Golden Crest Nursing Centre

In the surveyor’s words

From the most serious findings on record at Golden Crest Nursing Centre, in the surveyor’s own words.

• Actual harm, patternF600Oct 13, 2023

  Based on surveyor observation, record review, and staff and resident interviews, it has been determined that the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents reviewed, Resident ID #102. Findings are as follows: Review of the facility policy titled, Abuse Prohibition, states in part, .Resident abuse is defined as willful infliction of .unreasonable confinement, intimidation, or punishment resulting in .mental anguish; and included mental abuse. […]

• Actual harm, isolatedF686Dec 11, 2025

  Based on surveyor observation, clinical record review, and staff interview, the facility failed to prevent a new pressure ulcer from developing for 1 of 1 resident reviewed (Resident ID #7) with a physician's order to off load heels. The physician-ordered intervention to offload the resident's heels was not consistently implemented for Resident ID #7, despite the resident's identified risk factors for pressure ulcer development, including impaired mobility, malnutrition, and a moderate risk score on the Norton Plus Pressure Ulcer Scale (a tool utilized to assess a resident's risk for developing a pressure ulcer). This failure resulted in the development of a deep tissue injury (DTI) to the resident's left heel, which was identified during a skin assessment requested by the surveyor. […]

• Actual harm, isolatedF760Dec 13, 2022

  Based on record review, staff, and family representative interview, it has been determined that the facility failed to ensure that residents are free from any significant medication errors for 1 of 3 resident's reviewed for medication administration, Resident ID #1. Findings are as follows: Review of a community reported complaint submitted to the Rhode Island Department of Health on 12/13/2022 alleges in part, Pt. [patient] reported to not have received Prednisone [an immunosuppressant drug used to prevent the body from rejecting a transplanted organ] while at [facility] resulting in AKI [acute kidney injury] as [s/he] is a kidney transplant pt . […]

• Actual harm, isolatedF689Apr 11, 2022

  Based on record review and staff interview it has been determined that the facility failed to provide adequate supervision to prevent accidents for one of one resident reviewed, Resident ID# 1. Findings are as follows: According to the Lippincott Manual of Nursing Practice 10th Edition reveals in part, .pg.1233 Suicide Ideation .assess for risk factors .associated psychiatric illness .Determine whether patient has ever attempted suicide .the risk factor is much greater in these people . Review of the American Nursing Associations journal article, published January 4,2022, titled Suicide assessment and follow-up care, states in part: .Patients at risk .Risk factors include a history of suicide attempts .mental health or substance use disorder . […]

• Actual harm, isolatedF740Apr 11, 2022

  Based on record review and staff interview it has been determined that the facility failed to provide each resident with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings are as follows: According to the Lippincott Manual of Nursing Practice 10th Edition reveals in part, .pg.1233 Suicide Ideation .assess for risk factors .associated psychiatric illness .Determine whether patient has ever attempted suicide .the risk factor is much greater in these people . […]