Golfcrest Nursing and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF600Mar 20, 2024

  Based on interview and record review, the facility failed to ensure 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4) were kept free form abuse, in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. An Immediate Jeopardy (IJ) was identified on 03/15/2023 at 3:00PM. […]

• Immediate jeopardy, patternF607Mar 20, 2024

  Based on interview and record review, the facility failed to ensure the written policies and procedure to prevent abuse were implemented for 4 for of 10 residents reviewed for abuse (Residents #1, #2, #3 and #4), in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. […]

• Immediate jeopardy, isolatedF656Mar 20, 2024

  Based on interview and record review, the facility failed to revise the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 1 (Resident #1) of 6 residents reviewed for care plans in that: - Resident #1 had 3 incidents of resident-to resident altercations. - On 12/01/2023, Resident #1 hit Resident #2 in the face which resulted in laceration to the lips - On 01/01/2023, Resident #1 hit Resident #3 in the face unprovoked. - On 01/15/2023, Resident #1 hit Reident #4 in the face twice unprovoked. - CNA A, CNA B, RN C and the DON all reported Resident #1's aggressive behaviors were unpredictable or unprovoked and difficult to prevent without continuous one-on-one supervision. […]

• Actual harm, isolatedF677Dec 18, 2025

  Based on interviews, and record review, the facility failed to ensure a Resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 34 residents (Resident #1) reviewed for ADL.The facility's 3rd shift nursing staff failed to or ignored Resident #1's call light in a timely manner, which has consistently occurred throughout a period of time [January 2025 through December 2025], leaving Resident #1 needing assistance for incontinent care for several hours.Resident #1 felt neglected, belittlement, and shame due to the facility's failure. These failures could cause residents to experience compromised dignity, comfort, and place residents at risk for skin infection. […]

• Actual harm, isolatedF697Jul 27, 2025

  Based on observations, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #77) out of 6 residents reviewed for pain management. The facility failed to ensure Resident #77's pain medications were administered timely prior to traveling in an ambulance to the dialysis facility on 07/23/25 when he rated his pain as an 8 out of 10 pain scale. […]