Golden Heights Healthcare

In the surveyor’s words

From the most serious findings on record at Golden Heights Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 26, 2025

  Based on observation, interview, facility document review, and facility policy review, the facility failed to accurately record the discard date on the label for a potentially hazardous food (thawed chicken breast) stored in 1 of 3 refrigerators and failed to conduct temperature monitoring prior to placing a potentially hazardous cold food (chocolate mousse) on residents' meal trays that was identified prior to the tray line service with a temperature of 47.3 degrees Fahrenheit. […]

• No harm, potential for more than minimal, patternF725Apr 24, 2024

  Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for five of six residents (Resident 1, 2, 3, 4, and 6). The resident responsible party and confidential interview reported a pattern of delayed response to call lights and waiting for a long period of time for staff assistance. Additionally, there was no policy and procedure in place for the use of call light. These failures resulted in delayed provision of care and services for Resident 1, 2, 3, 4, and 6; and had the potential to negatively impact the resident ' s physical, mental, and emotional well-being. […]

• No harm, potential for more than minimal, patternF610Feb 23, 2024

  Based on interview and record review, the facility failed to provide protection to Resident 1 and other residents when Certified Nursing Assistant (CNA) 1 was not suspended immediately after an alleged abuse to Resident 1 was reported on 1/13/24. This failure placed Resident 1 at risk for further abuse and placed the other 15 residents assigned to CNA 1 for potential abuse. Findings: Resident 1 was admitted on [DATE] and was readmitted on [DATE], with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to remember, think, or make decisions that interferes with doing everyday activities), rheumatoid arthritis (chronic swelling and tenderness of joints and other parts of the body), and osteoarthritis (degenerative joint disease, in which the tissues… […]

• No harm, potential for more than minimal, patternF726Feb 23, 2024

  Based on interview and record review, the facility failed to ensure nursing staff had the knowledge and competency to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of three sampled residents (Resident 1) when: 1. Two Certified Nursing Assistants (CNA) failed to recognize inappropriate use of restraint after observing Resident 1's hand was tied to her bed; and 2. […]

• No harm, potential for more than minimal, patternF803Jul 24, 2023

  Based on food preparation observations, dietary management staff interview and departmental document review, the facility failed to ensure correct portioning for greater than 90 residents when the dessert for the noon meal was not prepared using the proper scoop size. Consistently providing incorrect food portions may result in over or undernutrition further compromising medical status. Findings: During general food production observations on 07/17/23 at 09:17 AM, Dietary Staff 1 was portioning butterscotch pudding, the noon dessert, into individual bowls using a scoop with an ivory handle. […]