F609 related to failure to report injuries of unknown origin and failure to investigate and follow up on the injury for Resident D.

The facility failed to ensure that an injury of unknown origin for one resident (Resident D) was reported timely to the appropriate authorities. Documentation and investigation into the injury were insufficient, and staff did not report the injury as required by policy.

This tag relates to Complaint IN00429037. The complaint involved failure to notify the physician and family about Resident D's condition changes including pain and diarrhea.

The facility failed to notify the physician and family timely about Resident D's right sided pain, diarrhea, and isolation status. Documentation and communication lapses were noted regarding the resident's symptoms and isolation for suspected C. Diff infection.

Complaint IN00428352 - No deficiencies related to the allegations are cited. Complaint IN00428429 - No deficiencies related to the allegations are cited. Complaint IN00429037 - Federal/State deficiencies related to the allegations are cited at F580. Complaint IN00428929 - No deficiencies related to the allegations are cited. Complaint IN00429177 - No deficiencies related to the allegations are cited.

The investigation found no deficiencies related to complaints IN00428352, IN00428429, IN00428929, and IN00429177. However, federal and state deficiencies were cited related to complaint IN00429037 concerning failure to timely notify the physician and family of a significant change in condition for one resident (Resident D).

The investigation was triggered by complaints IN00425478 and IN00426117 regarding unsafe transportation practices that led to a resident injury.

The facility failed to secure a resident in a wheelchair according to manufacturer recommendations during transport, causing the resident to fall and sustain a spinal injury. The facility lacked a written policy and safety assessment for van transportation and did not have a comprehensive QAPI program to monitor transportation safety.

The investigation was triggered by complaints IN00425478 and IN00426117. The complaints were substantiated with federal/state deficiencies cited at F689 and F865. The Immediate Jeopardy began on 2024-01-03 when a resident slid out of his wheelchair during transport and sustained a spinal injury. The Immediate Jeopardy was removed on 2024-01-30 after corrective training was completed.

The facility failed to ensure a resident was properly secured in a wheelchair during van transport, resulting in the resident falling and sustaining a spinal injury. The facility lacked a policy and safety assessment for van transport and did not have a comprehensive QAPI program to monitor transportation safety. Corrective actions included training van drivers on proper securing procedures and implementing a detailed policy and ongoing audits.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to perform annual fuel quality testing of the emergency generator, failure to inspect fire damper systems every four years, and improper segregation and marking of oxygen cylinders in storage.

This Federal Citation is related to Complaint IN00415824 and IN00417181.

The facility failed to ensure physician orders were followed for two residents regarding opioid medication administration. Medication administration records, controlled substance count sheets, and physician orders showed discrepancies and missed doses, with issues related to pharmacy supply and documentation.

The investigation was related to complaints IN00417181 and IN00415824. Federal deficiencies related to the allegations were cited at F684. The complaints involved failure to follow physician orders and medication administration issues.

The facility failed to ensure physician orders were followed for 2 of 2 residents reviewed, specifically regarding timely administration and documentation of narcotic medications including Fentanyl patches and Norco. Medication availability issues and discrepancies in medication administration records were noted.

This visit included investigations of Complaint IN00415824 and Complaint IN00417181, both related to federal deficiencies cited at F684.

The facility was found to have multiple deficiencies including failure to ensure resident self-determination regarding shower and meal choices, failure to follow physician orders for medication administration, inadequate pain management, failure to provide trauma-informed care, and food safety violations related to dishwasher temperature and dumpster sanitation.

This Federal Citation is related to Complaint IN00415824 and IN00417181.

The facility failed to ensure resident self-determination regarding shower and meal choices, did not follow physician medication orders for residents, lacked adequate supervision to prevent elopement, failed to provide adequate pain management including non-pharmacological interventions, did not provide culturally competent trauma-informed care, and failed to maintain sanitary kitchen conditions and proper dumpster maintenance.

The facility was found in substantial compliance with Emergency Preparedness Requirements and Life Safety Code requirements. However, deficiencies were identified related to emergency generator testing and fire watch policies, including failure to document a required 4-hour generator load test and incomplete fire watch procedures for fire alarm and sprinkler system outages.

This survey was conducted in conjunction with the Investigation of Complaints IN00392744, IN00392799, and IN00392903.

The facility was found to have multiple deficiencies including failure to complete appropriate PASARR assessments, failure to coordinate hospice care, failure to implement resident-specific fall interventions, failure to monitor adverse medication side effects including psychotropic medications, and medication administration errors exceeding 5%. The facility was found to be in compliance with State Residential Licensure Survey requirements.