Golden Gate Rehabilitation & Health Care Center

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey from 05/21/2024 to 05/29/2024 , the facility did not ensure that food was served at an appetizing temperature during meal service. This was evident for 2 of 2 units (Units 4 and 5) observed during dining observation. Specifically, food served during lunch meal service were not maintained at palatable and appetizing temperatures.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey from 05/21/2024 to 05/29/2024, the facility did not ensure the Minimum Data Set assessments accurately reflected the resident's status. This was evident for 2 (Resident #90 and #212) of 38 total sampled residents. Specifically, 1.) Resident #90's Minimum Data Set assessment did not accurately document the resident acquired pressure sores in the facility, and 2.) Resident #212's Minimum Data Assessment assessment documented the resident was discharged to the hospital.

Inspectors wroteBased on interview and record review conducted during the Recertification and Complaint Survey (NY00333382) from 05/21/2024 to 05/29/2024, the facility did not ensure services provided by the facility met professional standards of quality. This was evident for 1 of 1 resident reviewed for drugs and medication. Specifically, Resident #215 had Bacitracin allergy. Review of Resident's treatment administration record revealed that Bacitracin was administered from 02/24/2024 to 02/29/2024.

Inspectors wroteBased on record review and staff interview conducted during the Recertification Survey conducted from 05/21/2024 to 05/29/2024, the facility failed to address an irregularity identified by the pharmacist during Medication Regimen Review. This was evident for 1 (Resident # 67) of 5 residents reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, Divalproex (a mood stabilizer) serum level was recommended for Resident #67 by the Consultant Pharmacist during Drug Regimen Review. The recommendation was not addressed.

Inspectors wroteBased on observations, record review, and interview conducted during the Recertification Survey from 05/21/2024 to 05/29/2024, the facility did not ensure that infection control practices were maintained. This was evident in 1 of 4 floors (3rd Floor) observed for the Dining Task and Infection Control. Specifically, Transporter #1 did not perform hand hygiene while assisting multiple residents in the dining room.

Inspectors wroteBased on observation, interviews, and record review conducted during an Abbreviated Survey (NY00313864), the facility did not ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator or the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). This was evident for 1 out of 4 residents (Resident #1) sampled for abuse. [...]

Inspectors wroteBased on interviews and record review conducted during an abbreviated survey (NY00303546), the facility failed to complete a discharge summary for a discharged resident. This was evident for 1 of 4 residents (Resident #2) reviewed for discharge. Specifically, Resident #2 was discharged home on [DATE]. There was no documented evidence of a discharge summary detailing a summary of the resident's stay that includes, but not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.

Inspectors wroteBased on observation, record review and staff interviews conducted during the Recertification/Complaint/Extended survey (NY00257457, NY00290720 & NY00266488), 01/31/2022 through 02/11/2022, and 02/23/2022 through 03/03/2022, the facility failed to ensure residents remained free from abuse and neglect. This was evident for 3 (Resident #24, Resident #367, and Resident #203) of 10 residents reviewed. Specifically: 1). On 05/21/2020 at 6:05AM, Licensed Practical Nurse (LPN #1) witnessed Resident #24 being punched in the right thigh area by Certified Nursing Assistant (CNA) #1. CNA #1 was suspended and later returned to work (direct resident care) on 05/27/2020 and was assigned to the unit on which Resident #24 resided. 2). On 10/28/2020 at 07:30PM, LPN #2 witnessed Resident #367 being punched on the right arm by CNA #2. [...]

Inspectors wroteBased on observation, record review and staff interviews conducted during a Recertification/Complaint/Extended survey (NY00257457, NY00291683 & NY00291833) conducted from 02/23/2022 through 03/03/2022, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment and to prevent further potential abuse, neglect, exploitation, or mistreatment. This was evident for 3 (Resident #24, Resident #10, and Resident #192) out of 10 residents reviewed. Specifically: 1). On 05/21/2020 at 6:05AM, Licensed Practical Nurse (LPN #1) witnessed Resident #24 being punched in the right thigh area by Certified Nursing Assistant (CNA) #1. CNA #1 was suspended and later returned to work (direct resident care) on 05/27/2020 and was assigned to the unit on which Resident #24 resided. 2). [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification/Complaint/Extended survey (N00291683) conducted from 02/23/2022 through 03/03/2022, the facility failed to report immediately, but not later than 2 hours after forming a reasonable suspicion of a crime, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. This was evident for 1 (Resident #10) of 12 residents reviewed. Specifically, on 02/23/2022, in the morning, the Medical Director notified the Director of Nursing (DON) #1 that Resident #10 accused Certified Nursing Assistant (CNA) #5 of abuse, potentially causing a fracture to the right elbow. The allegation of alleged abuse was not reported to local law enforcement agencies. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification/Complaint/Extended survey (NY00257457, NY00266488, NY00290720, NY00291433, NY00291683, and NY00291833) conducted from 02/23/2022 through 03/04/2022 the facility failed to report all alleged violations involving abuse, neglect, including injuries of unknown source, immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury. This was evident for 5 out of 10 residents reviewed for Abuse, Neglect, and Mistreatment (Resident #24, Resident #367, Resident #211, Resident #10, and Resident #192). Specifically: 1. [...]

Inspectors wroteBased on observation, record reviews, and interviews conducted during the Recertification/Complaint survey, the facility did not ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately to reflect the resident's status. Specifically, Resident's use of oxygen therapy was not coded on the latest Quarterly MDS. This was evident for 1 of 1 resident reviewed for respiratory therapy out of a total investigation sample of 44 residents. (Resident #134).

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey, the facility did not ensure that all medications and biologicals were labeled in accordance with currently accepted pharmaceutical principles and practices. Specifically, three metered dose inhalers and two bottles of ophthalmic solution were not labelled with the opening date. This was evident for 1 of 4 carts on 1 of 4 units observed for medication and storage labeling (3rd floor).

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that a residents' dignity was maintained. Specifically, two residents one female and one male complained that they were not given notice that they would be residing in rooms with a bathroom shared by the opposite sex/gender. Resident #208 complained to the State Agency Surveyor (SA) that the male residents have walked in while she was using the bathroom. Furthermore the facility does not provide signs informing residents to knock prior to entering shared bathrooms in an effort to maintain privacy and dignity of the residents in adjoining rooms. This was evident for 2 out of 36 sampled residents. (Resident #208, Resident #4)

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that proper treatment and assistive devices to maintain vision were provided to a resident. Specifically, a resident who was evaluated for new eyeglasses did not receive new eyeglasses. This was true for 1 of 3 residents reviewed for vision/sensory care out of 36 sampled residents. (Resident #3)

Inspectors wroteBased on observation, record review and staff interviews during the recertification survey , the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments at each visit. Specifically, a resident diagnosed with Diabetes had consistently elevated blood sugars in the morning and at night as documented in the Medication Administration Record. There is no documented evidence that the physician assessed the trends of elevated blood sugars to ensure accurate monitoring of glucose levels. It was 10 months since the physician or designee ordered the Glycated hemoglobin ( HbAIc ) test (a test that measure the overall blood glucose control over a period of 60-120 days). The resident's most recent test was taken on 6/21/19 and the resident's results were elevated over normal parameters. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a resident was free from unnecessary antipsychotic medication. Specifically, a resident who was not previously receiving antipsychotic medication was prescribed Risperidone to treat Dementia-related symptoms. This was true for 1 of 5 residents reviewed for Unnecessary Medications. (Resident #48)

Inspectors wroteBased on observation, record review and interviews during the re-certification survey, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infections. Specifically, (1) One resident receiving Oxygen by nasal cannula with the oxygen tubing coming from the oxygen concentrator was resting on the floor and (2) a Certified Nursing Assistant (CNA) was observed physically attending to residents and touching a garbage can lid without handwashing in between. This was evident for 1 of 36 sampled residents (Resident #71) and 1 of 4 unit dining rooms observed during the Dining Observation (4th floor).