Golden Lodge Assisted Living LLC

A licensure complaint, prompted by #CO38186, was completed on 5/14/25. A deficiency was cited. Based on observation, interview, and record review, the residence failed to provide therapeutic diets when prescribed by the resident' s practitioner, affecting one of eight sample residents (#39). Findings include:1. Resident #39 was admitted to the residence on 7/24/23 with a diagnosis of neurocognitive disorder, dysphagia, and had a diet of pureed food and nectar-thick liquids. a. ObservationsOn 5/12/25, at 8:35 a.m., Staff #33 administered Resident #39' s medication in applesauce and then handed him a cup of water with no thickened liquid powder added.On 5/12/25, at approximately 8:52 a.m., Resident #39' s family member fed him his pureed breakfast meal and beverage. Staff #50 added a scoop of the thickened liquid powder, stirred it, and handed it to Resident #39' s family member. Resident #39' s family member immediately gave Resident #39 his orange juice.On 5/12/25, at 8:59 a.m., Staff #33 looked at his computer, pulled up Resident #39' s chart, and read aloud that Resident #39 was on a mechanical soft diet and nectar-thickened liquid.On 5/12/25 at 11:38 a.m., Staff #33 searched the refrigerator and cabinet for the thickened liquid powder and did not find it. Staff #50 pointed out where the thickened powder container was to Staff #33.On 5/13/25 at 8:21 a.m., the administrator entered the secure unit, found the thickened liquid powder, removed it from the kitchen cabinet, and took it to the kitchen. b. Record Review A written practitioner' s order, dated 3/16/25, directed the residence to provide a nectar-thickened liquid diet. On 4/17/25, the external health provider amended the order to change his diet to pureed.The resident' s care plan, effective 5/12/25, had six amended dates for Resident #39' s dining and cueing needs. On 2/25/25 and 3/18/25, the residence added that Resident #39 needed nectar thickened liquid.2. Interviews On 5/12/25 at 8:57 a.m., Staff #33 stated he was unaware that Resident #39 had a nectar-thickened liquid; he thought he was on a mechanical soft diet and only had issues with chewing food, not swa..

A licensure revisit was completed on 5/13/25 for all previous deficiencies cited on 10/21/24. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 10/21/24. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting five of eight sample residents (#32, #42, #43, #44, #46).This deficiency was previously cited during a relicensure survey on 10/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #42 was admitted to the residence on 4/25/25 with diagnoses including Parkinson' s dementia.A written practitioner' s order, dated 4/25/25, directed the residence to administer the following medications: Lysine 1000 mg once daily.Meloxicam 15 mg once daily.Tizanidine 2 mg once daily.However, the April and May medication administration records (MARs) for Resident #42 read the following medications were not administered because they were not available:Lysine 1000 mg on 4/27-4/29 and 5/1-5/6/25 for a total of nine missed doses. Meloxicam 15 mg on 4/27-4/30 5/1, 5/2, 5/4, 5/6, 5/7, for a total of nine missed doses.Tizanidine 2 mg on 4/27-4/30, 5/1-5/7/25 for a total of 11 missed doses. On 5/13/25 at 9:30 a.m., the administrator confirmed the medications listed above were not administered and were out of stock for Resident #42. On 5/13/25 at 1:05 p.m., the administrator said the reason the citation was not corrected was because of the residence' s problems with their external pharmacy. 2. Similar deficient practice was found for Residents #32, #43, #44, #46.

A licensure revisit was completed on 5/13/25 for all previous deficiencies cited on 10/21/24. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 3/17/25. Based on record review and interview, the residence failed to complete progress notes at the end of the shift, which included documentation regarding any out-of-the-ordinary event or issue that affected the resident' s physical, behavioral, cognitive, or functional condition, along with the action taken by staff to address that resident' s changing needs, affecting one of eight sample residents (#39).This deficiency was previously cited during a relicensure survey on 10/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:Resident #39 was admitted to the residence on 7/24/23 with a diagnosis of neurocognitive disorder and dysphagia. a. ObservationsOn 5/12/25 at 8:35 a.m., Resident #39 had four pinky-sized flat-round reddish-purple bruises on his forehead. Two were above his right eyebrow, and two smaller ones were near his hairline. On 5/12/25, at approximately 8:51 a.m., Staff #50 asked Resident #39' s family member if she knew what had happened to his face. He continued to say that he had not noticed the marks on his face last week and had just returned this morning and saw them.On 5/12/25, at approximately 8:52 a.m., the family member of Resident #39 told Staff #50 she was unaware of what happened and that the residence di.. Based on record review and interview, the residence failed to comply with authorized practitioner' s orders associated with medication administration, affecting five of eight sample residents (#32, #42, #43, #44, #46).This deficiency was previously cited during a relicensure survey on 10/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Resident #42 was admitted to the residence on 4/25/25 with diagnoses including Parkinson' s dementia.A written practitioner' s order, dated 4/25/25, directed the residence to administer the following medications: Lysine 1000 mg once daily.Meloxicam 15 mg once daily.Tizanidine 2 mg once daily.However, the April and May medication administration records (MARs) for Resident #42 read the following medications were not administered because they were not available:Lysine 1000 mg on 4/27-4/29 and 5/1-5/6/25 for a total of nine missed doses. Meloxicam 15 mg on 4/27-4/30 5/1, 5/2, 5/4, 5/6, 5/7, for a total of nine missed doses.Tizanidine 2 mg on 4/27-4/30, 5/1-5/7/25 for a total of 11 missed doses. On 5/13/25 at 9:30 a.m., the administrator confirmed the medications listed above were not administered and were out of stock for Resident #42. On 5/13/25 at 1:05 p.m., the administrator said the reason the..