Inspection Reports for
Golden Hill Nursing and Rehabilitation Center
99 Golden Hill Drive, Kingston, NY, 12401
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
214% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
13% occupied
Based on a April 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding inconsistent blood sugar monitoring and insulin administration for Resident #1 at Golden Hill Nursing and Rehabilitation Center.
Complaint Details
The investigation was complaint-related, focusing on blood sugar monitoring and insulin administration for Resident #1. The complaint was substantiated as the facility failed to have a proper order for blood sugar monitoring until after family concerns were raised on 10/06/2025.
Findings
The facility failed to ensure that Resident #1 received appropriate treatment and care according to physician orders and professional standards. Blood sugar monitoring was inconsistent and lacked a proper physician order until 10/08/2025, despite physician notes indicating monitoring prior to that date.
Deficiencies (1)
F 0684: The facility did not ensure Resident #1 received treatment and care according to orders and professional standards. Blood sugar monitoring was inconsistently performed without a physician order until 10/08/2025, despite physician notes documenting monitoring before that date.
Report Facts
Blood sugar readings frequency: 1
Insulin dosage: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #8 | Registered Nurse Unit Manager | Interviewed regarding blood sugar monitoring inconsistencies and order entry. |
| Physician #9 | Physician | Documented blood sugar monitoring in notes prior to order entry and interviewed about monitoring frequency. |
| Charge Licensed Practical Nurse #10 | Charge Licensed Practical Nurse | Interviewed about order entry process and family concerns regarding blood sugar monitoring. |
| Director of Nursing | Director of Nursing | Reviewed records and interviewed regarding lack of blood sugar monitoring order prior to 10/08/2025. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 20, 2025
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, safe and comfortable environment during construction, timely reporting of suspected abuse, provision of necessary care for activities of daily living, performance evaluations for Certified Nurse Aides, and food service quality. Several residents experienced delayed or inadequate care, and documentation was incomplete or missing in several cases.
Deficiencies (7)
F 0550: The facility failed to ensure residents were treated with dignity; Resident #16 was served lunch 12 minutes later than others at the table, and Certified Nurse Aide #4 had documented disciplinary issues related to poor customer service.
F 0584: The facility did not maintain comfortable sound levels during ongoing construction on the South 1 Unit, causing resident discomfort and complaints.
F 0609: The facility failed to timely report injuries of unknown origin to the state agency for Residents #32 and #489, and investigations were incomplete or not conducted.
F 0610: The facility did not ensure investigations were completed for alleged abuse related to bruising for Resident #489, and staff failed to report or document concerns appropriately.
F 0677: The facility failed to provide consistent assistance with activities of daily living for Residents #49, #338, #538, #488, and #489, with missing documentation and observed neglect such as long fingernails on Resident #49.
F 0730: The facility did not complete annual performance reviews for five Certified Nurse Aides, including one with multiple disciplinary notices and termination.
F 0804: The facility failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures; residents complained about cold and poor-quality food, and test tray temperatures were lukewarm or cold.
Report Facts
Corrective discipline notices: 14
Temperature measurements: 140
Temperature measurements: 120
Temperature measurements: 100
Temperature measurements: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in multiple customer service and disciplinary findings |
| Certified Nurse Aide #17 | Certified Nurse Aide | Interviewed regarding dining service and resident care |
| Unit Manager Registered Nurse #21 | Unit Manager Registered Nurse | Interviewed regarding dining service and resident concerns |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding abuse investigations and staff performance |
| Director of Maintenance | Director of Maintenance | Interviewed regarding construction and resident safety |
| Registered Nurse Unit Manager #8 | Registered Nurse Unit Manager | Interviewed regarding construction and resident relocation |
| Administrator | Administrator | Interviewed regarding construction complaints and stop work order |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Interviewed regarding bruising observations and reporting |
| Registered Nurse Supervisor #15 | Registered Nurse Supervisor | Interviewed regarding abuse reporting procedures |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed regarding incomplete documentation of care |
| Director of Human Resources | Director of Human Resources | Interviewed regarding Certified Nurse Aide performance reviews |
| Unit Managers of C1 | Unit Managers | Interviewed regarding responsibility for performance reviews |
| Director of Nursing | Director of Nursing | Interviewed regarding performance reviews and abuse investigations |
| Assistant Food Service Director | Assistant Food Service Director | Interviewed regarding food service complaints and tray temperatures |
| Diet Clerk | Diet Clerk | Interviewed regarding resident food preferences and complaints |
| Licensed Practical Nurse Charge Nurse #7 | Licensed Practical Nurse Charge Nurse | Interviewed regarding resident food complaints |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 22
Date: May 20, 2025
Visit Reason
Complaint Survey with 9 health citations and 13 life safety code citations, all Level 2 severity, mostly corrected by July/August 2025.
Findings
Complaint Survey with 9 health citations and 13 life safety code citations, all Level 2 severity, mostly corrected by July/August 2025.
Deficiencies (22)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Investigate/prevent/correct alleged violation
Nurse aide peform review-12 hr/yr in-service
Nutritive value/appear, palatable/prefer temp
Reporting of alleged violations
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Egress doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Elevators
Exit signage
Fire drills
Hazardous areas - enclosure
Illumination of means of egress
Physical environment
Sprinkler system - installation
Sprinkler system - maintenance and testing
Standards of construction for new existing nh
Organization and administration
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 20, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, failure to investigate injury of unknown origin, inadequate assistance with activities of daily living, lack of annual performance reviews for Certified Nurse Aides, food service issues including poor food temperature and quality, improper food storage and hygiene practices, and failure to implement proper infection control precautions.
Deficiencies (7)
F 0550: The facility did not ensure residents were treated with dignity; Resident #16 was served lunch 12 minutes late and Certified Nurse Aide #4 had multiple customer service complaints.
F 0610: The facility failed to investigate bruising of unknown origin for Resident #489, with no documented investigation or reporting.
F 0677: The facility did not provide consistent assistance with activities of daily living for 5 residents, including lack of documented care and observed poor grooming for Resident #49.
F 0730: Certified Nurse Aide performance reviews were not completed annually for 5 aides, including one terminated aide with multiple disciplinary notices but no annual review.
F 0804: Residents were provided food that was often cold, unpalatable, and unattractive; multiple residents complained about food quality and temperature.
F 0812: Food safety violations included undated, unsealed, and expired food items; non-working handwash sink; improper staff hygiene; and incomplete temperature logs in the pantry refrigerator.
F 0880: The facility failed to implement infection control precautions for Resident #167 with pressure ulcers; staff did not wear gowns during dressing changes and no enhanced barrier precautions were in place.
Report Facts
Corrective Discipline Notices: 14
Certified Nurse Aides without annual performance review: 5
Food temperature measurements: 78
Food temperature measurements: 100
Food temperature measurements: 120
Food temperature measurements: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #4 | Certified Nurse Aide | Named in multiple customer service complaints and disciplinary actions |
| Certified Nurse Aide #17 | Certified Nurse Aide | Interviewed regarding dining service and resident care observations |
| Assistant Director of Nursing | Interviewed regarding Certified Nurse Aide #4 and investigation procedures | |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Interviewed regarding bruising observations on Resident #489 |
| Registered Nurse Supervisor #15 | Registered Nurse Supervisor | Interviewed regarding reporting and investigation of bruises on Resident #489 |
| Director of Nursing | Director of Nursing | Interviewed regarding bruising investigation and annual performance reviews |
| Certified Nurse Aide #9 | Certified Nurse Aide | Interviewed regarding incomplete documentation of care |
| Director of Human Resources | Director of Human Resources | Interviewed regarding responsibility for annual performance reviews |
| Assistant Food Service Director | Interviewed regarding food complaints, food safety, and staff hygiene | |
| Diet Clerk | Interviewed regarding resident food preferences and complaints | |
| Licensed Practical Nurse Unit Manager #6 | Licensed Practical Nurse Unit Manager | Interviewed regarding food storage and refrigerator monitoring |
| Infection Preventionist | Interviewed regarding infection control practices for Resident #167 | |
| Licensed Practical Nurse Unit Manager #10 | Licensed Practical Nurse Unit Manager | Observed wound care and infection control practices |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 9, 2025
Visit Reason
The inspection was conducted as an abbreviated survey focusing on discharge notification procedures and medication administration safety.
Findings
The facility failed to provide proper written discharge notices and notifications to residents, representatives, and the Ombudsman for Resident #3. Additionally, a medication error occurred when a nurse administered Coumadin to Resident #1 despite a physician's order to hold the medication due to elevated INR levels.
Deficiencies (2)
F 0628: The facility did not provide Resident #3 or their representative with a 30-day written discharge notice, bed hold notification, or timely notification to the Ombudsman. Discharge planning and documentation were incomplete and not properly communicated.
F 0760: Licensed Practical Nurse #1 administered Coumadin to Resident #1 despite a physician's order to hold the medication due to an elevated International Normalized Ratio (INR) of 3.3, resulting in an increased INR of 7.9 and requiring administration of Vitamin K to prevent bleeding.
Report Facts
Residents reviewed for discharge: 3
Residents reviewed for medication administration: 4
International Normalized Ratio (INR): 3.3
International Normalized Ratio (INR): 7.9
Vitamin K dose: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Administered Coumadin to Resident #1 despite hold order | |
| Discharge Liaison #1 | Described weekly Utilization Review meetings and discharge planning | |
| Discharge Liaison #2 | Notified Resident #3's Managed Long-Term Care but lacked documentation | |
| Social Worker | Provided information on discharge planning and family involvement | |
| Physician #1 | Provided physician orders to hold Coumadin and commented on medication error risk | |
| Director of Nursing | Stated nurses should follow physician orders and medication administration rights |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: May 9, 2025
Visit Reason
Complaint Survey with 2 health citations related to discharge process and medication errors, both Level 2 severity.
Findings
Complaint Survey with 2 health citations related to discharge process and medication errors, both Level 2 severity.
Deficiencies (2)
Discharge process
Residents are free of significant med errors
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 6
Date: Apr 16, 2024
Visit Reason
The inspection was conducted as a recertification survey from April 8, 2024 to April 16, 2024 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including accessibility of call bell systems, maintenance of a safe and comfortable environment, timely completion of resident assessments, provision of ordered treatments, food safety practices, and implementation of infection prevention and control programs.
Deficiencies (6)
F 0558: The facility did not ensure the call bell system was accessible for 1 of 35 residents reviewed. Resident #133's call bell was observed out of reach on multiple occasions.
F 0584: The facility did not maintain a safe, clean, and comfortable environment in 2 resident rooms with holes and water damage in ceilings remaining unrepaired.
F 0636: The facility did not complete the Minimum Data Set 3.0 comprehensive annual assessment in a timely manner for Resident #120, missing the required assessment date.
F 0684: The facility did not provide appropriate treatment to prevent further decrease in range of motion for Resident #102, who was observed without the ordered blue carrot (hand roll) in their left hand.
F 0812: The facility did not ensure food was stored and labeled according to professional food safety standards, including expired items, unlabeled leftovers, and a soiled milk cooler.
F 0880: The facility did not fully implement an infection prevention and control program with enhanced barrier precautions for residents with indwelling medical devices, lacking signage, PPE caddies, and updated care plans.
Report Facts
Residents reviewed for call bell accessibility: 35
Residents reviewed for infection prevention: 5
Expired food items: 2
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 23
Date: Apr 16, 2024
Visit Reason
Complaint Survey with 6 health citations and 18 life safety code citations, mostly Level 2 severity, addressing assessments, food sanitation, infection control, quality of care, environment, and life safety features.
Findings
Complaint Survey with 6 health citations and 18 life safety code citations, mostly Level 2 severity, addressing assessments, food sanitation, infection control, quality of care, environment, and life safety features.
Deficiencies (23)
Comprehensive assessments & timing
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Quality of care
Reasonable accommodations needs/preferences
Safe/clean/comfortable/homelike environment
Cooking facilities
Corridor - doors
Egress doors
Electrical equipment - power cords and extens
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Hvac
Illumination of means of egress
Maintenance, inspection & testing - doors
Subdivision of building spaces - smoke barrie
Organization and administration
Physical environment
Sprinkler system - installation
Standards of construction for new existing nh
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 3
Date: Oct 2, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with safety, care, and medication administration standards at Golden Hill Nursing and Rehabilitation Center.
Findings
The facility failed to ensure a safe environment free from hazards, resulting in a resident fall due to a leaking ice machine. Additionally, medication administration errors were found where medications were not crushed as ordered for a resident with dysphagia. The facility also lacked adequate supervision to prevent accidents for high-risk residents.
Deficiencies (3)
F 0584: The facility did not ensure an area used by residents was safe due to a leaking ice machine causing a resident to slip and fall. Maintenance repairs were inadequate and supervision was insufficient to prevent access to hazardous areas.
F 0684: The facility failed to provide medications in the form ordered for Resident #3, who required crushed medications to prevent choking. No Dysphagia Care Plan was in place for this resident.
F 0689: The facility did not ensure the environment was free from accident hazards and failed to provide adequate supervision to prevent falls for Resident #1, who sustained a compression fracture after slipping near the kitchenette.
Report Facts
Residents on unit: 37
Fall risk score: 80
Medication doses observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered crushed medications to Resident #3 |
| LPN #2 | Licensed Practical Nurse | Reported leaking ice machine and monitored residents |
| Director of Nursing | Director of Nursing | Interviewed regarding repair work orders and medication policy |
| Maintenance Director | Maintenance Director | Interviewed about repair records for ice machine |
| Maintenance Aide | Maintenance Aide | Repaired ice machine and reported incident |
| RNUM #1 | Registered Nurse Unit Manager | Discussed medication administration protocol |
| RNUM #2 | Registered Nurse Unit Manager | Discussed medication crushing orders and protocols |
| CNA #1 | Certified Nurse Aide | Reported resident supervision and rounds |
| CNA #2 | Certified Nurse Aide | Reported resident behavior and supervision |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided details on resident supervision and incident |
| LPN #3 | Licensed Practical Nurse | Reported on resident wandering and ice machine condition |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Oct 2, 2023
Visit Reason
Complaint Survey with 3 health citations related to accident hazards, quality of care, and environment, all Level 2 severity and corrected by November 2023.
Findings
Complaint Survey with 3 health citations related to accident hazards, quality of care, and environment, all Level 2 severity and corrected by November 2023.
Deficiencies (3)
Free of accident hazards/supervision/devices
Quality of care
Safe/clean/comfortable/homelike environment
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jul 15, 2022
Visit Reason
Complaint Survey with 1 health citation for accident hazards, Level 2 severity, corrected by September 2022.
Findings
Complaint Survey with 1 health citation for accident hazards, Level 2 severity, corrected by September 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Aug 31, 2021
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with regulatory standards related to medication storage, rehabilitative services, and infection control.
Findings
The facility failed to ensure proper labeling and storage of multi-dose insulin and emergency drug box monitoring. One resident did not consistently receive ordered physical and occupational therapy services. Infection control lapses were observed during wound care, including improper glove use and hand hygiene.
Deficiencies (3)
F 0761: The facility did not ensure multi-dose insulin was dated and discarded per manufacturer guidelines, and the emergency drug box had conflicting expiration dates without proper monitoring.
F 0825: One resident did not receive consistent physical and occupational therapy as ordered, with missed therapy days and lack of documentation for discontinuation.
F 0880: Facility staff did not follow proper hand hygiene and gloving technique during wound care, risking cross contamination for one resident.
Report Facts
Therapy days missed: 1
Therapy days received: 10
Therapy days received: 4
Therapy days received: 10
Therapy days received: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in insulin storage deficiency observation. |
| RN #1 | Registered Nurse Manager | Interviewed regarding emergency drug box monitoring. |
| Director of Nursing | Director of Nursing | Interviewed regarding emergency drug box expiration and policy. |
| Physical Therapist | Physical Therapist | Interviewed regarding missed therapy services for Resident #428. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding missed therapy services and scheduling issues. |
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency during wound care. |
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