Golden Oaks Senior Living

87211(a)(D) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to…Any incident which threatens the welfare, safety or health of any resident or unexplained absence of any resident. This requirement is not met as evidence by: Based on interviews and record review, the licensee did not submit incident reports to the Department regarding a resident’s unexplained absence at the facility when resident left the facility alone and unassisted in two seperate incidents.

87411 (a) Facility personnel shall at all times be sufficient in numbers...or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on interviews and record review, the licensee did not provide adequate care and supervision by letting a dementia resident walk outside without supervision, which poses an immediate Health, Safety, Personal Rights risk to persons in care.

87463 (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate...shall document changes in the resident's physical, medical, mental, and social condition. The requirement is not met as evidence by:. Bases on interviews and record review, the licensee did not update the residents appraisal after resident had a change in condition when leaving the facility alone and unassisted in two seperate incidents.

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on LPAs' observation of the doorknob being covered with a cover to prevent people from getting out and it is a designated exit. This poses an immediate risk to residents.

Resident Records. 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 is not met as evidenced by: Based on LPAs review of the resident's file, it is missing a lot of documentation. This does not pose an immediate risk to residents.