Golden Heights Personal Care Home

A partially used tube of ointment was found on a resident's bedside nightstand without an assessment for self-administration.

A staff member performed a one-person transfer instead of the required two-person assist with a Hoyer lift, resulting in a skin tear for a resident.

A staff member struck a resident on the forehead with an open hand to get their attention during morning care.

The resident was subjected to mistreatment/neglect resulting in injury during transport.

Staff pushed a resident's wheelchair too hard and fast through a doorway without leg rests in place, causing the resident to fall and sustain facial and arm fractures.

Staff failed to evacuate all residents to the designated meeting place or fire-safe area during a fire alarm incident.

A bag of cut chicken in the freezer was found unlabeled and undated.

Staffing levels during the 7 shift were insufficient to meet resident needs and ensure safe evacuation within the required time.

A staff member used a loud, disrespectful voice toward a resident, calling them 'disgusting' and stating they were 'laying in [their] own filth' during a transfer.

Individual serving cups containing sour cream and cocktail sauce were left uncovered on trays, risking contamination.

The toilet seat grab bar in bedroom #103 was in poor condition with heavy rust on the metal bars.

The first aid kit at the North nurses station was missing tweezers and scissors.

Several windows in the front sitting room, dining room, and laundry room were missing screens or had torn screens.

Multiple food items in the kitchen refrigerator, including cheese and meats, were unlabeled and undated.