Inspection Reports for
Golden Gate Rehabilitation & Health Care Center
191 Bradley Ave, Staten Island, NY, 10314
Back to Facility ProfileCitations (last 4 years)
Citations (over 4 years)
8.8 citations/year
Citations are regulatory findings recorded during state inspections.
73% worse than New York average
New York average: 5.1 citations/yearCitations per year
12
9
6
3
0
Inspection Report
Annual Inspection
Capacity: 60
Citations: 0
Date: Jul 10, 2024
Visit Reason
No detailed deficiencies listed for this inspection; presumed complete with no citations.
Findings
No detailed deficiencies listed for this inspection; presumed complete with no citations.
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 7
Date: May 29, 2024
Visit Reason
Inspection identified 5 standard health citations and 2 life safety code citations, all corrected by late July 2024.
Findings
Inspection identified 5 standard health citations and 2 life safety code citations, all corrected by late July 2024.
Citations (7)
Accuracy of assessments
Drug regimen review, report irregular, act on
Infection prevention & control
Nutritive value/appear, palatable/prefer temp
Services provided meet professional standards
Sprinkler system - installation
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Citations: 5
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
Complaint Investigation
Capacity: 60
Citations: 2
Date: Nov 2, 2023
Visit Reason
Two standard health citations related to discharge summary and reporting of alleged violations, both corrected by December 15, 2023.
Findings
Two standard health citations related to discharge summary and reporting of alleged violations, both corrected by December 15, 2023.
Citations (2)
Discharge summary
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Citations: 2
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
Capacity: 60
Citations: 0
Date: Sep 30, 2023
Inspection Report
Capacity: 60
Citations: 1
Date: Mar 13, 2023
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Citations: 0
Date: Jan 15, 2023
Inspection Report
Capacity: 60
Citations: 0
Date: Dec 1, 2022
Inspection Report
Capacity: 60
Citations: 1
Date: Jun 21, 2022
Visit Reason
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
One standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Citations (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 9
Date: Mar 3, 2022
Visit Reason
Multiple standard health citations including immediate jeopardy level 4 deficiencies related to abuse, reporting violations, and reasonable suspicion of a crime; all corrected by April 28, 2022. One life safety code citation corrected.
Findings
Multiple standard health citations including immediate jeopardy level 4 deficiencies related to abuse, reporting violations, and reasonable suspicion of a crime; all corrected by April 28, 2022. One life safety code citation corrected.
Citations (9)
Accuracy of assessments
Care plan timing and revision
Free from abuse and neglect
Increase/prevent decrease in rom/mobility
Investigate/prevent/correct alleged violation
Label/store drugs and biologicals
Reporting of alleged violations
Reporting of reasonable suspicion of a crime
Vertical openings - enclosure
Inspection Report
Complaint Investigation
Capacity: 60
Citations: 2
Date: Mar 1, 2022
Visit Reason
Two standard health citations related to care plan and resident allergies, both corrected by April 15, 2022.
Findings
Two standard health citations related to care plan and resident allergies, both corrected by April 15, 2022.
Citations (2)
Develop/implement comprehensive care plan
Resident allergies, preferences, substitutes
Inspection Report
Annual Inspection
Citations: 6
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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