Gold Crest Care Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that each resident's right to privacy and confidentiality of their personal and medical records was maintained for one (1) (Resident #48) of two (2) residents investigated for Privacy, out of 35 total sample residents. Specifically, the names, room numbers, and dietary orders of Resident #48 and 12 other residents were posted on the 3rd floor bulletin board in an area that was visible to other residents and visitors on the unit.

Inspectors wroteBased on observation, record review, and interviews the facility failed to maintain a resident's right to a safe, clean, comfortable and homelike environment. This was evident for one (1) (Unit 1) of four (4) units observed. Specifically, residents' rooms in Unit 1 were noted with worn furniture, rusted bed frames, holes in the walls, windows in disrepair, peeled wallpaper, mismatched paint, and electrical outlets that were not secured to the wall.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that resident or resident representatives were included in all aspect of care planning. This was evident in one (1) (Resident #70) of three (3) residents reviewed for care planning out of 35 total sampled residents. Specifically, there was no evidence that Resident #70 or their representative was invited to care plan meetings.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, the staff bathroom on the first floor in the dayroom had discolored tiles and cracked ceiling.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that the binding arbitration agreement provides for the selection of a venue that is convenient to both parties. This was evident for three (3) (Residents #3, #83, and #174) of three (3) residents reviewed for arbitration.

Inspectors wroteBased on record review and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that a comprehensive care plan was developed and implemented to meet each resident's needs. This was evident in 2 (Resident #228 and #17) out of 36 sampled residents. Specifically, 1.) Resident #228, who had a diagnosis of osteomyelitis, had no comprehensive care plan developed to address the presence of infection. 2.) Resident #17, who had a diagnosis of osteomyelitis, had no comprehensive care plan developed to address the presence of infection.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that a resident was free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptom. This was evident in 1 (Resident #60) of 1 resident reviewed for physical restraints out of 36 total sampled residents. Specifically, Resident #60 was observed, on multiple occasions, in bed with upper quarter bed side rails raised on both sides.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that a resident was assessed for risk of entrapment from bed rails prior to use. Additionally, the facility did not ensure that the risk and benefits of bed rails were discussed with the resident, or their representative, and that informed consent was obtained prior to bed rail use. This was evident in 1 (Resident #60) of 1 resident reviewed for physical restraints out of 36 total sampled residents. Specifically, Resident #60 was observed, on multiple occasions, in bed with upper quarter bed side rails raised on both sides. The facility had no documented evidence of assessment for risk of entrapment and informed consent prior to bed rail use. There was also no documented evidence that preventive maintenance of bed rails was conducted.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 2 (Residents #14 and #60) of 4 residents observed for medication administration. Specifically, Enhanced Barrier Precautions were not maintained during medication administration for residents with gastrostomy tube.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case # NY00348463) on 07/22/2024-07/23/2024, the facility failed to notify Justice Involved Residents of their transfer or discharge and the reason for the move in writing. Additionally, the facility did not send a copy of the transfer or discharge notice to the Office of New York State Long Term Care Ombudsman. This was evident for 4 out of 5 Justice Involved Residents (Justice Involved Resident #1, Justice Involved Resident #2, Justice Involved Resident #3, and Justice Involved Resident #5). Specifically, Justice Involved Resident #1, #2, #3, and #5 were discharged from the facility, there was no documented evidence that a discharge or transfer notice was provided to them. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (Case # NY00314017) the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 1 out of 7 residents (Resident #6) sampled for abuse. Specifically, on 03/28/2023, Resident #6's adult child called Licensed Practical Nurse #2 and stated that Certified Nursing Assistant #1 was rough when providing personal care. The allegation of rough handling of Resident #6 was not reported to the New York State Department of Health.

Inspectors wroteBased on interviews and record review conducted during the Recertification survey from 7/11/22 to 7/18/22, the facility did not ensure that liability notices were provided appropriately to Medicare beneficiaries. Specifically, notices were not provided in a timely manner and notices were not mailed out when telephone notification was made. This was evident for 2 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 35 residents. (Resident #611 and Resident #612).

Inspectors wroteBased on record review and staff interviews conducted during a Recertification Survey from 7/11/22 to 7/18/22, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 of 2 residents reviewed for Nutrition, and 1 of 1 residents reviewed for Dialysis out of 35 sampled residents. (Residents #121 and #103).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification Survey 7/11/22 to 7/18/22, the facility did not ensure that medication and biologicals were labeled in accordance with currently accepted professional principles. Specifically, eye drops and inhalers did not have labels on the individual bottles and/or devices that specified the resident the medication was prescribed for. In addition, insulin pens were not stored in a sanitary manner to prevent cross-contamination. This was evident for 1 of 4 units observed for Medication Storage and Labeling. (Unit 4).

Inspectors wroteBased on interviews and record reviews conducted during a Recertification and Complaint Survey (NY00291851) 7/11/22 to 7/18/22, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for each resident. Specifically, the medical record for a resident had multiple missing entries documenting that toileting had been provided for the resident. This was evident for 1 of 1 residents reviewed for Activities of Daily Living (ADLs) out of a sample of 35 residents. (Resident #22)