Gold Country Health Center

In the surveyor’s words

From the most serious findings on record at Gold Country Health Center, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 25, 2023

  Based 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. […]

• Actual harm, isolatedF760Aug 25, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF814Sep 26, 2024

  Based 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. Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 9/23/24 at 8:38 a.m outside, three out of three dumpsters were covered with bent and deformed lids with bags of trash inside the bins. There were gaps between the deformed lids and the bins because the lids lacked integrity to securely cover the bins. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2023

  Based 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. […]