Golden Estates Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Golden Estates Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF584Feb 28, 2025

  Based on observation, interview, and record review, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, for 30 of 75 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 11 additional residents with rooms on the 200/100 hallways (all residents of 300 affected), 3 of 3 halls (halls 300, 200 and 100) and affected residents who utilized the facilities hallways, and main living area reviewed in that: 1. […]

• Immediate jeopardy, patternF684Jun 4, 2023

  47564 Based on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 12 out of 16 residents (Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #107, #257, and Resident #258) reviewed for diabetic care in that; 1. The facility failed to administer injectable insulin for Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #257, and Resident #258, sporadically from 04/14/2023 to 05/13/2023, due to an update in the electronic medication system. 2. […]

• Immediate jeopardy, isolatedF689May 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Residents #1) reviewed for accidents hazards and supervision: The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility near the access road near the expressway on Saturday, 5/10/25. The facility did not have a plan in place for monitoring the front door to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. An IJ was identified on 5/28/25. The IJ template was provided to the facility on 5/28/25 at 5:04 p.m. […]

• Immediate jeopardy, isolatedF580Jul 28, 2024

  Based on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 17 residents (Resident #63) reviewed for physician notification of changes. The facility failed to consult with Resident #63's physician and provide all necessary details to the DON when Resident #63 had a significant change in condition on [DATE], that included pain, vomiting, diarrhea, and low oxygenation and subsequently died . An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:28 PM. […]

• Immediate jeopardy, isolatedF678Jul 28, 2024

  Based on observation, interview and record review LVN A failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 17 residents (Resident #63) reviewed for Full Code status. The facility failed to ensure emergency protocol was followed and failed to ensure Resident #63, who had a Full Code order in place, was provided continuous and uninterrupted CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice on [DATE] when LVN A stopped CPR once and continued after obtaining an AED, and Resident #63 subsequently died . […]