Golden Age Care Center

In the surveyor’s words

From the most serious findings on record at Golden Age Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF610Aug 29, 2022

  Based on observation, interview, and record review, the facility failed to thoroughly investigate concerns with staff treatment towards residents and failed to separate residents from an alleged perpetrator after staff had become aware of an allegation for three of four residents reviewed for abuse (Resident #14, Resident #15, Resident #22). This resulted in an immediate jeopardy to residents health and safety. The facility reported a census of 36 residents. Findings include: 1. The Significant Change Minimum Data Set (MDS) assessment for Resident #15 dated [DATE] documented the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF689Aug 10, 2026

  Based on observation, record review, resident interview, staff interviews, and the facility policy, the facility failed to provide adequate supervision to prevent the elopement of Resident #25. The resident has a history of falling, behaviors of persistent exit seeking and a history of elopements at the facility without staff knowledge. On 6/23/26 at approximately 4:15 PM the resident was found outside on the front patio. The door alarms had not sounded and the staff were unaware she was outside. The staff implemented the intervention 1 on 1 as needed. On 6/24/26 at approximately 6:30 AM Resident #25 was found outside again. She was on the facility property walking toward a gravel road that led to a busy highway 50 feet away. […]

• No harm, potential for more than minimal, widespreadF880Feb 8, 2024

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out infection control measures for 1 of 7 residents observed during the medication pass (Resident #21). The facility also failed to develop and implement a plan to prevent the growth of Legionella(a bacteria) in water systems. The facility reported a census of 37 residents. Findings Include: 1. The Infection Prevention and Control Program policy, reviewed 5/19/22, stated the facility would provide a safe environment to help prevent the development and transmission of disease and infection and stated the facility would ensure compliance with State and Federal Regulations. […]

• No harm, potential for more than minimal, patternF883Jul 31, 2025

  Based on clinical record review, facility policy review, Centers for Disease Control and Prevention (CDC) guidelines, resident and staff interview, the facility failed to offer the pneumococcal vaccine to 4 of 5 sampled residents reviewed for immunizations (Residents #4, #5, 26 and #27). The facility reported a census of 40 residents. On 7/31/2025 at 8:49AM, the Director of Nursing (DON) reported she had been in her role as the DON and Infection Preventionist (IP) since May 2023. The DON reported they should check the immunization status of residents upon admission and residents should be offered immunizations at that time. The DON reported she followed the Center for Disease Control and Prevention (CDC) guidelines for offering residents the pneumococcal vaccine. […]

• No harm, potential for more than minimal, patternF803Feb 8, 2024

  Based on observation, record review, policy review, and staff interview, the facility failed to serve diets at the appropriate consistency for 5 of 5 residents receiving a mechanical soft diet (a soft diet consisting of finely chopped, blended, or ground foods). The residents received diced chicken instead of ground chicken at a meal. The facility reported a census of 37 residents. Findings include: The 12/7/23 facility Diet List revealed 5 residents on a mechanical soft diet. During the noon meal service on 2/7/24 at 11:56 a.m., Staff H Cook served 5 residents on a mechanical soft diet diced chicken with pieces approximately 1 centimeter in size. […]