Gold City Health And Rehab
GOLD CITY HEALTH AND REHAB in DAHLONEGA, GA — inspection on August 27, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/29/2025 at 3:26 PM, LPN1 stated that the incident occurred at shift change. LPN1 stated that she had just left her office and as she entered the area around the nurses' station, she saw R9 and R10. R9 was holding R10's arm and R9 attempted to pull away but was unable. R9 was seated in a wheelchair facing R10 who was standing. R9 attempted to pull on R10's arm which created a back-and-forth motion as R10 attempted to pull his arm back. LPN1 stated that R9 attempted to kiss R10's hand but was unsuccessful. LPN1 stated the certified nurse aides (CNAs) were making rounds and no staff member was at the nurses' station. R9 became upset when R10 was escorted to his room and attempted to follow R10. LPN1 stated that she stood between R9 and the entrance to R10's hallway at the double doors so that R9 could not follow R10.
During an interview on 8/29/2025 at 5:30 PM, the Administrator stated that her expectations of staff were to meet the basic needs of residents, know their characteristics and behaviors, strategize their interventions, and talk to family members to glean more clues about resident interventions.
The Administrator stated she would educate staff, hold impromptu care plan meetings, and provide an individualized supervision approach in the care and protection of the residents.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Gold City Health and Rehab
222 Moore Drive Dahlonega, GA 30533
SUMMARY STATEMENT OF DEFICIENCIES
Observation on 8/26/2025 at 4:05 PM revealed R4 in her electric wheelchair attempting to get an item from inside the personal refrigerator that was on the floor.
Observed clear trash liners in R4's roommate's trash can and in R4's trash can.In an interview on 8/26/2025 at 4:45 PM Certified Nurse Aide (CNA)1 stated that it would be ok to have a trash liner in the trash can if it was not in reach of the resident. In an interview on 8/26/2025 at 4:49 PM CNA2 stated that it would be ok the have a trash liner in the trash can.In an interview on 8/29/2025 at 5:30 PM, when asked about specific care plan interventions and how to communicate those interventions to staff, the Administrator stated 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 stated going forward, all care plans would have to be reviewed and triaged regarding negative potential impact on residents.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/27/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Gold City Health and Rehab
222 Moore Drive Dahlonega, GA 30533
SUMMARY STATEMENT OF DEFICIENCIES
Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure a resident was evaluated for appropriate bed rail use and that alternative measures were attempted prior to installation of bed rails for one of one resident (Resident (R) 4) reviewed for bed rails out of a total sample of 20.
The lack of alternate bed rail measures had the potential to lead to safety concerns related to bed rail use.
Findings include:
Review of the facility's policy titled Bed Safety and Bed Rails, provided by the facility, with a revision date of August 2022 indicated, Use of Bed Rails.The use of bed rails or side rails (including temporarily) raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.Review of R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed diagnoses of cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, and paraplegia, Review of R4's admission Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/25/2024 indicated a Brief Interview for Mental Status (BIM) score of 15, which indicated R4 was cognitively intact.Review of R4's Care Plan dated 11/14/2024 and located in the EMR under the Care Plan tab revealed an Activity of Daily Living self-care performance deficit related to cerebral palsy care plan with a side rail intervention initiated on 1/28/2025.
Quarter rails up on both sides to assist with bed mobility.
Observe for injury or entrapment related to side rail use.
Reposition as necessary to avoid injury.
Review of R4's medical record did not reveal an initial bed rail assessment; documented alternatives tried prior to consideration of bed rail or a consent for bed rails.Observation on 8/25/2025 at 5:30 PM revealed a bedrail in the lowered position on the right side of the bed and the bed pushed against the wall on the left side.
During an interview on 8/26/2015 at 2:15 PM, Licensed Practical Nurse (LPN)2 acknowledged that there was a bed rail on R4's bed and stated that she had not seen R4 use it.In an interview on 8/29/2025 at 10:00 AM, the Administrator confirmed that R4's bed rail evaluation, consent for use, and alternatives tried before installing the bed rail were not done.In an interview on 8/29/2025 at 5:30 PM, the Administrator and Director of Nursing (DON) stated that they did not know how the alternatives tried documentation, assessment by nurses and interdisciplinary (IDT) review and documentation were missed.
The Administrator stated that her expectations going forward would be for more communication between nurses, IDT members and herself prior to installing bed rails to ensure that they were appropriate for resident use and safety.
Facility ID: