A list of the most recent deficiencies for Golden Hill Post Acute. 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-11-15 | 2024-02-13 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-15 | 2024-02-13 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-15 | 2024-02-13 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-06-02 | 2023-06-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-30 | 2022-12-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-20 | 2022-11-30 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-08 | 2022-05-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-08 | 2022-05-18 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-02 | 2021-11-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-21 | 2021-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-21 | 2021-11-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-21 | 2021-11-19 | 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 | 2021-10-21 | 2021-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-21 | 2021-11-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-16 | 2021-10-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-16 | 2021-10-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-02 | 2021-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-10-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-02 | 2021-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-20 | 2021-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-20 | 2021-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-04 | 2021-06-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-19 | 2021-06-13 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-19 | 2021-06-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-19 | 2021-06-13 | Y |
| 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 | 2021-05-19 | 2021-06-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-19 | 2021-06-13 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-05 | 2021-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-03 | 2021-03-29 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-03-03 | 2021-03-29 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-31 | 2019-11-19 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-31 | 2019-11-19 | 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 | 2019-10-31 | 2019-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-31 | 2019-11-19 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2019-10-31 | 2019-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-10 | 2019-11-06 | 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 | 2019-10-10 | 2019-11-06 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-10-10 | 2019-11-06 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-10 | 2019-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-10 | 2019-11-06 | 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 | 2019-10-10 | 2019-11-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-10 | 2019-11-06 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-10-10 | 2019-11-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-10 | 2019-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-12-13 | 2019-01-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-10-04 | 2018-11-04 | N |
| 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. | Health | 2018-10-04 | 2018-11-04 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-04 | 2018-11-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-04 | 2018-11-04 | 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 | 2018-10-04 | 2018-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-04 | 2018-11-04 | 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 | 2018-10-04 | 2018-11-04 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-04 | 2018-11-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-11-04 | N |
