Golden Age Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 1, 2025

  Based on interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse and psychological harm for 1 (#2) of 3 (#1, #2, and #3) sampled residents reviewed for sexual abuse. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in actual psychological harm on 02/11/2025, when Resident #2, a cognitively intact resident, stated a visitor of the facility showed her unwanted pictures of his penis and then later forced his penis into Resident #2's mouth. Resident #2 reported the incident to the facility on [DATE] and stated she did not report it sooner because she was embarrassed. […]

• No harm, potential for more than minimal, patternF584Mar 18, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for 2 of 2 (#5 and #58) residents reviewed for environment. Resident #5 Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Idiopathic Peripheral Autonomic Neuropathy, Chronic Ischemic Heart Disease, Morbid Severe Obesity due to Excess Calories, and Acute on Chronic Diastolic Congestive Heart Failure. Review of Resident #5's Quarterly MDS with an ARD of 03/04/2026 revealed a BIMS of 13, which indicated the resident was cognitively intact. An observation was made on 03/15/2026 at 1:26 p.m. of Resident #5's room. […]

• No harm, potential for more than minimal, patternF658Mar 18, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure services provided as outlined in the comprehensive care plan met professional standards of quality by failing to ensure nursing staff primed insulin pen needles prior to administering insulin for 3 (#12, #129, and #144) of 5 residents reviewed for insulin administration.Findings: Review of the facility's insulin pen needle product insert revealed the following: 2. Prepare the pen needle: Check that the pen needle is attached correctly and prime the pen according to the manufacturer's instructions for use. Select the insulin dose. […]

• No harm, potential for more than minimal, patternF677Mar 18, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 3 (#7, #98, and #144) of 3 residents reviewed for ADLs. The facility failed to ensure: Resident #7 and #144 received their shower as scheduled; and Resident #98 was dressed in clean attire daily. Findings: 1. Resident #7 Review of Resident #7's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis, which included Radiculopathy, Lumbar Region. Review of Resident #7's Quarterly MDS with an ARD of 12/12/2025 revealed BIMS of 11, which indicated the resident was moderately cognitively impaired. Further review revealed Section GG0130. […]

• No harm, potential for more than minimal, patternF726Mar 18, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure nursing staff had the specific competencies and skill sets necessary to care for resident's needs as identified through resident assessments and plans of care. The facility failed to ensure nursing staff had competencies and skill sets to:Accurately administer insulin via insulin pens for 3 (#12, #129, and #144) of 5 residents reviewed for insulin administration; andProperly clean a non-invasive mechanical ventilation mask and tubing for 1 (#10) of 2 residents reviewed for respiratory care.Findings: 1. Review of the facility's insulin pen needle product insert revealed the following: 2. […]