Golden Age Operations

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 25, 2025

  Based on review of the facility's policy, record review, and interviews, the facility neglected to provide care and services for Resident (R)1, resulting in R1 successfully eloping from the facility, for 1 of 3 residents reviewed for neglect. On 06/06/25 at 12:30 PM the Administrator was notified that the failure to prevent a successful elopement from the facility constituted Immediate Jeopardy at F600. On 06/06/25 at 12:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/12/25. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect and Exploitation. On 06/06/25 at 3:42 PM, the facility provided an acceptable IJ Removal Plan. […]

• Immediate jeopardy, isolatedF689Jun 25, 2025

  Based on review of the facility's policy, record review, and interviews, the facility failed to provide adequate supervision for 1 out of 3 residents reviewed for accidents. On 06/06/25 at 12:30 PM, the Administrator was notified that the failure to prevent a successful elopement from the facility constituted Immediate Jeopardy at F689. On 06/06/25 at 12:30 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 05/12/25. The IJ was related to 42 CFR 483.25 - Quality of Care. On 06/25/25, the facility provided an acceptable IJ Removal Plan. […]

• No harm, potential for more than minimal, patternF689Apr 20, 2023

  Based on interviews, record reviews and review of the facility's policy, the facility failed to assess the resident's risk and/or underlying causes, and the impact of the resident's condition upon admission into the facility for 1 of 1 resident (R )189. This failure had the potential to cause harm and neglect by failing to reveal possible preventable risks for repeated falls. Findings Include: Review of the undated policy titled, Fall Prevention Program, states, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 2. […]

• No harm, potential for more than minimal, patternF689Apr 20, 2023

  Based on interviews, record reviews and review of the facility's policy, the facility failed to assess the resident's risk and/or underlying causes, and the impact of the resident's condition upon admission into the facility for 1 of 1 resident (R )189. This failure had the potential to cause harm and neglect by failing to reveal possible preventable risks for repeated falls. Findings Include: Review of the undated policy titled, Fall Prevention Program, states, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 2. […]

• No harm, potential for more than minimal, isolatedF656Mar 19, 2025

  Based on facility policy, observation, record review, and interview, the facility failed to develop a comprehensive care plan for of 2 of 3 residents. (Resident (R)22 and R24). Findings include; Record review of the facility policy dated 2025, titled Comprehensive Care Plan revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. […]