A list of the most recent deficiencies for Golden Heights Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-08 | 2023-09-27 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-08-08 | 2023-09-27 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-24 | 2023-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-24 | 2023-08-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-24 | 2023-08-30 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-07-24 | 2023-08-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-07-24 | 2023-08-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-24 | 2023-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-24 | 2023-08-29 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-07-24 | 2023-08-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-24 | 2023-08-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-24 | 2023-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-24 | 2023-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-24 | 2023-08-29 | N |
| 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. | Health | 2023-07-24 | 2023-08-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-26 | 2023-08-21 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-27 | 2023-08-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-17 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-07-24 | 2023-07-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-24 | 2023-07-24 | N |
| 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. | Health | 2023-07-24 | 2023-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-02 | 2023-06-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-17 | 2023-03-22 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-24 | 2020-02-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-11-22 | 2020-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-22 | 2020-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-22 | 2020-01-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-22 | 2020-01-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-22 | 2020-01-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-22 | 2020-01-21 | N |
| 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. | Health | 2019-11-22 | 2020-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-22 | 2020-01-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-22 | 2020-01-21 | N |
| 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. | Health | 2019-11-22 | 2020-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-22 | 2020-01-21 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-11-22 | 2020-01-21 | N |
| Dispose of garbage and refuse properly. | Health | 2019-11-22 | 2020-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-22 | 2020-01-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-15 | 2019-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-15 | 2019-02-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-15 | 2019-02-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-15 | 2019-02-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-20 | 2019-01-15 | N |
| 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. | Health | 2018-11-20 | 2019-01-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-20 | 2019-01-15 | N |
| 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. | Health | 2018-11-20 | 2019-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-20 | 2019-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-20 | 2019-01-15 | N |
| Keep all essential equipment working safely. | Health | 2018-11-20 | 2019-01-15 | N |
