Golden Hill Nursing and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF550May 20, 2025

  2) During an observation on 5/14/25 at 12:48 PM Resident #105, #93, #121 were served lunch and began eating. Fourth table mate, Resident #16 was not served lunch until 1:00 PM. Resident #93 verbalized that Resident #16 had not received lunch and repeatedly asked for them to be served. During an interview on 5/15/25 at 12:30 PM Certified Nurse Aide #17 stated they were not aware that all residents at the same table should have been served at the time before moving onto the next table. Unit Manager Registered Nurse #21 stated they were not aware of any residents' concern for everyone to be served at the same time. […]

• No harm, potential for more than minimal, patternF677May 20, 2025

  2) Resident #538 had diagnoses that included metabolic encephalopathy, hypertension, and muscle wasting. The 9/25/2024 admission Minimum Data Set (assessment tool) documented moderately impaired cognition, foley catheter, occasional incontinence of bowel, maximum assistance for toileting hygiene and transfers. The 12/18/2024 Discharge Minimum Data Set documented moderately impaired cognition, foley catheter, incontinent of bowel, dependent on assistance for toileting hygiene and transfers. […]

• No harm, potential for more than minimal, patternF730May 20, 2025

  Based on interview and record review during the recertification and abbreviated (NY00376199) survey from 05/13/25 through 05/20/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, five of five Certified Nurse Aides (#1, #2, #3, #4, #5) did not have a performance review documented at least once every 12 months. The findings include: Policy and Procedure Titled Staff Evaluations dated 1/25 documented the purpose is to establish a consistent and fair process for evaluating the performance of Nursing Home staff to ensure high-quality resident care, compliance with regulations and professional development. […]

• No harm, potential for more than minimal, patternF804May 20, 2025

  Based on observation and interview conducted during the recertification and abbreviated (NY00365130) surveys from 5/13/25 to 5/20/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, a test tray was sampled and found food was not served at a palatable, appetizing temperature; and many residents complained about the food. Findings include: The facility policy titled Meal Delivery documented, meals should be delivered promptly to ensure appropriate temperatures, and all staff is responsible to report any concerns regarding meal temperatures and resident satisfaction. During an interview on 05/13/25 at 10:52 AM, Resident #174 stated the food at the facility is terrible. […]

• No harm, potential for more than minimal, patternF812May 20, 2025

  Based on observation and interviews conducted during the recertification survey from 5/13/25 to 5/20/25, the facility did not ensure food was distributed and served in accordance with professional standards for food service safety. Specifically, 1.) On initial kitchen tour, food items were found undated, unsealed, and expired. The handwash sink in food prep area did not work. 2) On follow-up kitchen tour, food temperatures were not at control level on the steam table and dietary staff did not wear proper hair/beard restraint or utilize hygienic practices. 3) The pantry refrigerator on Unit C1 contained undated foods, expired foods and an incomplete temperature log. […]