Golfcrest Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 29, 2021

  Based upon interview, observation and record review, the facility failed to provide supervision and a safe environment to prevent 1 of 3 sampled residents assessed for elopement risk (Resident #300) from eloping. Resident #300 exited the facility undetected on 12/13/21 at approximately 3:00 AM. The facility's system failure, and lack of adequate supervision, allowed the resident to elope undetected by staff. The facility contacted the police after conducting a facility wide search. At approximately 4:00 AM on 12/13/21, Resident #300 was found by the police and returned to the facility. This situation resulted in Immediate Jeopardy. […]

• Actual harm, isolatedF693Apr 10, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide nutritional assessments and interventions in a timely manner which resulted in significant weight loss for 1 of 1 sampled resident (Resident #51); The facility also failed to follow tube feeding Physician's orders for 2 of 5 sampled residents (Resident #167 and Resident #169). The findings included: A review of the facility's policy titled Weighing and Weight at-risk Protocol and revised in March 2020 showed the following: Weights: Nursing to complete all weights with reweights on the following parameters: 0-175 pounds - variances of 4 pounds - loss or gain. […]

• No harm, potential for more than minimal, widespreadF812Jan 19, 2024

  Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food, in accordance with professional standards for food service safety, for potentially 55 of the facility's 61 residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 01/16/24 at 8:50 AM, and accompanied with the Food Service Director (FSD), the following were noted: a) Staff A was noted to be washing resident dishware in the facility dish machine. Staff A stated to the surveyor that the dish machine is at a low temperature and sanitizes by Chlorine chemical. The surveyor requested the FSD to test the final rinse chemical level. […]

• No harm, potential for more than minimal, widespreadF812Sep 2, 2022

  Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include: ensure dishware are are chemically sanitized as per regulation, holding of foods are regulatory temperatures, maintenance of refrigeration unit to maintain temperatures as per regulation, maintenance of the exhaust hood to prevent food contamination, and failure to defrost foods as per regulation. This has the potential to affect 53 residents, who reside at the facility and eat orally. […]

• No harm, potential for more than minimal, widespreadF812Jul 22, 2021

  Based on observations and interview, it was determined that the facility failed to store, prepare, distribute, and served food in accordance with professional standards for food service safety. These include labeling and dating all refrigerated food items and keeping the floors clean and free of debris. The findings included: In a tour of the main kitchen conducted on 07/19/21 at 9:50 AM, accompanied by the Dietary Manager, the following issues were identified: 1. The dry storage was observed with pests and debris underneath the racks. Closer observation showed a bag of breadcrumbs which was partially opened, and breadcrumbs were noted outside the bag. 2. The reach in refrigerator was noted with 7 single pieces of cheesecakes, that were exposed to the air. […]