Gold Country Health Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were only transferred or discharged for valid, allowable reasons, when the facility discharged two of five sampled residents (Resident 3 and Resident 4) from skilled nursing facility (SNF) 1 to SNF 2 without documented medical justification, even though both facilities provided the same level of care. The required physician documentation supporting improvement or unmet needs was absent or contradictory, and the residents were not given a choice. This failure violated Resident 3 and Resident 4's discharge rights to remain in the facility and placed them at risk for transfer trauma and disruption of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure required transfer and discharge notifications were provided for three of three sampled residents (Resident 2, Resident 3, and Resident 4), when the facility notified Resident 3 and Resident 4 of their discharges on 7/13/26, the same day they were discharged , without any documented exception permitting shorter notice; the facility did not notify the Office of the State Long-Term Care Ombudsman (OMB, an independent advocate for residents of long-term care facilities) before the transfer/discharge of Resident 3; and the facility issued no written notice while attempting to discharge Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and keep secure when not in use confidential resident health data and records for a census of 67 residents. This failure had the potential to expose and disclose personal and confidential residents' health information to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed for three of 26 sampled residents (Resident 7, Resident 82 and Resident 85), when:1. A lidocaine (anesthetic used to treat pain) five percent (%, a unit of measurement) patch was applied to Resident 82's lower back without date, time and initials of the nurse applying it;2. Licensed Nurse 4 (LN 4) did not identify Resident 85 prior to medication administration;3. LN 4 did not wear gloves during preparation and administration of hazardous medication; and4. Nursing staff did not clarify overlapping PRN (as needed) pain medication orders. These failures had the potential to result in inappropriate medication administration, preventable medication errors, increased risk of adverse drug events, oversedation, and resident harm or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure nursing staff accurately documented the removal of controlled medications (those with high potential for abuse or addiction) during medication pass;2. Ensure accurate accountability and effective storage of controlled medication when random controlled medication audits for two out of two residents (Resident 14 and Resident 17) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps a record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; and,3. Demonstrate adequate safeguards were implemented to ensure chain of custody of controlled substances and limit their potential for diversion prior to final destruction. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 14.81 percent (%, a unit of measure) error rate when four medication errors out of 27 opportunities were observed during a medication pass for two of three Residents (Resident 82 and Resident 85). This failure resulted in medications not given in accordance with the prescriber's orders and increased potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure multi-dose medications with shortened expiration dates were labeled correctly after use with an open date;2. Ensure medications were securely stored within manufacturer's specifications; and3. Ensure safe storage and monitoring of over the counter (OTC) medications. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate storage that was left unsupervised and open to anyone in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe for three residents of a census of 67 (Resident 16, Resident 24, and Resident 85), when an unmeasured amount of milk was added to pureed (a very smooth, lump-free, and moist consistency similar to pudding, requiring no chewing and able to be swallowed easily) rice. This failure had the potential to add extra liquids to the rice serving and decrease the intake of nutrients.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly prepare and store food for a census of 67 residents, when:1. Stored food was found expired and unlabeled; and 2. The cool down procedure was not followed for cooked meat. This failure decreased the facility's potential to prevent foodborne illnesses among vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose garbage for a census of 67 residents, when a kitchen garbage dumpster was found to have two gaping, warped lids. This failure had the potential to produce unsanitary conditions for residents due to easy access for rodents and other pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 67 residents, when:1. Multiple surfaces in the laundry room's clean area were found with an accumulation of a gray powdery substance;2. Resident 73's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mask was found on top of the nightstand without a bag;3. Resident 34's bathroom toilet contained a large, thick soiled dressing;4. Licensed Nurse (LN) 3 and LN 4 did not maintain fingernails in accordance with the facility's policy;5. Multi-resident medical equipment was not sanitized and disinfected in accordance with professional standards; and6. Single use Styrofoam tray used during med pass was not disposed after use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 26 sampled residents (Resident 16 and Resident 11) and their responsible parties (RP- a person responsible for health care decisions) were informed of the residents' change of condition and medical appointments. This failure had the potential for the residents' RP not to be able to make an informed decision about the residents' healthcare. FindingsA review of Resident 16's admission Record, indicated she was admitted to the facility in 2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). The record also indicated Resident 16's son was the RP.During an interview on 9/8/25 at 12:19 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy for one of 26 sampled residents (Resident 82), when Resident 82's urinary catheter (a tube left in the bladder to continuously drain urine into a collection bag) collection bag had no privacy cover. This failure decreased the facility's potential to maintain Resident 82's dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess one of 26 sampled residents (Resident 5), when the Minimum Data Set (MDS, a federally mandated assessment tool) inaccurately indicated Resident 5 had no pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential to incorrectly recognize Resident 5's care needs.

Inspectors wroteBased on interview and record review, the facility failed to accommodate the needs of one of 26 sampled residents (Resident 76), when Resident 76 was not given a shower as scheduled. This failure decreased the facility's potential to provide comfort to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper care of respiratory equipment was consistent with the facility's policy and professional standards of practice for one of 26 sampled residents (Resident 10), when Resident 10's nebulizer tubing and nasal cannula (a thin, flexible tube that goes around your head and into the nose and gives additional oxygen through the nose) were not changed after seven days. This failure decreased the facility's potential to provide safe respiratory care for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity for one of three sampled residents (Resident 2), when the resident was not provided shower for five days. This failure had the potential to result in Resident 2 ' s not attaining her feelings of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The microwave in the kitchen was not clean; 2. Several various sizes of metal sheet pans were stacked wet stored at the clean and ready-to-use storage areas; 3. Produce items were not fresh and not discarded; and, 4. One dishwasher was not able to verbalize the procedure for the manual dishwashing with 3-compartment sinks correctly. These failures had potential to cause food-borne illness in a highly susceptible population of 59 out of 59 residents who received food from the kitchen. 1. During a concurrent observation and interview with Dietary Supervisor (DS) on 9/23/24 at 8:48 a.m. [...]

Inspectors wroteBased on observation and interview, the facility was unable to provide a clean environment for the residents and visitors when three of three garbage dumpsters, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch meals on 9/23/24 and 9/24/24 when: 1. Resident 257 with dysphagia (difficulty swallowing) mechanical texture diet (a diet that consist of foods that are moist, mechanically altered, easily mashed) who: a. Received puree zucchini instead of chopped and mashable zucchini on 9/23/24 lunch meal b. Received puree apple bread pudding instead of bread pudding chopped into half inch (1/2) and soak in milk on 9/24/24 lunch meal 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a homelike environment for one of 15 sampled residents (Resident 42), when the chain that is used to turn on Resident 42's overhead light was broken and unreachable. This failure had the potential to result in Resident 42 not experiencing a homelike environment which can negatively impact his psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a Significant Change in Status Assessment (SCSA, an assessment that indicates a major decline or improvement in the resident's status) was completed for one of 15 sampled residents (Resident 45), when Resident 45 developed a stage four pressure ulcer (PU, deep wound reaching the muscles, ligaments, and bones) to the left sacrum (triangular bone, back portion of the pelvis). This failure decreased the facility's potential to provide appropriate care and services to Resident 45 based on her status.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used for care) accurately reflected the status of one of 15 sampled residents (Resident 45), when Resident 45's pressure ulcer (PU, an injury that breaks down the skin and underlying tissue) was not coded accordingly. This failure had the potential for Resident 45 to receive inadequate wound care management.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for one of 15 sampled residents (Resident 208), when Resident 208's care plan did not address the use of a leg immobilizer. This failure had the potential for Resident 208's order to be missed and not implemented.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services which meet professional standards of quality for one of 15 sampled residents (Resident 208), when Resident 208 was allowed to use a right knee/leg immobilizer without a physician's order. This failure increased Resident 208's potential to use a knee/leg immobilizer without a physician order.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an ancillary service was provided to one of 15 sampled residents (Resident 42), when Resident 42 was not assisted to use his hearing aids (HAs) daily as ordered. This failure increased Resident 42's inability to hear clearly and communicate properly.

Inspectors wrote2. A review of Resident 15's admission Record, indicated Resident 15 was admitted in May 2024 with diagnoses including complete paraplegia (inability to move lower body from waist down), weakness, and presurre ulcer on the sacral region (lower back between hip bones). A review of Resident 15's Minimum Data Set (MDS; an assessment tool), dated 8/30/24, indicated presence of a stage three pressure ulcer on the sacral region. During a concurrent observation and interview on 9/24/24 at 11:28 a.m. with LN 3, Resident 15's room was observed. There was no sign on the door indicating EBP. LN 3 checked the personal protective supplies in the lower drawer of Resident 15's dresser as per facility practice and no supplies were available. LN 3 agreed EBP sign and PPE supplies were missing. During an interview on 9/26/24 at 10:30 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of 15 sampled residents (Resident 18). This failure decreased Resident 18's potential to get assistance from staff in a timely manner when needed.

Inspectors wroteBased on interview and record review the facility failed to follow the professional standards of practice for one of three sampled residents (Resident 1) when required documentation in the resident's chart was not completed timely. This failure decreased the facility's potential to provide complete and accurate nursing care for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure physician's orders were implemented for one of five sampled residents (Resident 1) when an order for a topical (used on the skin) cream used for pain was not entered from the hospital orders into Resident 1's medication orders. This failure resulted in Resident 1 not having access to her topical pain cream.

Inspectors wroteBased on interview and record review, the facility failed to provide a qualified activities director to direct their activities program for a census of 59. This failure potentially placed the residents at risk for decreased physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide services according to professional standards of quality for four of seven sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when doses of antibiotics (medicine that fights bacterial infection) were missed and/or not administered intravenously (IV; into the vein) on time as indicated in physician's orders. This failure increased the residents' potential to have unmet health needs.

Inspectors wroteBased on interview and record review , the facility failed to provide a qualified activities director for their activities program for a census of 61. This failure potentially placed the residents at risk for decreased physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement measures to prevent the development of a pressure ulcer (PU, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) on the sacrum (tailbone) for one of 19 sampled residents (Resident 31) when: 1. A Risk for Pressure Ulcer Care Plan was not updated; 2. Shower/Bath skin assessments were not completed as scheduled; 3. Nursing weekly summary assessments did not include direct observation of the resident's skin; and 4. Turning and repositioning documentation was not accurate. These failures resulted in Resident 31 developing a facility acquired Stage 3 (affecting the top 2 layers of the skin as well as the fatty tissue) PU.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 13) was free of a significant medication error when tramadol (opioid medicine used for the short-term relief of moderate to severe pain) was not available for routine administration. This failure resulted in Resident 13 experiencing pain and psychosocial (the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm when pain was left untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, when: 1) One dietary aide did not use appropriate handwashing during food handling; 2) The ice machine was not cleaned and sanitized correctly; 3) Two kitchen staff did not wear hair restraints in the food prep area; 4) Nineteen various size metal pans were found wet or dirty, stacked in the ready to use shelves; 5) Nine dry goods were not sealed or dated in the dry storage area; 6) Eleven cartons of supplement shakes (drinks that provide additional nutrients) were not dated with the correct use by date; and 7) The microwave in the resident's nutrition room was dirty. These failures had the potential to lead to food-borne illnesses.

Inspectors wroteBased on interview, and record review, the facility failed to develop and complete a comprehensive person-centered care plan for one out of 19 sampled residents (Resident 19). This failure had the potential for Resident 19 to not receive appropriate care, services, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of two residents (Residents 21 and 303) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 52; 3. Store discontinued controlled medications in accordance with facility policy and procedure (P&P); and, 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 19 sampled residents (Resident 19 and Resident 202) were free of unnecessary medications when: 1. Resident 202 was prescribed three psychotropic (a drug that affects behavior, mood, thoughts, or perception) medications without adequate indication and behavior monitoring, a PRN psychotropic had no end date and consent was not obtained prior to its administration; and 2. Resident 19 was prescribed four psychotropic medications without adequate side effect and behavior monitoring. These failures placed the residents at risk for use of unecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility had a 32.26% error rate when ten medication errors out of 31 opportunities were observed during a medication pass for three out of four residents (Residents 3, 13 and 47). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: - Medication carts were kept securely locked when left unattended; - Opened biologicals, multi-dose inhalers, and inhalation solutions were dated with an open and discard date to ensure they were not used beyond the discard date; - Medication was appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and - Expired and discontinued medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, and diversion or misuse of medications from not being securely stored in medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diets (a modification of a regular diet, to fit the residents nutritional needs) during the lunch meal on 8/22/2023 when nine residents (Residents 9, 18,20,23,31,43,203, 205 and 305) did not receive the correct dessert. These failures had the potential to result in compromising the medical and nutritional status of nine residents for a census of 52.

Inspectors wrote3. During an observation on 8/21/23 at 8:33 a.m. with Licensed Nurse 2 (LN 2), LN 2 used a blood pressure cuff to measure Resident 47's blood pressure. After the resident's blood pressure was taken, LN 2 removed the cuff and placed it on the top of the medication cart without sanitizing and disinfecting it. LN 2 was observed taking the blood pressure of Resident 3 and Resident 13 without sanitizing or disinfecting in-between uses. 4. During a medication pass observation on 8/21/23 at 9 a.m. with LN 2, LN 2 was observed administering medications to Resident 13. LN 2 placed Resident 13's medication cup on her bedside table then touched her own hair and glasses. LN 2 left the room to prepare applesauce for Resident 13 and returned to the resident without performing hand hygiene. During an interview on 8/21/23 at 12:09 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reasonably accommodate the needs of two of 19 sampled residents (Resident 22 and Resident 31) when their call lights were not within reach. This failure had the potential to result in residents being unable to request assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST) form for one resident (Resident 29) of 19 sampled residents was valid in the electronic health record (EHR). This failure decreased the staff's potential to safely follow Resident 29's POLST during emergencies.

Inspectors wroteBased on interview and record review, the facility failed to timely submit an MDS (Minimum Data Set, an assessment tool) for one of 19 sampled residents (Resident 24) when a discharge MDS from 4/23 had not yet been submitted. This failure had the potential to result in incomplete information being submitted to CMS (Centers for Medicare and Medicaid Services).

Inspectors wroteBased on interview and record review, the facility failed to develop and complete a baseline care plan (BCP) within 48 hours of admission for one resident (Resident 29) of 19 sampled residents. This failure decreased the facility's potential to communicate the initial plan of care with residents, promote their continuity of care, and increase their safety.

Inspectors wroteBased on interview and record review, the facility failed to revise care plans at least quarterly for one of 19 sampled residents (Resident 31) when her risk for pressure ulcer and risk for incontinence care plans had not been revised since 4/19/23. This failure had the potential to result in unmet nursing needs for Resident 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide baths/showers as scheduled for two out of 19 sampled residents (Resident 16 and Resident 13) when Resident 16 and Resident 13 did not have a shower as scheduled. These failures had the potential to decrease cleanliness and comfort for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences during the lunch meal on 8/22/23 for two sampled residents (Resident 12 and Resident 8) out of a census of 53 when; 1. Resident 12 was served a whole slice of turkey even though ground meats was documented on Resident 12's meal card; and, 2. Resident 8 was served fresh fruit as a dessert instead of the regular dessert which was documented on Resident 8's meal card. This failure increased the potential for Resident 12 and Resident 8 to have an unpleasant dining experience and had the potential to result in altered nutrition.

Inspectors wroteBased on interview and record review, the facility failed to document and communicate the necessary information for a hospital transfer for one resident (Resident 29) of 19 sampled residents, when Resident 29's Interact SBAR [Situation-Background-Assessment-Recommendation] Communication Form was not completed. This failure decreased the facility's potential to prevent delayed care for transferred residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a pneumococcal vaccine (a vaccine to prevent infection of one or both lungs) for one of 19 sampled residents (Resident 32) when Resident 32 did not receive a pneumococcal vaccine when it was due. This failure had the potential to increase the chance of Resident 32 getting a lung infection.

Inspectors wroteBased on interview and record review, the facility failed to provide education regarding risks and benefits associated with COVID-19 (Coronavirus Disease, an infection affecting the lungs) vaccination for one of 19 sampled residents (Resident 35) when Resident 35 did not receive the risks and benefits education upon refusal of a COVID-19 vaccination. This failure had the potential to decrease the chance of Resident 35 getting a COVID-19 vaccination.