Gold City Health and Rehab

Inspectors wroteBased on staff interviews, record review, and review of the facility policies titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation and Use of Restraints, the facility failed to report an allegation of abuse timely involving one of three sampled residents (R) (R1) to the State Survey Agency. This deficient practice resulted in delayed investigation, placing facility residents at risk for continued or unaddressed abuse.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Functional Impairment-Clinical Protocol, the facility failed to ensure that one of three sampled residents (R) (R1) was assessed for use of a medical device (Broda (specialized seating designed for individuals with mobility challenges, physical disabilities, or those requiring enhanced postural support) chair) prior to its use. This deficient practice placed R1 at risk for use of medical equipment without assessment to determine appropriateness, need, and safe use.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to prevent resident to resident abuse for one of three residents (Resident (R)10) reviewed in a total sample of 20. This failure resulted in R9 having unsupervised access to R10 providing opportunity for R9 to pull R10's arm inappropriately and attempt to kiss R10's hands.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan that included specific interventions to ensure psychosocial well-being and safety for one of three residents (Resident (R) 4) reviewed in a sample of 20 residents.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure a resident was evaluated for appropriate bed rail use and that alternative measures were attempted prior to installation of bed rails for one of one resident (Resident (R) 4) reviewed for bed rails out of a total sample of 20. The lack of alternate bed rail measures had the potential to lead to safety concerns related to bed rail use.

Inspectors wroteBased on staff interview and review of the facility provided form titled Daily Nursing Staff Report(s), the facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours seven days a week on 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024. This failure had the potential to render all 68 residents without the necessary medical assistance that only an RN could provide, leading to adverse outcomes.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policies titled Dishwashing and Temperature Log Guidelines, the facility failed to ensure the chemical level of the low temperature dishwasher was maintained at a level that would sanitize the soiled dishes with the potential to affect 68 of 68 residents. The deficient practice had the potential to result in the spread of infections/viruses and food borne illness.

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect the residents' right to be free from mental/verbal abuse for four of 13 residents (R) (R53, R11, R122, and R71) and free from physical abuse for one of one resident (R48) reviewed for abuse out of a total sample of 43 residents. Specifically, R19 verbally harassed R53 and verbally insulted R11. Also, R16 verbally harassed R53 and verbally disrespected R122 and R71. This failure had the potential to cause psychosocial harm to the residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy Abuse, Neglect, and Exploitation, the facility failed to provide adequate supervision to prevent accidents for four of four residents (R) (R6, R3, R23, and R36) reviewed for supervision out of a total sample of 43. Specifically, R6 had diagnoses of severe dementia, delusions, and paranoid schizophrenia and exhibited aggressive behaviors towards R3, R23, and R36. As a result of this deficient practice the residents in the facility had the potential for harm from the aggressive behaviors from R6.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Advanced Directives, the facility failed to ensure one of 43 sampled residents (R) (R16) reviewed for advanced directives had a medical record that accurately reflected her request to not have cardiopulmonary resuscitation (CPR) in the event she should experience cardiopulmonary failure. The deficient practice had the potential to result in the resident receiving CPR against her wishes.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure an allegation of abuse was reported within two hours of occurrence for two of 12 residents (R) (R6 and R36) sampled for abuse out of a total sample of 43. The deficient practice had the potential for timely intervention to not be implemented for the protection of the residents.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate an allegation of staff to resident abuse involving one of 12 residents (R) (R68) reviewed for abuse out of a total sample of 43. This failure increased the risk of ongoing staff to resident abuse.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Transfer and Discharge, the facility failed to provide the resident and the responsible party with notice of the transfer and the reasons for the transfer in writing and in a language and manner they understand for one of two residents (R) (R4) reviewed for hospitalization out of a total sample of 43. The deficient practice had the potential to result in the resident and/or responsible party not knowing the resident was transferred to the hospital and the reasons for the transfer.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Antipsychotic Medication Use, the facility failed to monitor for adverse consequences and behaviors related to antidepressant use for one of five residents (R) (R24) reviewed for unnecessary medications out of a total sample of 43. The deficient practice had the potential to place the resident at risk of untreated adverse consequences to the medication.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that one of three medication carts (B Hall) was secure when left unattended and out of the site of the nursing staff. The deficient practice had the potential to allow residents and/or visitors unauthorized access to medications.

Inspectors wroteBased on staff interview and review of the facility provided form titled Daily Nursing Staff Report(s), the facility failed to indicate the daily census in the space provided on the daily posted form. This failure had the potential for resident family, friends, or other visitors to not know the ratio of nursing staff to residents causing uncertainty of ability and availability of the staff for residents' needs. The facility census was 68 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure the call light was placed within reach to enable the resident to call for assistance, for one resident (R) (R#61) of 21 sampled residents.

Inspectors wroteBased on record review, interviews, and review of the policy titled Change in a Resident's Condition or Status, the facility failed to ensure the physician was immediately notified of a significant change in condition for one resident (R)(R#69). The sample size was 30.

Inspectors wroteBased on observation, record review, interviews, and review of the policy titled Resident Assessments, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurately reflected residents' status for two residents (R) (R#25 and R#46) of 30 sampled residents.

Inspectors wroteBased on record review, interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive person-centered care plan to address the care, treatment, and monitoring of pressure ulcers for one resident (R) (R#172) of four sampled residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, interview, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure one resident (R) (R#17) of two sampled residents was provided the opportunity to participate in care plan meetings.

Inspectors wroteBased on record review, interviews, review of Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, and policy review, the facility failed to maintain professional nursing standards of quality evidenced by Licensed Practical Nurse (LPN) CC failing to consult the Director of Nursing or attending physician for one resident (R) (R#69), with an episode of hypoglycemia, low blood sugar of 32. LPN CC administered instant glucose to resident, waited one hour before rechecking the blood sugar and failed to notify the physician of change in condition for R#69. Additionally, licensed nursing staff failed to request the physician define blood sugar parameters to guide the nursing staff on when to notify the physician and/or when and how to provide treatment for hypoglycemia or hyperglycemia (high blood sugar).

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to maintain an effective Infection Control Program (ICP) to prevent potential cross-contamination which could result in disease or infection, by not ensuring staff removed a urinal and disinfected one resident (R) (R#40) bedside table before placing residents' meal tray on the table. The sample size was 30.