Golfcrest Nursing and Rehabilitation

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments for one (Nurse Cart for 200 Hall) of three medication carts reviewed for storage of medications. The Nurse Cart for 200 Hall had a one (1) Liter (L) bottle of Jevity 1.5 calorie, (a prescription liquid nutritional food), left unattended on top of the cart. This failure could place all residents at risk of adverse reactions to medications, drug diversion and spillage. In an observation on 07/14/2026 at 8:15 AM, a 1L bottle of Jevity 1.5 calorie, a prescription liquid nutritional food for administration into gastrotomy tube (a tube placed into the stomach for supplemental feeding) was left unattended by the 200 hall nursing station, where residents have the availability to access the medications cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and public on 2 of 3 Halls (100 and 200 Halls) reviewed for environmental concerns in that. 1. Overhead light was not illuminating in the overbed light of room [ROOM NUMBER].2. Baseboard coming off the wall in rooms 107, 1094. Peeling paint on the walls in rooms [ROOM NUMBERS]. 5. Bedroom and with trash, dust and food on the floor in room [ROOM NUMBER], 205, 105.6. Bathroom in 107 had dirty bathtub, broken sheetrock and dirty shower chair.7. Resident's feeding pump, air mattress and pump and O2 concentrator were not cleaned. 8. Electric outlet not covered in room [ROOM NUMBER]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so the facility was free of pests on two of three halls (Hall 100 and Hall 200) reviewed for pest control. The facility failed to ensure that resident's rooms were free of roaches, flies and gnats. This failure could place residents at risk of infection, skin irritation, allergies, and unsanitary living conditions which could result in a decline in their health and well-being. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that resident's care plan was reviewed and revised by the interdisciplinary team to address 1 of 6 residents ( Resident #1's) behavior of refusing care in that:The facility failed to ensure that Resident #1's care plan was revised to address his refusal of showers. This failure could place residents at risk of not getting the care and services needed to improve their quality of life. Findings Included Record review of Resident #1's admission face sheet dated 1/15/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure a Resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 34 residents (Resident #1) reviewed for ADL.The facility's 3rd shift nursing staff failed to or ignored Resident #1's call light in a timely manner, which has consistently occurred throughout a period of time [January 2025 through December 2025], leaving Resident #1 needing assistance for incontinent care for several hours. Resident #1 felt neglected, belittlement, and shame due to the facility's failure. These failures could cause residents to experience compromised dignity, comfort, and place residents at risk for skin infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 34 residents (Residents #10, #11, and #12,) reviewed for accidents and supervision. 1. The facility failed to ensure Residents #10, #11, and #12 were supervised while smoking on 12/18/2025 at 5:09 AM. 2. The facility failed to ensure Residents #10, #11, and #12 smoking supplies were stored securely when they were observed smoking unsupervised on 12/18/2025 at 5:09AM. These deficient practices could place residents at risk of burns causing injury or harm.

Inspectors wroteBased on observation, interview and record review, the facility did not 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 1 out of 4 staff (CNA A) and 2 of 3 residents (Resident #3 and Resident #4) reviewed for infection control. CNA A failed to place Resident #3's Hoyer transfer sling and bed sheets in the appropriate linen barrel after use and placed them in the rubbish bin at the resident's bedside. CNA A failed to place Resident #4's bed blanket in the appropriate linen barrel and tried to replace it on the resident's bed after it had been lying on the floor. These failures could place residents at risk for cross contamination, infection and decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside. Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 out of 10 (Resident #2) of the residents reviewed for call-lights. The facility failed to ensure Resident #2 had a functioning call light, the call light was empty inside the device, presenting only the white outer coating. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #77) out of 6 residents reviewed for pain management. The facility failed to ensure Resident #77's pain medications were administered timely prior to traveling in an ambulance to the dialysis facility on 07/23/25 when he rated his pain as an 8 out of 10 pain scale. This failure could place Resident #77 and other residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free of significant medication error for 1 of 6 residents (Resident #77) reviewed for medication administration. The facility failed to ensure Resident #77 received the correct controlled substance for pain medication as ordered by the physician leading to multiple opioid administrations between 06/12/25 and 07/26/25.-Resident #77's narcotic sheets for Oxycontin ER 10mg contained documented sign out dates from 06/12/25 to 07/26/25. There were no physician orders for Oxycontin ER 10mg.-Resident #77's narcotic sheet for Oxycodone IR 10mg one tablet every 12 hours contained documented sign out dates that did not match the instructions on the pharmacy label. These failures could place other residents at risk of medication errors, opioid overdose, CNS depression, respiratory distress and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #77) reviewed for pharmacy services. MA-B failed to administer Sevelamer (a phosphate binder used to control high phosphorus levels in residents on dialysis) as instructed on the pharmacy label. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of four medication carts reviewed for storage of medications. RN-M failed to ensure the 200 Hall nurse medication cart was locked when unattended. This deficient practice could place residents at risk for loss of biologicals and place residents at risk of access to hazards.

Inspectors wroteBased on observation, interview, and record review the facility failed to 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 one of 5 residents (Resident #112). -CNA-K failed to properly clean Resident #112 during incontinent care.-CNA-K failed to perform hand hygiene between glove changes.-CNA-K and LVN-L failed to put on a gown prior to incontinent care for Resident #112 who was in Enhanced Barrier Precaution (EBP). These failures could place residents at risk of urinary tract infections (UTI), discomfort, skin breakdown and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to properly dispose of waste in the appropriate receptacles. Two red cylindrical 32-gallon containers with white letters on the outside of it reading Infectious Waste: Biohazard containing unknown waste were located outside of the facility. This deficient practice could place residents, staff, and the public at risk of being exposed to potentially hazardous waste.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish an infection prevention and control program that included handling of soiled linen, and patient care equipment as well as to help prevent the development of communicable diseases and infections, on 2 of 3 halls (Hall 100 and Hall 200) observed for infection control. CNA D and CNA E were observed taking dirty linen and soiled brief to the trash can across the hallway and they were not in clear trash bag. Personal care basins and bed pans were on the bathroom floor not labeled with resident's name and not in plastic bags. These failures have the potential to affect all residents by placing them at risk of infections and diminishing quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents on 2 of 3 Halls (100 and 200 Halls) reviewed for environmental concerns. 1. Overhead light was not illuminating in the bathroom of room [ROOM NUMBER]. 2. Baseboard coming off the wall in rooms 118, 201, 3. Broken sheet rack in rooms 113, 219, 206 4. Peeling paint on the wall in rooms 103, 120, 5. Floor tile lifting in room [ROOM NUMBER] 6. Strong urine/feces odor in room [ROOM NUMBER], 116 and 120. In 116 and 120 brown substance that looked like feces the toilet and floor. This deficient practice could affect residents who resided in rooms on hall 100 and hall 200 by causing the residents to live in an environment that would not improve their quality of life. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so the facility was free of pests on two of three halls (Hall 100 and Hall 200) reviewed for pest control. The facility failed to ensure the building was free of roaches and gnats. This failure could place residents at risk of infection, skin irritation, allergies, and unsanitary living conditions which could result in a decline in health and well-being.

Inspectors wroteThe facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was given as ordered by the physician. This failure could place residents who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication for blood pressure which could result in decreased quality of life.

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 for 1 of 1 kitchen in that: 1. Food items were not sealed and/or not dated in the facility pantry . 2. One can of canned food was dented and stored with the non-dented food cans . These deficient practices could place 89 residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #44) reviewed for medication administration were free of significant medication errors. MA L administered Doxazosin Tablet 4mg and Amiodarone HCl Tablet 200mg (medications used to treat high blood pressure), while Resident #44 was assessed with blood pressure lower than the physician recommended parameters for administering the medications. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (1st quarter October 1, 2023-December 31, 2023) reviewed for fiscal year quarter one of 2024. The facility failed to submit staffing information to CMS for the 1st quarter of the fiscal year 2024. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, and a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4) were kept free form abuse, in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the written policies and procedure to prevent abuse were implemented for 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4), in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. - The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 1 (Resident #1) of 6 residents reviewed for care plans in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. - The facility failed to develop and implement interventions to prevent Resident #1's aggression and abuse of Residents #3 and #4. [...]