Golden Hills Care Home

Maintain separate complete record for each resident

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met based on records review.

Based on record review, the licensee did not comply with the section cited above in1 of 1 staff (S1] which poses/posed a potential health, safety or personal rights risk to persons in care.

Food quality controls and rejected damaged goods

Based on observation, the licensee did not comply with the section cited above in observed 2 cans of food past use by date in the kitched cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met based on report and interviews. This posed an immediate risk to R1.

Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, ... to prepare a written record of the care the resident will receive in the facility...This requirement was not met based on records review. This posed a potential risk for resdents.

87631 Healing Wounds (a) ...accept or retain... a healing wound ...: (3) Residents with a stage one or two pressure injury ...(A) ...shall receive care...from a...appropriately skilled professional. This requirement was not met based on lack or records for staging or care. This posed a potential risk

Maintain facilities for fire and panic safety

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marsha... This requirement was not met based on observation of ubstructed exits. This posed and immediate risk to residents.

Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another. This requirenment was not met based on record review and interview. This posed a potential risk to residents.

Certified administrator requirements and substitute coverage

Administrator - Qualifications and Duties (a) ...The administrator shall ... shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement was not met based on the issues and citations noted in this visit. This poses a potential risk to residents.

Based on records review the licensee did not comply with the section cited above in 2 of 2 staff were in need of some annual training and training for restricted health conditions which poses/posed a potential health, safety or personal rights risk to persons in care.

Notify agency before locking doors or gates

Based on observations the licensee did not comply with the section cited above in drawers and cabinets in the kitchen not locked when staff left the area which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: It was determined that staff did not provide adequate care and supervision to R1 which resulted in R1 eloping to an elementary school six minutes away from the facility. It took staff approxmiately 22-30 minutes to locate R1 which poses an immediate health and safety risk to residents in care.

Report specified resident events within seven days

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews the licensee did not report incident which lead to R1's pressure injury which poses a potential health and safety risk to residents in care.