Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Hill Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, depression, and psychosis was re-admitted with an order for Clozapine 100 mg, 1.75 tablets at bedtime. The pharmacy notified the facility that the tablets could not be cut as ordered and requested a revised order using 100 mg and 25 mg tablets together, but staff did not obtain physician clarification at that time. An LPN continued to administer Clozapine over several days, including using 25 mg tablets intended for a different order without physician authorization, and the medication was not available at the scheduled administration time due to late pharmacy delivery. The original Clozapine order remained active until it was discontinued and rewritten days later, contrary to facility policy requiring prompt review and clarification of unclear or potentially inappropriate orders.
A resident with chronic pain and insomnia, ordered to receive routine pain monitoring and scheduled evening doses of Melatonin and Gabapentin, did not receive a documented pain assessment at the ordered time and did not have timely administration of scheduled medications. The MAR showed missed assessments and late documentation, with entries referring to progress notes that were not present for the date in question. The resident reported yelling and arguing with staff over delayed medications and experiencing pain and difficulty sleeping, while an LPN stated the resident repeatedly called out and rang the call bell for about an hour but was not assessed or medicated due to staffing issues, and that medications were offered much later and then refused, with documentation completed several hours after administration time expectations.
A resident with diabetes did not receive consistent blood sugar monitoring as required by professional standards and the care plan. Although insulin was ordered, there was no clear order for blood sugar checks, leading to inconsistent monitoring by nursing staff until a formal order was entered after family concerns. Physician notes referenced monitoring before meals and at bedtime, but this was not supported by an actual order until later, resulting in irregular documentation and practice.
Surveyors found that food items were stored unsealed, undated, and expired in multiple areas, with some items kept on the floor and a non-functioning handwash sink in the kitchen. Food temperatures on the steam table were below required levels, and dietary staff failed to use proper hair and beard restraints or maintain hygienic practices. In a unit pantry refrigerator, undated and expired foods were present, and temperature logs were incomplete, with both nursing and food service staff acknowledging responsibility for oversight.
Several residents were not treated with dignity during care and meal service, including one resident who was served lunch significantly later than tablemates and others who experienced curt or unhelpful interactions with a CNA. Staff interviews revealed a lack of awareness regarding proper meal service protocols and concerns about the aide's communication and attitude toward residents.
Surveyors found that several residents dependent on staff for ADLs did not consistently receive or have documented assistance with personal hygiene, toileting, and transfers. One resident developed skin issues associated with inadequate care, while another was repeatedly observed with long, untrimmed fingernails despite staff acknowledging the need for grooming. Staff interviews confirmed gaps in both care provision and documentation, contrary to facility policy.
The facility did not complete required annual performance reviews for CNAs, as none of the reviewed staff had a documented appraisal within the past year. Despite having policies and staff awareness of the requirement, the process was not followed, and even CNAs with multiple disciplinary actions lacked proper evaluations.
Multiple residents reported that meals were frequently served cold or lukewarm, with some refusing facility food and opting for takeout due to poor quality and temperature. Test trays confirmed that certain food items, such as steak fries and coffee, were not served at appetizing temperatures. Staff acknowledged ongoing complaints and inconsistent use of insulated carts, but no comprehensive solution was in place to ensure all meals were delivered at safe and palatable temperatures.
During ongoing construction, the facility did not adequately control noise levels or formally notify residents, resulting in significant disruption and discomfort. Construction activities, including loud noises and dust, occurred near resident rooms and common areas, with staff and visitors reporting concerns about the environment. The deficiency was cited for not ensuring a safe and comfortable setting during renovations.
Surveyors found that two residents with cognitive impairments and significant care needs developed unexplained bruising that was not properly investigated or reported to the state agency as required. Internal investigations were incomplete, lacked proper documentation, and did not include timely or thorough staff interviews, resulting in a failure to meet regulatory reporting obligations.
A resident with a Stage 3 pressure ulcer and chronic vascular ulcer did not receive enhanced barrier precautions during wound care, as required by facility policy. Staff, including the Infection Preventionist and an LPN, did not wear gowns during dressing changes, and there was no care plan or physician's order for these precautions documented in the medical record.
A resident with severe cognitive impairment and on a blood thinner was found to have bruising on both arms and the left hip, but no investigation was conducted. An LPN observed the discolorations but did not report or document them, and the RN Supervisor and DON confirmed that proper protocols for investigating and reporting such injuries were not followed.
A resident was discharged without documented evidence of a 30-day written notice, bed hold notification, or ombudsman notification, and there was no record of discussions regarding discharge planning or post-discharge care arrangements. The facility also failed to document communication with the resident's MLTC provider for assessment of additional home care hours, resulting in incomplete discharge documentation.
A significant medication error occurred when an LPN administered Coumadin to a resident despite a physician's order to hold the medication due to an elevated INR. The error was attributed to the LPN being overwhelmed and not checking the updated orders, resulting in the resident's INR rising further and requiring immediate intervention with Vitamin K. Staff interviews confirmed that nurses are responsible for verifying current orders before medication administration.
Failure to Obtain Timely Physician Clarification and Properly Administer Clozapine
Penalty
Summary
The deficiency involves the facility’s failure to ensure medication administration services met professional standards, specifically by not obtaining timely physician clarification when a prescribed medication could not be dispensed as ordered. Resident #2, who had diagnoses including dementia, depression, and psychosis and was documented as having severely impaired cognition and receiving antipsychotic medication, was re-admitted with a physician’s order for Clozapine 100 milligrams, 1.75 tablets by mouth at bedtime for psychosis. On 01/16/2026 at 8:01 PM, the pharmacy notified the facility via email that Clozapine 100 milligram tablets could not be cut into three-quarters and requested that the physician change the order to Clozapine 100 milligrams plus Clozapine 25 milligrams (three tablets) to be given together. Despite this notification, there was no documented evidence that the physician was contacted or that a clarified order was obtained on that date. From 01/16/2026 through 01/19/2026, the January 2026 Medication Administration Record showed that Licensed Practical Nurse #2 administered Clozapine to Resident #2. On 01/16, the LPN used Clozapine 25 milligram tablets that were intended for a different physician’s order, without physician authorization for the change in formulation or administration. Additionally, pharmacy delivery records showed that 42 Clozapine 25 milligram tablets were delivered to the facility at 12:07 AM, after the scheduled 9:00 PM administration time on 01/16/2026, meaning the medication was not available at the ordered time and was therefore not administered as scheduled. The original Clozapine 100 milligram, 1.75 tablet order was not discontinued until 01/20/2026, when a new clarified order was written, contrary to the facility’s policy requiring prompt review and clarification of unclear or potentially inappropriate physician orders prior to implementation.
Failure to Provide Timely Pain Assessment and Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to provide timely and appropriate pain management and related medication administration for one resident with chronic pain conditions. The resident had diagnoses including low back pain, fibromyalgia, diabetic neuropathy, osteoarthritis, and insomnia, and physician orders required pain monitoring every shift and administration of Melatonin at bedtime and Gabapentin in the evening. The facility’s pain policy required monitoring at least each shift for acute pain or significant changes in chronic pain, and assessment whenever there was suspicion of new or worsening pain. On the evening in question, the Medication Administration Record (MAR) showed a scheduled pain assessment at 7:00 PM that was not documented as completed, and the resident’s Melatonin and Gabapentin, scheduled for 8:00 PM and 9:00 PM respectively, were not documented as administered at those times. The MAR instead reflected a code indicating “other/see progress notes,” but there was no corresponding nursing progress note for that date from the assigned LPN, and documentation of medication administration was not entered until 2:10 AM the following day. The resident reported recalling an incident where they yelled and argued with staff over medications not being given on time, and stated they experienced pain and difficulty sleeping when medications were not provided when requested. The LPN reported that upon starting the shift at 7:00 PM, the resident was already calling out for medication and continued to call out and ring the call bell every five minutes for about an hour, but the LPN did not perform a pain assessment or administer pain medication at that time, citing insufficient staffing and competing responsibilities. The LPN stated that medications were brought to the resident around midnight, at which point the resident, upset, refused them, and the LPN acknowledged that documentation was not completed until several hours later, contrary to the expectation that medications be administered within one hour of the scheduled time and documented at the time of administration.
Failure to Ensure Consistent Blood Sugar Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident with diabetes received blood sugar monitoring and insulin administration in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. Upon admission, the resident was prescribed 70/30 insulin twice daily, but there was no clear physician order for blood sugar monitoring. Nursing staff inconsistently monitored the resident's blood sugar without an order until one was entered two weeks after admission, following concerns raised by the resident's family. Documentation showed irregularities in the frequency and timing of blood sugar checks, with some days missing readings entirely and others not aligning with the expected schedule of monitoring before meals and at bedtime. Physician notes indicated that blood sugar monitoring should have occurred before meals and at bedtime, but no corresponding order was present until later. Interviews with nursing staff and the DON revealed uncertainty about the lack of a monitoring order and the inconsistent practice prior to the formal order being entered. The facility's policy required that insulin administration and blood glucose monitoring be performed per physician order and care plan, but this was not followed. The resident had diagnoses including diabetes, heart failure, and a recent ankle fracture and repair, and was cognitively intact at the time of the deficiency.
Deficiencies in Food Storage, Preparation, and Staff Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations during the recertification survey. On the initial kitchen tour, food items were found unsealed, undated, and expired in the freezer, dry storage, and refrigerator. Specific items included unsealed frozen hamburgers, chicken nuggets, and rolls, as well as expired waffles, angel food cake mix, and biscuit mix. Boxes of grape jelly were stored on the floor, and several refrigerated items such as pepperoni, tortillas, salads, sandwiches, fruit cups, and pudding were undated. The handwash sink in the food preparation area was not functioning, and staff reported the sensor had been broken for about a week. During a follow-up kitchen visit, food temperatures on the steam table were below required levels, with steak fries at 120°F and pureed meat at 130°F. Dietary staff were observed not wearing proper hair or beard restraints, and one staff member used gloved hands to handle food and then touched their face without changing gloves. In the C1 unit pantry refrigerator, there were undated and expired food items, including juice bottles, applesauce, pizza, guacamole, sandwiches, and yogurt. The temperature log for the refrigerator was incomplete, and both nursing and food service staff acknowledged responsibility for monitoring and discarding outdated items.
Failure to Ensure Resident Dignity During Care and Meal Service
Penalty
Summary
Multiple residents were not treated in a dignified manner, as evidenced by both dining observations and staff performance documentation. During a lunch service, three residents at a table were served and began eating, while a fourth resident at the same table was not served until 12 minutes later. Another resident at the table repeatedly requested that the fourth resident be served, indicating awareness and concern among peers. Interviews with staff revealed a lack of awareness regarding the expectation that all residents at a table should be served simultaneously. Additionally, a review of a Certified Nurse Aide's employment file revealed several disciplinary notices related to interactions with residents. One resident reported feeling like a bother when requesting assistance with personal care, while another resident described the aide as aggravated and unhelpful during bedtime care. A third resident's spouse reported the resident was left soaked at lunchtime and was told by the aide to stop ringing the call bell. The aide's body language and mannerisms were noted as contributing to residents and families feeling upset during these interactions.
Failure to Provide and Document Required ADL Care and Hygiene Assistance
Penalty
Summary
Surveyors identified that multiple residents who were dependent on staff for activities of daily living (ADLs) did not consistently receive necessary care and assistance. Documentation Survey Reports and Certified Nurse Aide records for several residents, including those with diagnoses such as metabolic encephalopathy, dementia, Parkinson's disease, and muscle wasting, showed repeated omissions in recording the completion of personal hygiene, toileting hygiene, and toilet transfers across various shifts and dates. Interviews with staff confirmed that these omissions could be due to either care not being provided or a lack of documentation, with some staff unable to explain the missing records. Facility policy required that ADL care be provided based on assessed needs and that documentation be completed accordingly. One resident with moderately impaired cognition, a Foley catheter, and bowel incontinence was documented as requiring maximum assistance for ADLs and transfers. However, there was no documented evidence that personal hygiene and toileting care were provided on multiple shifts over several months. This resident also developed skin issues, including dry, fragile skin, reddened areas in the groin, and moisture-associated skin damage to the sacrum and buttocks, as noted in nursing assessments and wound consultations. Staff interviews confirmed that peri care should be completed every shift, and that lack of documentation indicated the care was not done. Another resident with severely impaired cognition and dependence on staff for personal hygiene was repeatedly observed with long, ungroomed fingernails. Both a Certified Nurse Aide and an LPN acknowledged the resident's need for assistance with grooming and that the fingernails required trimming, but neither knew when this had last been done. The facility's policy assigned responsibility for such care to the Certified Nurse Aide, and staff confirmed that the resident was not diabetic, so nail care should have been performed by aides.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months, as required by policy and regulation. A review of five CNA personnel files revealed that none had a documented annual performance appraisal within the past year. One CNA had an undated and unsigned performance review, while the others had no documentation of a performance review at all. Additionally, one CNA with multiple corrective discipline notices and eventual termination also lacked an annual performance appraisal in their file. Interviews with the Director of Human Resources, Unit Managers, and the Director of Nursing confirmed that the responsibility for completing annual performance reviews was understood but not carried out. The Unit Managers maintained lists of staff and hire dates and acknowledged that annual reviews should have been completed. The Director of Nursing was unaware that the reviews were not being performed. The facility's policy required consistent and fair evaluation of staff performance to ensure high-quality care and regulatory compliance, but this process was not followed for the CNAs reviewed.
Failure to Provide Palatable and Appropriately Tempered Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature, as required by facility policy. Multiple residents reported dissatisfaction with the quality and temperature of the food, describing meals as often lukewarm, vegetables as undercooked and hard, and meats as overdone. Some residents stated they refused facility meals and instead ordered takeout due to poor food quality and temperature. A test tray sampled during the survey revealed that while some items were at acceptable temperatures, others, such as steak fries and coffee, were served cold or lukewarm, and the soup was only 100 degrees Fahrenheit. The Assistant Food Service Director acknowledged complaints about cold food and noted that while insulated food carts were used for units farther from the kitchen, open racks were still used for closer units, and there was no plan to transition all units to enclosed thermal carts. Staff interviews confirmed ongoing complaints about food temperature and quality, with dietary staff making efforts to address individual preferences but not resolving the underlying issue. The Assistant Food Service Director indicated that the pellet system used to keep food warm was being serviced, but there was no evidence of a comprehensive solution in place. Residents and their representatives reported that complaints about cold meals had been made to staff without resolution, and some residents regularly sought alternative food sources due to dissatisfaction with the meals provided.
Failure to Maintain Comfortable Sound Levels During Construction
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents by not adequately controlling noise levels during ongoing construction on the South 1 Unit. Observations revealed active construction with tarps, signage, and unfinished sheet rock near the nurses' station while residents were present in the area. Multiple staff interviews indicated uncertainty about the construction timeline and lack of specific instructions regarding resident safety and comfort during the renovation. The facility's Renovation/Construction Policy required noise and dust control measures, but there was no documented evidence that residents were formally notified about the construction, and complaints about excessive noise and dust were reported by visitors. The construction was scheduled to occur during daytime hours, with some adjustments made to resident placement when possible. However, interviews with staff and visitors confirmed that construction activities, including loud noises such as jackhammering, occurred near resident rooms and common areas, causing significant disruption. A stop work order was issued due to failed and missing inspections, but not specifically for noise concerns. The deficiency was cited under 10NYCRR 415.5(h)(5) for not ensuring a safe, clean, and comfortable environment for residents during the renovation process.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
Surveyors identified that the facility failed to report injuries of unknown origin to the state agency for two residents. For one resident with osteoarthritis, bipolar disorder, and dementia, bruising was observed on the hand and arm, and the resident reported the injury occurred during care. The incident was documented, and an internal investigation was conducted, but the investigation lacked proper documentation, including signed, dated, and timed statements. Staff statements did not address the presence or absence of bruises, and the investigation did not conclusively rule out abuse. Despite these gaps, the incident was not reported to the Department of Health as required by facility policy. For another resident with a history of cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness, bruising was documented on both arms and the left hip. The resident was on a blood thinner and required significant assistance with daily activities. Although the care plan required regular skin checks, there was no evidence that an investigation was initiated or that an Accident/Incident Report was completed for the bruising. The nurse did not report the bruises, and the required investigation and notification to the Department of Health did not occur. Interviews with facility leadership confirmed that the required steps for investigating and reporting injuries of unknown origin were not followed in both cases. The Director of Nursing and Assistant Director of Nursing acknowledged that investigations were incomplete and that the incidents were not reported to the state agency, contrary to facility policy and regulatory requirements.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified that the facility failed to implement enhanced barrier precautions for a resident with a Stage 3 pressure ulcer and a chronic vascular ulcer, both requiring physician-ordered dressing changes. Despite a facility policy requiring the use of gowns and gloves for high-contact care activities for residents with wounds, staff did not place the resident on enhanced barrier precautions, and there was no signage indicating such precautions on the resident's door. During wound care observations, both the Infection Preventionist and the LPN Unit Manager did not don gowns while performing dressing changes. The resident involved had diagnoses including diabetes, dementia, and a pressure ulcer to the left buttock, with documented moderate cognitive impairment and the need for assistance with most activities of daily living. The electronic medical record lacked a physician's order or care plan for enhanced barrier precautions. The Infection Preventionist acknowledged during an interview that the resident should have been on enhanced barrier precautions and that a gown should have been worn during dressing changes.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency was identified when the facility failed to conduct an investigation into an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including a history of cerebrovascular accident, non-Alzheimer's dementia, and muscle weakness. The resident was dependent on staff for most activities of daily living and was prescribed a blood thinner. Documentation showed that the resident had bruising on both arms and a small area on the left hip, but there was no evidence that an investigation was initiated or completed regarding these findings. Interviews revealed that the LPN who observed the skin discolorations did not consider them to be bruises and chose not to report or document the findings to a supervisor, despite annual in-services on accident/incident and abuse protocols. The RN Supervisor confirmed that any bruises of unknown origin, especially in cognitively impaired residents, should have been reported and investigated, with notification to the physician and family. The DON also stated that the nurse should have initiated an investigation and informed the appropriate parties, which did not occur in this case.
Failure to Provide Required Discharge and Notification Documentation
Penalty
Summary
The facility failed to provide the required written notification of transfer or discharge to a resident, their representative, or the ombudsman, as mandated by both facility policy and state regulations. Specifically, a resident was discharged home without documented evidence that a 30-day written notice was given, nor was there documentation of the reasons for discharge, the effective date, or the discharge location in the medical record. Additionally, there was no evidence that a bed hold notice was provided, or that the ombudsman was notified at the time of discharge. The resident in question had diagnoses including anxiety disorder, COPD, depression, and polyosteoarthritis, and was assessed as having intact cognition but requiring significant assistance with most activities of daily living. Although a care plan meeting was held with the resident, family, and interdisciplinary team, and the resident requested an assessment from their Managed Long-Term Care (MLTC) provider for increased home care hours, there was no documentation that the MLTC was notified or that an assessment was scheduled prior to discharge. Progress notes did not reflect discussions about discharge planning or arrangements for post-discharge care, and the discharge documentation was incomplete regarding notifications to home care services. Interviews with facility staff revealed that while discharge planning discussions may have occurred verbally, required documentation was not completed. The discharge liaison and social worker both acknowledged that notifications and progress notes were not consistently documented, and the facility was unable to provide evidence of compliance with notification requirements when records were requested. This lack of documentation and notification represents a failure to meet regulatory requirements for resident discharge.
Significant Medication Error: Held Anticoagulant Administered
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered Coumadin 2mg to a resident despite a physician's order to hold the medication due to an elevated International Normalized Ratio (INR) of 3.3. The order to hold Coumadin was documented earlier that day, but the LPN administered the medication during the evening medication pass. The resident had a medical history including atrial fibrillation, cervical disc degeneration, congestive heart failure, and pulmonary edema, and was receiving anticoagulant therapy. Following the administration of the held medication, the resident's INR increased to 7.9, and the resident required immediate administration of Vitamin K as per physician's orders. Interviews revealed that the LPN acknowledged seeing the physician's order to hold the medication but administered it by mistake, citing being overwhelmed and working alone. The facility's policy defines a medication error as any event that may cause or lead to inappropriate medication use or resident harm, including administering a medication that has been held. Other staff interviews indicated that while nurses receive reports about medications on hold or discontinued, it is their responsibility to check electronic health records and physician orders prior to administration. The Director of Nursing confirmed that nurses are expected to follow physician orders and adhere to the five rights of medication administration.
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 102 citations issued within 25 miles in the last 12 months — 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 Kingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northeast Ctr For Rehabilitation And Brain Injury | 4.6 mi | ★★★★★ | 0 | 0 |
| Ferncliff Nursing Home Co Inc | 4.9 mi | ★★★★★ | 1 | 0 |
| Ten Broeck Commons | 5.7 mi | ★★★★★ | 11 | 0 |
| The Baptist Home At Brookmeade | 6.7 mi | ★★★★★ | 0 | 0 |
| Renaissance Rehabilitation And Nursing Care Center | 7.3 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Hill Nursing And Rehabilitation 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.