GOLDEN LIVINGCENTER – CAMELOT
LOCATED: 1101 LYNDON LANE, LOUISVILLE, KY 40222
GOLDEN LIVINGCENTER – CAMELOT was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure the staff provided adequate supervision to prevent Sexual Acting Out (SAO) behaviors; and, failed to have an effective system to evaluate and identify interventions to prevent injurious falls for five (5) of twenty-nine (29) sampled residents (Resident #10, #1, #6, #11, and #12). In addition, the facility failed to ensure safe storage of hazardous materials in three (3) of four (4) shower rooms.
Review of the facility’s staffing for 03/11/15 revealed one nurse and one nurse aide was scheduled to care for thirty-one residents. Interview with Registered Nurse #6, on 04/23/15 at 1:45 PM, revealed there were two locked units, the Alzheimer’s Care Unit (ACU) and the Advanced Alzheimer’s Care Unit (AACU). She revealed she and the nurse aide was on the AACU together leaving the ACU with fifteen (15) residents unsupervised during the incident. The facility’s failure to monitor Resident #10’s SAO behaviors and provide adequate supervision resulted in an unsafe environment for other residents.
Resident #12 was identified by the facility as at risk for falls with a history of falling at home. Resident #12 sustained a fall on 03/26/15 transferring from the toilet unassisted. The resident sustained [REDACTED]. On 04/11/15, Resident #12 experienced slurred speech and was transferred to the hospital. The resident was admitted to the hospital with [REDACTED].
Resident #6 was identified as being at risk for falls and sustained falls on 01/18/15 with no injuries. On 02/22/15, the resident sustained [REDACTED]. Resident #6 was sent to the hospital and admitted to the hospital with [REDACTED].
Resident #11 was identified at risk for falls and sustained a fall on 03/14/15. The resident sustained [REDACTED].
Resident #1 sustained falls on 01/02/15, 01/27/15 and, on 03/14/15 and the facility failed to identify the root cause of the falls.
In addition, observation of the shower rooms on the Alzheimer’s Care Unit, Advanced Alzheimer’s Care Unit and the East Wing-Hall C, revealed chemicals stored in unlocked cabinets. The units had cognitively impaired residents who wandered the units. On 05/05/15, observation of the East Wing Shower Room revealed a utility cart with a utility knife, a bottle of glue, a box that contained screws and other sharp metals.
A telephone interview with CNA #12, on 05/05/15 at 9:40 PM, revealed third shift, when staffed with one (1) nurse and one (1) CNA, could not have adequately supervised the ACU and AACU. The CNA stated she was unable to see both units at the same time. CNA #12 revealed that from the nurses’ station one could see down the AACU and could see about half of the rooms on the ACU hall. From the nurses’ station, one would not be able to view down the back half of the ACU. The CNA stated many of the residents on the backside of the ACU wandered. Those residents wandered into each other’s rooms frequently, including at night. CNA #12 revealed there were times when the nurse and the CNA would have to work on the same hallway, leaving the other hallway unsupervised. She stated when this happened there was no way to know what was happening on the other unit. Further, CNA #12 stated many of the residents on the unit had behaviors, including SAO’s and fighting. Many residents were often up at all hours of the night.
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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