Inspection Reports for
Golden Gate Rehabilitation & Health Care Center
191 Bradley Ave, Staten Island, NY, 10314
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Inspection Report — May 29, 2024
Annual Inspection CMS
Date: May 29, 2024
Visit Reason
The inspection was conducted as a Recertification Survey from 05/21/2024 to 05/29/2024 to assess compliance with regulatory requirements for the nursing facility.
Findings
The facility was found deficient in several areas including inaccurate Minimum Data Set assessments, failure to meet professional standards in medication administration, failure to address pharmacist recommendations, serving food at unsafe temperatures, and inadequate infection prevention and control practices.
Citations (5)
Minimum Data Set assessments did not accurately reflect resident status, including failure to document facility-acquired pressure ulcers and incorrect discharge coding.
Services provided did not meet professional standards, evidenced by administration of Bacitracin to a resident with a known allergy.
Failure to address pharmacist's recommendation to obtain Divalproex serum level for a resident, despite repeated recommendations.
Food served during lunch was not maintained at palatable and appetizing temperatures, with hot foods served lukewarm or cold.
Infection control practices were not maintained; specifically, a transporter failed to perform hand hygiene between residents and while handling food and trash.
Report Facts
Residents sampled: 38
Residents reviewed for unnecessary medications: 5
Food temperature: 112
Food temperature: 117.5
Food temperature: 108
Food temperature: 136.4
Food temperature: 131.9
Food temperature: 131
Food temperature: 55
Food temperature: 122
Food temperature: 138
Food temperature: 128
Food temperature: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #3 | Nurse Practitioner | Named in medication allergy deficiency related to Bacitracin administration |
| Registered Nurse #2 | Registered Nurse | Named in medication allergy deficiency related to Bacitracin administration |
| Registered Nurse #17 | Staff Educator | Named in medication allergy deficiency related to Bacitracin administration |
| Pharmacy Consultant #3 | Pharmacy Consultant | Named in medication allergy deficiency related to Bacitracin administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in medication allergy deficiency and drug regimen review deficiency |
| Pharmacy Consultant #2 | Pharmacy Consultant | Named in drug regimen review deficiency for Divalproex serum level recommendation |
| Attending Physician #1 | Attending Physician | Named in drug regimen review deficiency for Divalproex serum level recommendation |
| Nurse Practitioner #1 | Nurse Practitioner | Named in drug regimen review deficiency for Divalproex serum level recommendation |
| Medical Director | Medical Director | Named in drug regimen review deficiency for Divalproex serum level recommendation |
| Food Service Director | Food Service Director | Named in food temperature deficiency |
| Administrator | Administrator | Named in food temperature deficiency |
| Transporter #1 | Transporter | Named in infection control deficiency for failure to perform hand hygiene |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in infection control deficiency |
| Registered Nurse #9 | Registered Nurse Supervisor | Named in infection control deficiency |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection control deficiency |
Inspection Report — May 29, 2024
Certification/complaint State
Date: May 29, 2024
Visit Reason
State-compiled facility profile showing 7 inspections from 2022 to 2026 with citation and complaint history including enforcement actions.
Complaint Details
The state logged 101 complaints about this facility; 9 led to on-site inspections.
Findings
Across 7 inspections, 4 had no citations and 3 resulted in 10 total citations primarily related to standard health and life safety code issues. The facility had 101 complaints with 9 on-site inspections and 1 enforcement action involving fines.
Citations (10)
Standard Health Citation — quality of care: Accuracy Of Assessments found deficient.
Standard Health Citation — quality of care: Drug Regimen Review, Report Irregular, Act On found deficient.
Standard Health Citation — quality of care: Infection Prevention & Control found deficient.
Standard Health Citation — quality of care: Nutritive Value/appear, Palatable/prefer Temp found deficient.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards found deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation found deficient.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures found deficient.
Standard Health Citation — quality of care: Discharge Summary found deficient.
Standard Health Citation — quality of care: Reporting Of Alleged Violations found deficient.
Standard Health Citation — quality of care: Reporting - National Health Safety Network found deficient and not yet corrected.
Report Facts
Inspections on page: 7
Total violations/deficiencies cited: 10
Inspections with violations: 3
Inspections without violations: 4
Total complaints: 101
On-site complaint inspections: 9
Citations from complaints: 3
Enforcement actions: 1
Total fines: 6000
Inspection Report — Nov 2, 2023
Abbreviated Survey CMS
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with regulatory requirements, including investigation of an alleged abuse incident and review of discharge procedures.
Complaint Details
The visit included investigation of a complaint regarding alleged abuse of Resident #1 by a Certified Nursing Assistant, which was not reported within the required timeframe. The allegation was substantiated as the facility failed to report timely, though no injury was found.
Findings
The facility failed to timely report an alleged abuse incident involving a resident, reporting it more than two hours after the allegation was made. Additionally, the facility failed to complete a discharge summary and lacked documented evidence of physician evaluation and orders prior to a resident's discharge.
Citations (2)
Failure to timely report suspected abuse within two hours to the State Survey Agency as required.
Failure to complete a discharge summary and lack of documented physician evaluation and orders prior to discharge.
Report Facts
Residents sampled for abuse: 4
Residents affected: 1
Residents reviewed for discharge: 4
Residents affected: 1
BIMS score: 15
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Documented abuse allegation made by Resident #1 |
| Director of Nursing | Director of Nursing | Notified of abuse allegation and responsible for reporting to NYSDOH |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding discharge procedures and responsibilities |
| Medical Director | Medical Director | Interviewed regarding discharge evaluation responsibilities |
| Nurse Practitioner | Nurse Practitioner | Signed discharge scripts but not responsible for discharge summaries |
Inspection Report — Mar 3, 2022
Complaint Investigation CMS
Date: Mar 3, 2022
Visit Reason
The inspection was conducted as a Recertification/Complaint/Extended survey to investigate allegations of abuse, neglect, and failure to report and respond appropriately to abuse and injuries.
Complaint Details
The complaint investigation revealed multiple allegations of abuse including physical abuse, verbal abuse, neglect of care, and failure to report and respond appropriately. Some allegations were substantiated, others were not. Immediate Jeopardy was declared due to the risk of serious harm to residents.
Findings
The facility failed to ensure residents were free from abuse and neglect, failed to report allegations of abuse and injuries timely to authorities, failed to thoroughly investigate abuse allegations, and failed to remove accused staff from direct care pending investigation. Additionally, the facility did not ensure accurate MDS assessments and proper medication labeling.
Citations (5)
Failure to protect residents from abuse and neglect, including physical abuse and neglect of Activities of Daily Living (ADL) care.
Failure to report suspected abuse and injuries immediately or within required timeframes to law enforcement and state agencies.
Failure to respond appropriately to alleged violations by not removing accused staff from direct care pending investigation.
Failure to complete accurate Minimum Data Set (MDS) assessments, specifically omission of oxygen therapy for a resident.
Failure to label medications and biologicals with opening dates and ensure proper storage.
Report Facts
Residents reviewed for abuse: 10
Residents affected by abuse findings: 3
Residents affected by reporting failures: 5
Medication labeling errors: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in physical abuse allegation involving Resident #24; suspended and later reinstated |
| CNA #2 | Certified Nursing Assistant | Named in physical abuse allegation involving Resident #367; resigned after investigation |
| CNA #3 | Certified Nursing Assistant | Named in verbal abuse allegation involving Resident #192; removed from direct care pending investigation |
| CNA #4 | Certified Nursing Assistant | Named in neglect allegation involving Resident #203; suspended for one day |
| CNA #5 | Certified Nursing Assistant | Named in abuse allegation involving Resident #10; not removed from schedule during investigation |
| LPN #1 | Licensed Practical Nurse | Witnessed abuse of Resident #24; no longer employed |
| LPN #2 | Licensed Practical Nurse | Witnessed abuse of Resident #367; no longer employed |
| LPN #4 | Licensed Practical Nurse | Assisted CNA #5 with treatment of Resident #10 |
| DON #1 | Director of Nursing | Provided statements regarding investigations and reporting failures |
| Administrator | Provided statements regarding investigations and staff discipline | |
| RN #3 | Registered Nurse | Observed medication labeling deficiencies |
| RN #4 | Registered Nurse Manager | Observed medication labeling deficiencies |
Inspection Report — Jun 27, 2019
Annual Inspection CMS
Date: Jun 27, 2019
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including residents' dignity related to shared bathrooms, failure to provide ordered eyeglasses, inadequate physician review of diabetic care, inappropriate use of antipsychotic medication for dementia-related psychosis, and lapses in infection control practices such as oxygen tubing placement and hand hygiene.
Citations (6)
Residents were not given notice about sharing bathrooms with opposite sex residents, and no signs were posted to maintain privacy.
A resident evaluated for new eyeglasses did not receive them due to delays and lack of tracking system.
Physician did not adequately review and adjust care for a diabetic resident with consistently elevated blood sugars and delayed HbA1c testing.
A resident was prescribed Risperidone for dementia-related psychosis without documented trial of non-pharmacological interventions and despite risks.
Oxygen tubing was observed touching the floor, violating infection control policies.
Certified Nursing Assistant failed to perform hand hygiene between touching a garbage can lid and residents during hand care.
Report Facts
Residents sampled: 36
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
FSBS highest value: 436
FSBS lowest value: 256
HbA1c test results: 8.3
HbA1c test interval: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Interviewed regarding resident #208's bathroom sharing concerns |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding residents #4 and #11 bathroom use |
| Director of Social Work | Director of Social Work | Interviewed regarding bathroom sharing policies |
| Assistance Director of Nursing | Assistant Director of Nursing (ADNS) | Interviewed regarding eyeglasses delivery and infection control |
| NP #3 | Nurse Practitioner | Interviewed regarding diabetic care and antipsychotic medication |
| Physician #2 | Attending Physician | Interviewed regarding diabetic care and antipsychotic medication |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding resident #48 behavior and care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding resident #48 condition |
| Director of Nurse Practitioner Program | Director of NP Program | Interviewed regarding NP prescribing practices |
| Psychiatrist | Psychiatrist | Interviewed regarding resident #48 antipsychotic use |
| MD #2 | Medical Doctor | Interviewed regarding resident #48 antipsychotic medication and behavior |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding oxygen tubing infection control |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding oxygen tubing infection control |
| RN #1 | Registered Nurse | Interviewed regarding oxygen tubing infection control |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding hand hygiene during dining service |
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