Golden Age Living

1. It is our policy to ensure the move in evaluation addresses all the required elements, as stated in the QAR-411-054-0034. Resident 2's move in evaluation was reviewed and updated by our facility RN. All the missing elements (customary routines, mental health issues including history of treatment, communication and sensory including ability to undertsand, fluid preferences, fall risk or history, and unsuccessful placements) were addressed, as per our policy. Resident move in evaluations will be reviewed, and all the missing elements will be addressed for our recently moved in residents, to ensure completion. Our RN was educated on the importance of comprehensively addressing all areas in the evaluation form, and not leave any areas blank, even if some areas might not neccessarly apply to the resident evaluated. 2. Moving forward, the facility RN will make sure all the required elements, including: customary routines, mental issues/history of treatment, communication and memory/ability to understand, fluid preferences, fall risk or history, unsuccessful placement, will be addressed.3. The area needing correction will be evaluated with every new patient admission, every new move in, and re-evaluated quarterly.4. The professional responsible for completion and monitorization of this correction is the facility RN

1.To correct the rule violation, a second night shift direct care staff member has been added on to the schedule, effective immediately. This is to ensure a minimum of two direct care staff members are scheduled and available at all times, whenever a resident requires assistance with scheduled and unscheduled needs and to ensure residents and staff safety. 2. Golden Age Living will add a second night shift direct care staff member at all times when a resident requires two person assistance for scheduled and unscheduled needs.3. The above change will be evaluated quarterly, with each new resident move in, and as needed with changes in residents' condition4. Our administrator is responsible to ensure the correction is completed and monitored

1. To correct this rule violation our facility will be using the ABST tool provided by the Long Term Care Facility Portal. This is to ensure Golden Age Living has the adequate number of direct care staff members available to safely meet the scheduled and unscheduled needs of our residents. 2. As required by the regulations, the ABST tool will be updated with every new resident move in, change in residents' condition and quarterly. 3. An evaluation will be done with each new resident move in, change in resident condition, and quarterly. 4. The person responsible to ensure the correction is completed and monitored is the facility RN.

1. To correct the rule violation a handrail was installed in the small corridor that connects the main living and dining area to resident room 11 (correction states 12, but it is 11). 2. To ensure this violation does not happen again, a tour of the facility will be done annually by the administrator. During the annual tour/inspection of the facility the administrator will observe that the hand rails are properly installed in all the necessary places, and in good condition, to ensure the safety of our residents.3. We will be performing the tour/inspection of the handrails annually.4. The person responsible for monitoring and ensuring the handrails are properly intalled in all the right places, and are in good condition is the administrator.

1. To correct the rule violation all ceiling lights and lighting fixtures will be replaced with LED lights by a licensed electrician. The skylights have already been cleaned. 2. To prevent this violation from happening again, the lighting system will be checked quarterly by our facility maintanance person, whom will replace the burned out lights, as needed, to ensure all ceiling lights are always in good working condition. The skylights will be cleaned monthly.3. The administrator will be checking the ceiling lights and skylights quarterly. All staff members were educated to report any areas where burned out lights are seen, or any other malfunctioning of the ceiling lights. 4. The person responsible for monitoring and ensuring completion is the administrator.

1. To correct the rule violation, all wall heaters were disabled on 4/18/24. The two bathroom heaters were permanently disabled. The bedroom heater will be replaced with a "split system heat pump" that complies with the building codes, so the ventilation unit will not be directly accessible to the residents. 2. To avoid this violation from happening again, the wall heaters are not to ever be used again in our building.3. To ensure the heating and cooling system are functioning properly, and to ensure the safety of our residents, staff and the building, the heating and cooling system will be serviced annually.4. The administrator will be responsible to ensure the above is properly monitored and completed.

Initial Evaluation for Resident #1 reviewed and all missing items updated.Our policies and our tools to complete move-in evaluations are in accordance with the regulations and do not need updating at this time. However, we have re-educated our staff on the importance of completing these accurately and comprehensively prior to Resident move-in. We have also performed an audit of other Residents who have recently moved in to determine missing items that require updating. The Administrative Assistant will review each move-in evalaution to ensure it is completed in accordance with policies and requirements. This plan will be re-evaluated on a quarterly basis. The Administrative Assistant is responsible for this plan of correction.

This Facility had scheduled meetings to discuss Care Plan with Resident and/or Resident's Representative for Resident #2 and 4, in the past, but since meetings were done virtually, signatures haven't been colected. This Facility scheduled new meetings to discuss Care Plan with Resident and/or Representative for Resident #2 and 4, and will document collaboration/collect signatures from appropriate parties and all members involved, such as Facility RN, Caregiver(s), Resident and/or Resident's Representative, Administrator. Our policies and our tools to complete Care Plans as compared to their last evaluations in collaboration with the Resident and/or Resident's Representative, Facility RN and Caregiver(s) are in accordance with the regulations and do not need updating at this time. However, we have reviewed all Residents' care plans to identify other Residents that may need updates in this area and others.These areas will be re-evaluated on a quarterly basis. The Administrative Assistant is responsible for this plan of correction.

Our policies and tools in place, to ensure short-term changes in condition are monitored, are in accordance with the regulations and do not need updating at this time. 1. We have reviewed Resident #2 Care Plan and Progress Notes and we have re-educated our staff on the importance of following the steps in our 24 hour Report Book and our Temporary Service Plans accurately and that every report communicated verbally, even when there is no changes, needs to be documented in writing, at least weekly and as needed if any changes, through resolution. Also we re-educated staff to follow steps in our Temporary Service Plans reflecting short-term changes in condition regarding when to nofity the facility RN or Administrator/Administrative Assistant. We have reviewed all Resident's charts to identify any missing documentation regarding short term change in condition. These short-term changes areas will be reviewed on a weekly basis. The Administrative Assistant is responsible for this plan of correction.2. Resident #4 was evaluated by Hospice and admitted on 12/17/21. No changes to her care, several supplements were discontinued and "Comfort Kit" medications ordered, per Hospice protocol. All medications in the "Comfort Kit" are PRN medications and written parameters are in place, completed by Hospice RN, that include instructions for staff with possible adverse reactions to look for and when to notify RN. None of the medications in Resident's "Comfort Kit" have been administered to the Resident yet.Our RN and Administrative Assistant have been reeducated concerning significant change of status and their roles and responsibilities and our RN completed an evaluation regarding changes in Resident's status and changes in medication. Our policies and tools for documenting and monitoring any skin issues as well as when to complete an Incident Report are in accordance with the regulations and no changes needed at this time. We have reeducated our staff regarding documentation and monitoring of any skin issue in our CBC and Skin Integrity Chart as well as when to complete and Incident Report, signs to look for and when to notify RN and Administrator and/or Admnistrative Assistant. Hospice RN wrote a progress note on 1/21/22, stating the Resident had "yellow bruising to lower extremities". Meeting set up with Hospice RN and staff to investigate this matter. During this visit, Hospice RN is stating she discovered 2 yellow spots, of approximately 0.8 and 1.2 cm diameter, at Resident's Right knee area. While evaluating Resident's skin during this meeting, RN was showing us the exact area at around her Right knee where she previously saw those spots. At this time, Resident is crossing her legs, touching her knees together. RN evaluates the way Resident is laying and concludes these small yellow spots may be caused by bone pressing on bone when she's crossing her legs and touching her knees. Staff also reports no purple bruises observed before at this area, but sometimes these very small yellow bruising/spots apear and dissapear, when Resident crossing her legs. Resident has history of bruising easily. Educated staff to place small pillow in between Resident's knees, to prevent yellow bruising/spots from forming when her knees are touching and Resident's care plan has been updated. ***Resident has been observed not keeping small pillow in place in between her knees, she is removing it shortly after staff place it. We have reviewed all our Residents' care plans to identify other Residents that may require updates in this area and others. Staff will perform a full skin check for Resident twice a week, during bed bath. The Administrative Assistant is responsible for this plan of correction.

Our policies and tools we have in place to ensure recommendations made by outside service providers are included in Resident's care plan are in accordance with the regulatioons and no updates or changes are needed at this time. On 1/5/22 the HHPT recommended the Resident use her walker to move from her recliner to the bathroom two to four times a day with stand-by assistance. Staff in collaboration with Resident made a schedule and posted it in Resident's bathroom where it was documented on this schedule every time this was accomplished. On 1/31/22 HHRN recommended to "try putting PT on toileting schedule every two hours change incontinent briefs change ostomy pouch when 1/3 or 1/2 full. Staff in collaboration with Resident made a schedule and posted it in Resident's bathroom and it was documented on this schedule every time this task was performed.However, we have reeducated our staff about documenting in Resident's care plan any recommendations made by outside providers. We have reviewed all other Residents' care plans to identify any changes needed to be made in this area and others. These areas will be reviewed on a quarterly basis. The Administrative Assistant is responsible for this plan of correction.

All pathway edges have been leveled and will be kept in good maintanance. All equipment found outdoor has been disposed. The refrigerator has been disposed and the freezer moved indoors. All the vases and rodent bait trays have been disposed. The two unsecured patio drains covers have been secured in place. All garden chemicals and yard tools moved and kept in the locked outdoor storage. The Code for the back hallway has been posted, the sliding door for the courtyard access kept free of blockage, allowing access at all times. One of the gates is not an exit and willl be permanently locked. Code has been posted on the other two gates. These areas will be reviewed on a quarterly basis. The Administrator is responsible for this correction.

The exit door will be replaced completely. This area will be reviewed on a quarterly basis. Administrator is responsible for this correction.