A list of the most recent deficiencies for Golden Pavilion 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-15 | 2024-01-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-15 | 2024-01-08 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-15 | 2024-01-08 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-11-15 | 2024-01-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-15 | 2024-01-08 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-11-15 | 2024-01-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-11-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-11-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-11-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-11-27 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-06-01 | 2023-07-14 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-01 | 2023-07-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-31 | 2023-06-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-26 | 2023-06-23 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-17 | 2023-05-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-17 | 2023-05-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-17 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-17 | 2023-05-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-17 | 2023-05-22 | Y |
| 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 | 2023-03-17 | 2023-05-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-17 | 2023-05-22 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-02 | 2023-04-27 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-03-02 | 2023-04-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-28 | 2023-04-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-13 | 2023-03-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-13 | 2023-03-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-13 | 2023-03-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-13 | 2023-03-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-03-27 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-13 | 2023-03-27 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-01-17 | 2023-02-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-17 | 2023-02-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-17 | 2023-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-17 | 2023-02-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-05 | 2023-02-01 | Y |
| Report COVID19 data to residents and families. | Health | 2022-12-05 | 2023-02-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-06-24 | Y |
| 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 | 2021-06-28 | 2022-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-28 | 2022-02-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-06-28 | 2021-12-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-28 | 2021-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-28 | 2021-09-23 | 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 | 2021-06-28 | 2021-09-23 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-06-28 | 2021-09-23 | 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 | 2021-06-28 | 2021-09-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-28 | 2021-09-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-07-01 | 2021-08-05 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-01 | 2021-08-05 | 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 | 2021-07-01 | 2021-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-01 | 2021-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-01 | 2021-08-05 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-07-01 | 2021-08-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-07-01 | 2021-08-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-01 | 2021-08-05 | 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 | 2021-04-21 | 2021-06-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-06 | 2020-02-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-12-06 | 2020-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-06 | 2020-02-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-06 | 2020-02-14 | 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 | 2019-12-06 | 2020-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-06 | 2020-02-14 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-01-23 | 2020-02-03 | 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 | 2020-01-23 | 2020-02-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-23 | 2020-02-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-02-05 | 2019-02-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-05 | 2019-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-05 | 2019-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-05 | 2019-02-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-05 | 2019-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-30 | 2019-01-24 | 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 | 2018-11-30 | 2019-01-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-30 | 2019-01-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-30 | 2019-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-30 | 2019-01-24 | 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 | 2018-11-30 | 2019-01-24 | 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 | 2018-11-30 | 2019-01-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-30 | 2019-01-24 | 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 | 2018-11-30 | 2019-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-30 | 2019-01-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-30 | 2019-01-24 | N |
