Helen Newberry Joy HLTCU Golden Leaves Living Cent

In the surveyor’s words

From the most serious findings on record at Helen Newberry Joy HLTCU Golden Leaves Living Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Apr 27, 2021

  This citation has two Deficient Practice Statements, A and B: A. Based on observation, interview, and record review, the facility failed to implement COVID-19 (a highly transmissible [CONDITION(S)] disease) infection control practices to prevent the possible spread of COVID-19 by: a) Failing to quarantine a resident (#17) exposed to a COVID-19 positive staff member, Staff U, on 4/12/21, when Staff U's COVID-19 positive test results were received on 4/14/21. This potentially resulted in Resident #17's positive COVID-19 status on 4/20/21. b) Failing to immediately restrict from the facility two staff members exposed to a COVID-19 positive resident (#17) on 4/20/21, who were observed in the clinical area without appropriate Personal Protective Equipment (PPE) on 4/21/21. […]

• Actual harm, isolatedF686Jan 2, 2026

  This deficiency pertains to Intake #2694753Based on observation, interview, and record review, the facility failed to implement interventions consistent with recognized standards of practice to promote the healing of a pressure injury for one Resident (R1) of three residents reviewed for pressure injury. This deficient practice resulted in the worsening of stage 3 pressure injury on the right heel of R1. Findings include:Intake #2694753 was submitted to the state agency on 12/10/25. […]

• Actual harm, isolatedF584Jun 5, 2025

  This deficiency pertains to Intakes #MI00153229 and #MI00152446 Based on observation, interview, and record review, the facility failed to prevent one Resident (#3) of eight residents reviewed for homelike environment related to personal property from entering the rooms and taking personal possessions of other residents. This deficient practice resulted in Residents #2, #4, & #5 experiencing fear of continued resident to resident abuse, frustration, and emotional distress and items being taken from #7 and #8. Findings include: On 6/4/25 at 10:15 AM, the doorways to residents' room were observed with mesh-type barriers with stop sign notifications on the barriers. The barriers extended across the doorways and were secured with Velcro on each end to the doorframes. […]

• Actual harm, isolatedF600Jun 5, 2025

  This deficiency pertains to Intakes #MI00152446 and #MI00153229 Based on interview and record review, the facility failed to ensure three Residents (#2, #4, and #7) of five residents reviewed for abuse were free from physical abuse by another Resident (#3) with a documented history of physical abuse of others. This deficient practice resulted in R2 and R4 experiencing fearfulness, frustration, and emotional distress, and R7 experiencing fear, pain and sustaining reddened areas on the neck after a choking event. Findings include: Two facility-reported incidents (FRI) regarding resident-to-resident altercations were reported to the state agency. #MI00152446 was reported on 4/14/25 and #MI00153229 was reported on 5/18/25. […]

• Actual harm, isolatedF686Jun 26, 2024

  Based on observation, interview, and record review, the facility failed to assess and monitor pressure injuries, develop and implement a plan of care for pressure injuries, and maintain infection control practices during dressing changes for One Resident (R14) of One resident reviewed for pressure injuries. This deficient practice resulted in harm when R14 experienced worsening of wounds and the development of three stage 3 pressure injuries. Findings include: Resident #14 (R14) was interviewed on 6/24/24 at 12:56 p.m. R14 was noted to be lying on his back in bed with the sides of his body pressed against the side rails on the bed. R14 said, they ordered me a new bed - it should have been here by now. […]