Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Gate Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain appetizing food temperatures during meal service in two units, as observed during a survey. Residents reported meals being served cold or lukewarm, and test trays confirmed food temperatures below the ideal range. The Food Service Director acknowledged the issue, citing the use of disposable ware and the need for quick delivery as contributing factors.
The facility failed to ensure accurate MDS assessments for two residents. One resident's pressure ulcers were incorrectly documented as present upon admission, despite being facility-acquired. Another resident was inaccurately recorded as discharged to a hospital, while records showed discharge against medical advice. These errors were due to coding mistakes acknowledged by the MDS Coordinator.
A facility failed to act on a pharmacist's recommendation to monitor serum levels for a resident on Divalproex, a mood stabilizer. Despite recommendations made in October 2022 and February 2023, no serum level was ordered or obtained. Interviews with staff confirmed the oversight, with the attending physician and nurse practitioner acknowledging the need for monitoring, while the medical director dismissed its necessity.
During a survey, a transporter failed to perform hand hygiene between assisting residents in the dining room, despite changing gloves. Interviews with staff highlighted a lack of adherence to the facility's infection control policy, which requires hand hygiene between resident interactions and after glove removal.
A resident with severe cognitive impairment and multiple diagnoses was administered Bacitracin despite a documented allergy. The medication was prescribed for a heel cut, but staff interviews revealed a failure to check allergy alerts in the electronic medical record, leading to the administration of the allergic medication.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food was served at appetizing temperatures during meal service, as observed during the recertification survey. This deficiency was noted in two units, Units 4 and 5, where residents reported that their meals were often served cold or lukewarm. Resident #25, who has diagnoses of heart failure, diabetes mellitus, and hyperlipidemia, stated that their breakfast was always cold and lunch was served lukewarm. Similarly, Resident #415, with osteoarthritis, atrial fibrillation, and gastro-esophageal reflux disease, reported that hot foods were often delivered lukewarm or cold. Resident #19, with diabetes mellitus, hypertension, and hyperlipidemia, was observed waiting for their lunch, and subsequent test trays revealed that food temperatures were below the ideal range. On May 24, 2024, test trays were conducted on Units 4 and 5, revealing that food temperatures were not maintained at appropriate levels. For example, crusted fish was measured at 112 degrees Fahrenheit, and mashed potatoes at 117.5 degrees Fahrenheit, which are below the ideal temperature range of 150-155 degrees Fahrenheit as stated by the Food Service Director. The Food Service Director acknowledged that the temperatures were not appropriate and mentioned that the issue had been identified in the past. The use of disposable ware for meal service was noted as a factor, emphasizing the need for quick meal delivery. The Administrator recognized the problem and mentioned plans to implement a new food service system to improve food presentation and temperatures.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status, as evidenced by discrepancies found during the recertification survey. For one resident with diagnoses of anemia and hypertension, the MDS assessment inaccurately documented the presence of pressure sores as being present upon admission, despite medical notes indicating that the pressure ulcers on the resident's heels were acquired in the facility. This discrepancy was attributed to a coding error by the MDS Coordinator, who acknowledged the mistake during an interview. Another resident, diagnosed with diabetes mellitus and bipolar disorder, was inaccurately documented in the MDS assessment as being discharged to an acute hospital. However, medical records indicated that the resident was discharged against medical advice. The MDS Coordinator confirmed during an interview that the resident should have been coded as discharged against medical advice. These inaccuracies in the MDS assessments highlight a failure in accurately documenting residents' conditions and discharge statuses.
Failure to Address Pharmacist's Recommendation for Serum Level Monitoring
Penalty
Summary
The facility failed to address an irregularity identified by the consultant pharmacist during a Medication Regimen Review for a resident diagnosed with Schizophrenia, Type 2 Diabetes Mellitus, and Parkinsonism. The resident was prescribed Divalproex, a mood stabilizer, and the pharmacist recommended obtaining serum levels to monitor for potential toxicity. Despite the recommendation being made twice, once in October 2022 and again in February 2023, there was no documented evidence that the serum level was ordered or obtained. Interviews with facility staff, including the attending physician, nurse practitioner, and assistant director of nursing, confirmed that the recommendation was not acted upon. The attending physician acknowledged the need for the serum level check, and the nurse practitioner stated it should be done at least annually. However, the medical director dismissed the necessity of the serum level, citing the medication's purpose for mood stabilization. This oversight was identified during a recertification survey, highlighting a lapse in following the facility's policy for addressing medication irregularities.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to maintain proper infection control practices during the Recertification Survey conducted from May 21 to May 29, 2024. Specifically, on the 3rd Floor, Transporter #1 did not perform hand hygiene while assisting multiple residents in the dining room. Despite changing gloves between residents, the transporter did not wash or sanitize their hands after removing and donning new gloves. This was observed during a period when the transporter assisted several residents with hand hygiene and meal preparation tasks, including handling food and disposing of trash, without performing the required hand hygiene. Interviews with staff revealed a lack of adherence to the facility's infection control policy, which mandates hand hygiene between resident interactions and after glove removal. Licensed Practical Nurse #3 and the Registered Nurse Supervisor both confirmed that staff are expected to perform hand hygiene to prevent the spread of germs. The Assistant Director of Nursing reiterated the importance of hand hygiene before and after resident contact and after touching trash. Despite these guidelines, the transporter believed they had followed proper procedures, indicating a possible gap in training or understanding of the infection control policy.
Failure to Prevent Administration of Allergic Medication
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the administration of Bacitracin to a resident with a known allergy to the medication. The resident, who had severe cognitive impairment and was admitted with diagnoses including heart failure, cerebrovascular accident, and malignant neoplasm of the colon, was prescribed Bacitracin for a cut on the heel. Despite the resident's allergy being documented in the physician's order and the electronic medical record, Bacitracin was administered from February 24, 2024, to February 29, 2024. Interviews with facility staff revealed a breakdown in the process of checking for allergies before medication administration. The nurse practitioner who prescribed the medication did not recall doing so, and the registered nurse acknowledged the responsibility of licensed nurses, prescribing physicians, and the pharmacy to verify allergies. The staff educator noted that allergy alerts are visible in the electronic medical record, and the pharmacy consultant confirmed that allergies are coded in the system. However, treatment orders for in-house stock were not sent to the pharmacy, which contributed to the oversight.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,414 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Staten Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clove Lakes Health Care And Rehabilitation Center, | 0.5 mi | ★★★★★ | 10 | 2 |
| Sea View Hospital Rehabilitation Center And Home | 0.9 mi | ★★★★★ | 0 | 0 |
| Archcare At Eger Health Care And Rehabilitation Ce | 1.9 mi | ★★★★★ | 0 | 0 |
| Carmel Richmond Healthcare And Rehabilitation Cent | 2.3 mi | ★★★★★ | 4 | 0 |
| Silver Lake Specialized Rehab And Care Center | 2.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Gate Rehabilitation & Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.