Gold City Health: Suicide Prevention Plan Fails - GA
Gold City Health and Rehab developed a care plan for Resident 4 that required removing "items that are potentially harmful" from her room after she attempted suicide multiple times. But inspectors found clear trash liners in both her trash can and her roommate's trash can during their August visit.
The resident has cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder and anxiety disorder. Her care plan, revised on June 15, noted she experiences auditory and visual hallucinations and "has a history of suicidal ideations and suicidal attempts."
On May 20, the resident called out to a nurse tearfully and said she was suicidal after drinking hand sanitizer.
Two weeks later, Licensed Practical Nurse 3 found the resident with a plastic bag over her head "loosely" on June 3. The resident told the nurse "she was trying to kill herself."
The facility's response included 15-minute safety checks, giving the resident only plastic silverware, moving her to a room with a roommate, and clearing the room of potentially harmful items. But the interventions began June 16 — two weeks after the plastic bag incident.
During the August 26 inspection, investigators observed the resident in her electric wheelchair trying to reach inside a personal refrigerator on the floor. They also found clear plastic trash liners in both trash cans in the room.
When questioned about the trash liners, Certified Nurse Aide 1 said "it would be ok to have a trash liner in the trash can if it was not in reach of the resident." Certified Nurse Aide 2 gave a similar response, stating "it would be ok the have a trash liner in the trash can."
The facility's own policy, implemented April 1, requires developing "a comprehensive person-centered care plan for each resident" that includes "measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs."
But the resident's care plan lacked specific interventions to ensure her psychosocial well-being and safety, inspectors determined. The plan called for removing potentially harmful items but failed to specify what those items were or how staff should identify them.
The resident scored 15 on her Brief Interview for Mental Status assessment, indicating she was cognitively intact and understood her situation.
When asked about communicating care plan interventions to staff, the Administrator acknowledged problems with the facility's approach. The Administrator said "it didn't matter what the changes were, they should document the specific interventions that relate to the situation, and then ensure they monitor for effectiveness."
The Administrator promised that "going forward, all care plans would have to be reviewed and triaged regarding negative potential impact on residents."
The inspection found the facility failed to develop adequate safeguards for a resident who had already demonstrated she would use available materials in suicide attempts. Despite her history of using a plastic bag and drinking sanitizer, similar items remained accessible in her room two months after her last documented attempt.
Federal regulations require nursing homes to develop comprehensive care plans that address all aspects of resident safety, particularly for those with mental health conditions and suicide risk. The facility's policy acknowledged this requirement but staff failed to implement specific, measurable interventions.
The resident's multiple diagnoses and history of suicide attempts should have triggered more detailed safety protocols, but the care plan remained vague about what constituted "potentially harmful items." Staff interviews revealed confusion about basic safety measures, with aides uncertain about when plastic materials posed risks.
The two-week delay between the plastic bag incident and implementing safety interventions left the resident vulnerable during a critical period. The facility's 15-minute safety checks and roommate assignment came only after the second documented attempt, suggesting reactive rather than preventive care planning.
The case illustrates broader challenges nursing homes face caring for residents with complex mental health needs. The resident required specialized interventions that went beyond standard medical care, but the facility's approach lacked the specificity needed to protect someone actively seeking ways to harm herself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gold City Health and Rehab from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GOLD CITY HEALTH AND REHAB in DAHLONEGA, GA was cited for violations during a health inspection on August 27, 2025.
But inspectors found clear trash liners in both her trash can and her roommate's trash can during their August visit.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.