ElderGrade

Inspection citations at Golfcrest Nursing Center

22 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 9 1
2024 5 0
2022 8 0
D May 21, 2025 Tag F0635 Complaint investigation Corrected Jun 2025

Resident Assessment and Care Planning Deficiencies

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0880 Corrected May 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0758 Corrected May 2025

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0686 Corrected May 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0684 Corrected May 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0656 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0584 Corrected May 2025

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D April 10, 2025 Tag F0558 Corrected May 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

G April 10, 2025 Tag F0693 Corrected May 2025

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Actual harm to a resident

D January 19, 2024 Tag F0805 Corrected Feb 2024

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

No actual harm, potential for more than minimal harm

D January 19, 2024 Tag F0692 Corrected Feb 2024

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D January 19, 2024 Tag F0684 Corrected Feb 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E January 19, 2024 Tag F0803 Corrected Feb 2024

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

F January 19, 2024 Tag F0812 Corrected Feb 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D September 2, 2022 Tag F0805 Corrected Oct 2022

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

No actual harm, potential for more than minimal harm

D September 2, 2022 Tag F0761 Corrected Oct 2022

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D September 2, 2022 Tag F0695 Corrected Oct 2022

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D September 2, 2022 Tag F0677 Corrected Oct 2022

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

E September 2, 2022 Tag F0808 Corrected Oct 2022

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

No actual harm, potential for more than minimal harm

E September 2, 2022 Tag F0803 Corrected Oct 2022

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

E September 2, 2022 Tag F0584 Corrected Oct 2022

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

F September 2, 2022 Tag F0812 Corrected Oct 2022

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.