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Gold City Health and Rehab: Bed Rail Safety Failure - GA
No nurse assessed whether the rails were appropriate....
Latest reports, citations, and penalties from CMS data
No nurse assessed whether the rails were appropriate....
The symptoms were not reported to the facility's physician or nurse practitioner....
On the evening of August 16, staff delivered his dinner tray at 5:55 PM, containing cheese pizza, salad, a breadstick, and ambrosia....
The maintenance director told inspectors he had redirected the resident, identified in the report as R5, out of the room often....
The violations centered on monitoring failures....
The violation was documented during a complaint inspection completed August 28, 2025....
What happened next was thorough....
The resident, identified in inspection records as R10, had a PEG tube, a feeding device threaded through the abdominal wall into the stomach....
Federal inspectors cited Zearing Health Care, LLC following a complaint investigation conducted on August 27, 2025....
Inspectors visiting the facility on August 25, 2025, found the interior of the kitchen ice machine covered in the discoloration....
The wound vac had been reapplied after a seal leak the week before....
The dietary manager, interviewed the following morning, confirmed the number was wrong....
The resident, identified in inspection records only as R1, tripped on a worn floor mat near the staff breakroom door and struck her head....
The medications were controlled substances....
The incident happened on July 11, 2025, at approximately 7:15 in the morning....
The complaint came up at the facility's Resident Council meeting on February 11, 2025....
The incident happened on July 14, 2025, at Pilgrim Manor Skilled Nursing and Rehabilitation....
Inspectors visited Franklin Plaza Extended Care on August 28, 2025, as part of an investigation into four separate complaints filed against the facility....
On August 5, 2025, a physician ordered valproic acid along with a complete blood count and comprehensive metabolic panel for the resident....
Federal inspectors visiting Frederick Villa Healthcare on August 27, 2025, pulled the facility's pest problem logs for the year....