Golden Hill Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and interviews conducted during the Abbreviated Survey the facility did not ensure the services provided were consistent with professional standards of medication administration that include obtaining physician clarification when the ordered medication could not be dispensed as written prior to administration, for one (Resident #2) of three residents reviewed for medication administration. Specifically, Resident #2 was re-admitted to the facility on [DATE] with a physician's order for Clozapine 100 milligrams, give 1.75 tablet by mouth at bedtime for psychosis. A Pharmacy clarification email provided by the Director of Nursing documented that on 01/16/2026, the pharmacy notified the facility that the medication could not be dispensed as ordered and requested that the physician be contacted to change the order. [...]

Inspectors wroteBased on record review and interviews conducted during the Abbreviated Survey, the facility did not ensure that a resident who was experiencing pain was assessed and provided appropriate and timely pain management, including the timely administration of medications, for one (Resident #3) of four (4) residents reviewed for pain management. Specifically, the Facility Medication Administration Audit Report dated 08/02/2025 through 08/03/2025 documented that Resident #3 was scheduled to have a pain assessment completed at 7:00 PM on 08/02/2025. There was no documentation that the pain assessment was completed as ordered. 2. The 08/02/2025 Medication Administration Audit Report also documented that Resident #3 was scheduled to receive Melatonin 10 milligrams at 8:00 PM and Gabapentin 100 milligrams at 9:00 PM on 08/02/2025. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that one (1) of three (3) residents reviewed for blood sugar monitoring and insulin administration received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #1 had an order placed on admission, 09/24/2025, for 70/30 insulin with no clear order for blood sugar monitoring. Nursing staff inconsistently monitored Resident #1's blood sugar without an order for blood sugar monitoring until one was placed on 10/08/2025. Additionally, the physician notes indicated that Resident #1's blood sugars were being monitored before meals and at hour of sleep from 09/29/2025, but no order was entered until 10/08/2025. [...]

Inspectors wrote2) During an observation on 5/14/25 at 12:48 PM Resident #105, #93, #121 were served lunch and began eating. Fourth table mate, Resident #16 was not served lunch until 1:00 PM. Resident #93 verbalized that Resident #16 had not received lunch and repeatedly asked for them to be served. During an interview on 5/15/25 at 12:30 PM Certified Nurse Aide #17 stated they were not aware that all residents at the same table should have been served at the time before moving onto the next table. Unit Manager Registered Nurse #21 stated they were not aware of any residents' concern for everyone to be served at the same time. [...]

Inspectors wrote2) Resident #538 had diagnoses that included metabolic encephalopathy, hypertension, and muscle wasting. The 9/25/2024 admission Minimum Data Set (assessment tool) documented moderately impaired cognition, foley catheter, occasional incontinence of bowel, maximum assistance for toileting hygiene and transfers. The 12/18/2024 Discharge Minimum Data Set documented moderately impaired cognition, foley catheter, incontinent of bowel, dependent on assistance for toileting hygiene and transfers. The Certified Nurse Aide Kardex dated 12/7/24 documented Resident #528 required maximum assistance and was dependent on staff for all ADLs and transfers, except oral and personal hygiene. [...]

Inspectors wroteBased on interview and record review during the recertification and abbreviated (NY00376199) survey from 05/13/25 through 05/20/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#1, #2, #3, #4, #5) did not have a performance review documented at least once every 12 months.

Inspectors wroteBased on observation and interview conducted during the recertification and abbreviated (NY00365130) surveys from 5/13/25 to 5/20/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, a test tray was sampled and found food was not served at a palatable, appetizing temperature; and many residents complained about the food.

Inspectors wroteBased on observation and interviews conducted during the recertification survey from 5/13/25 to 5/20/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, 1.) On initial kitchen tour, food items were found undated, unsealed, and expired. The handwash sink in food prep area did not work. 2) On follow-up kitchen tour, food temperatures were not at control level on the steam table and dietary staff did not wear proper hair/beard restraint or utilize hygienic practices. 3) The pantry refrigerator on Unit C1 contained undated foods, expired foods and an incomplete temperature log.

Inspectors wroteBased on observation, record review and interviews during the recertification survey and abbreviated (NY00352562) surveys, the facility did not ensure that an investigation was completed for a resident with an injury of unknown origin for 1 (Resident #489) of 4 residents reviewed for abuse. Specifically, there was no documented evidence an investigation was conducted for Resident #489 with documented bruising on bilateral arms and left hip.

Inspectors wroteBased on observation, interview, and record review completed during a Recertification survey from 5/13/25-5/20/25 the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #167) of five (5) residents reviewed for Pressure Ulcers. Specifically, Resident #167 who had a Pressure Ulcer and a Chronic Vascular ulcer with Physician ordered dressing changes was not placed on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during care while completing wound dressing changes. The finding is: [...]

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification and Abbreviated (NY00363234) surveys from 5/13/2025-5/20/2025, the facility did not ensure a comfortable and homelike environment by maintaining comfortable sound levels. Specifically, during construction on the South 1 Unit, sounds were not maintained at comfortable levels.

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification and abbreviated (NY00346686, NY00352562) surveys from 5/13/25 to 5/20/25 it was determined that for 1 of 6 residents (Resident #32) reviewed for Accidents, and for 1 of 4 residents (Resident #489) reviewed for Abuse, the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, 1) Resident #32 the Department of Health was not notified after the 12/07/24 Accident/Incident Report documented Resident #32 was observed with bruising to their hand and arm, and 2) Resident #489 was documented on 6/24/24 to have bruising to bilateral arms and small area on left hip, and it was not investigated or reported to the Department of Health.

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (NY00377486) the facility did not ensure that the resident, resident's representative(s), or ombudsman was notified of the transfer or discharge, and the reasons for the move, in writing and in a language and manner they understand for 1 (Resident #3) of 3 residents reviewed for discharge. Specifically, Resident #3 was discharged home on 3/13/2025 and there was no documented evidence that the facility provided a notice of discharge at least 30 days before the resident was discharged . a bed hold notice was not provided, the facility did not document discussions with the resident and/or the representative that included information on discharge planning and arrangements for post-discharge care. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during an Abbreviated Survey (NY00340219), the facility did not ensure residents were free of significant medication errors for 1 (Resident #1) of 4 residents reviewed for Medication Administration. Specifically, on 4/23/24 at 8pm, Licensed Practical Nurse #1 administered Coumadin 2mg to Resident #1 which was put on hold as per Physicians orders on 4/23/24 at 1:24 pm, due to their International Normalized Ratio (INR) being high at 3.3 (normal range 2.0-3.0). Subsequently, Resident #1's International Normalized Ratio (INR) rate increased to 7.9. Resident #1 received 2.5mg of Vitamin K (for prevention of bleeding) immediately. Resident #1's coumadin 2.5mg was discontinued until the International Normalized Ratio (INR) became therapeutic.

Inspectors wroteBased on observation and interview conducted during a recertification survey from 4/8/24 to 4/16/24, the facility did not ensure that food was stored in accordance with professional standards for food safety practice, contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with the standards for food service safety. Specifically, leftover foods were unlabeled and labeled foods were expired in the kitchen refrigerator, expired food items were stored on the shelve and dented cans were not separated from good cans, and the milk cooler was full of food particles and debris.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted from 4/8/24 to 4/16/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents reviewed for indwelling medical devices. Specifically, Residents #230, #38, #198, and #122 had urinary catheters, Resident # 224 had nephrostomy tubes, and enhanced barrier precautions were not implemented.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey from 4/8/24- 4/16/24, the facility did not ensure that the call bell system was accessible for 1 of 35 residents reviewed for environment. Specifically, Resident #133 was observed on two occasions with the call bell system not within the resident's reach.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 4/8/24 to 4/16/24, the facility did not maintain a safe, clean, and comfortable environment in 2 resident rooms (Room C2-14, and C2-16). Specifically, Room C2-14 had a hole in the ceiling near the resident's bed and damaged ceiling tiles towards the front of the room, and Room C2-16 had large areas of uncovered ceiling where tiles were missing.

Inspectors wroteBased on record review and interviews during the re-certification survey from 4/8/24 to 4/16/24, the facility did not ensure Minimum Data Set 3.0 comprehensive assessments were completed in a timely manner. Specifically, the annual assessment was not completed within 14 calendar days from admission and/or by the required Assessment Reference Date. This was evident for 1 of 1 resident reviewed for Resident Assessment (Resident #120).

Inspectors wroteBased on observation, record review, and staff interview during the recertification survey from 4/8/24 to 4/16/24, the facility did not ensure that appropriate treatment and services were provided to prevent a further decrease in range of motion for 1 of 2 residents (Resident #102) reviewed for position and mobility. Specifically, Resident #102 was observed on two occasions without the blue carrot (or hand roll) in their left hand as ordered.

Inspectors wroteBased on observation, record review, and interview during an abbreviated survey (NY00300850), the facility did not ensure an area of the facility used by residents was safe for residents to receive services safely and that an equipment was in good repair. Specifically, Resident #1 slipped and fell on the floor while getting water to drink due to an ice machine that leaked and caused moisture on the floor.

Inspectors wroteBased on observation, record review and interview conducted during an Abbreviated Survey (NY00300850), it was determined that for one (Resident #3) of three residents reviewed for Quality of Care, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plan. Specifically, (1) medications were not provided to Resident #3 in the form it was ordered and necessary to prevent choking. Resident #3 was on a puree diet and had a crush order for their medications. On 8/18/2023 at 10:50AM the survey team observed Resident #3 in bed with partially dissolved 1 oval pinkish pill on the mattress and 1 round white pill on their abdomen. Facility staff identified the pills as a Diltazem ER 180mg tablet and a Furosemide 40mg or Acetaminophen 325mg tablet; [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during an abbreviated and extended survey (NY00300850), the facility did not ensure that 1 of 3 residents' (Resident #1) environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, on 8/3/2023 Resident # 1 who was cognitively impaired, required extensive 1-person physical assistance for locomotion on and off the unit, and assessed as high risk for falls slipped and fell by the kitchenette off the dining room. Resident #1 complained of lower back pain post incident and a spinal x-ray dated 8/3/2023 revealed T-12 mild compression fracture of indeterminate acuity.

Inspectors wroteBased on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that current acceptable professional standard of practice regarding storage of multi-dose insulin injection medication were followed. Specifically, (1) An opened, undated and in use multi-dose Levemir Flex Pen Insulin was observed in a plastic bag, assigned to Resident #195, in the B side medication cart; (2) Review of the facility's portable emergency drug box revealed a pharmacy expiration date of 7/2021 affixed to the box. There were conflicting expiration dates on the box and the content list; and (3) The facility provided no evidence that the box was checked or monitored by the nursing staff to ensure accuracy and to detect expiration of the drugs in order to notify the pharmacy of replacement, discrepancies, or to prevent potential problems. [...]

Inspectors wroteBased on interview and record review conducted during a recertification and Abbreviated survey (NY00264492), the facility did ensure that a resident received the necessary care and services to maintain functional ability. Specifically, 1) one of 5 residents (Resident # 428) reviewed for activities of daily living (ADLs) did not receive consistent physical and occupational therapy as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, conducted during a recertification survey, the facility did not ensure that facility staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) cross contamination of wound and wound supplies was observed; and (2) removal of soiled gloves and hand hygiene were not observed during a wound care procedure for 1 of 5 residents (Residents #157) reviewed for pressure ulcer/injury.