Golden Acres Home and Care

Based on record review, the licensee did not comply with the section cited above in that [3] out of [5] facility resident files were missing required updated forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in [3] out of [5] facility personnel files did not have updated annual training hours which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in [5] out of [5] facility resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Administrator Qualifications and DutiesThe administrator shall have the responsibility to:…Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement was not met as evidenced by: Based on the License's inability to provide evidence that the hallways have been addressed for mold remediation during the course of a site visit on 7/20/23 and based on LPA Jensen receiving notification that the Licensee was provided an estimate for the work required on 5/25/23. This poses a potential risk to the health, safety and personal rights of residents in care.

Buildings and GroundsThe facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Based on LPA Jensen's review of the supplemental invoice # 47973 for mold abatement from Indoor Restore and Licensee's own admission that mold abatement in the facility hallways has not been completed. This poses a potential risk to the health, safety and personal rights of residents in care.

Personal RightsResidents in all residential care facilities for the elderly shall have all of the following personal rights:...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on LPA Jensen's review of the supplemental invoice # 47973 for mold abatement from Indoor Restore and Licensee's own admission that mold abatement in the facility hallways has not been completed. This poses a potential risk to the health, safety and personal rights of residents in care.

Reporting RequirementsA 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....Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on interviews conducted the roof leaks occurred in January of 2023 and were not reported to the Department. This poses a potential health, safety and personal rights risk to residents in care.

Inspection Authority of the Licensing Agency...The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours....This requirement was not met as evidenced by: This requirement was not met as evidenced by LPA Jensen's written request that consent be provided on 5/10/23 which did not yet occur as of the date of this report. This poses a potential risk to the health, safety and personal rights of residents in care.

Maintenance and OperationThe facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on LPA Jensen's review of a Mold Inspection Report and visual inspection of the facility staff did not ensure the facility was kept free of mold. This poses a potential risk to the health, safety and personal rights of residents in care.

Based on LPAs observation of ceiling damage in teh bedrooms and water pooling in the resident bedroom sink, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs review of a resident file and an interview with Administrator Maricel Tapo-Teske, the licensee did not comply with the section cited which poses/posed a potential health, safety or personal rights risk to persons in care.

Personal Accomodations(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. The licensee did not meet this requirement as evidenced by: Based on LPA Jensen's observation of debris stored on grounds including broken toilet and damaged shopping carts as well as observation of unsanitary vents in shower. This poses a potential health and safety risk to residents in care.

Based on observation and interview, the licensee did not comply with the section cited above in that there is not a signal system in working order. Licensee stated the facility does not have a call system in working order which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that the facility shall be in good repair at all times. LPA observed window missing screen, broken patio table loose bricks, shed without door, two cracked windows, and stored items not in working order on property grounds accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency (1) A written report ....within seven days of the occurrence of (D )Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidence by: Based on records reviewed and interview the Licensee did not ensure the incident report for R1's threatening behavior was submitted timely. Licensee stated the machine used did not provide confirmation of transmission receipt to ensure it was sent within 7 days which poses a potential health and safety risk to residents in care.