Deficiency Records for Golden Acres Living and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Golden Acres Living and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-20 | 2024-01-21 | Y |
| 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 | 2023-08-24 | 2023-10-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-24 | 2023-10-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-24 | 2023-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-24 | 2023-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-24 | 2023-10-04 | 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 | 2023-08-24 | 2023-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-24 | 2023-10-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-08-24 | 2023-10-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-24 | 2023-10-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-24 | 2023-10-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-24 | 2023-10-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-24 | 2023-08-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-24 | 2023-08-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-24 | 2023-08-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-24 | 2023-08-25 | 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 | 2023-06-29 | 2023-06-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-29 | 2023-06-30 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-22 | 2022-08-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-23 | 2022-08-02 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-23 | 2022-07-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-23 | 2022-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-23 | 2022-07-22 | 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 | 2022-06-23 | 2022-07-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-23 | 2022-07-19 | 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 | 2022-06-23 | 2022-07-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-23 | 2022-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-23 | 2022-06-24 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-06-23 | 2022-06-24 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-06-23 | 2022-06-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-23 | 2022-06-24 | 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 | 2022-06-22 | 2022-06-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-22 | 2022-06-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-11 | 2021-04-13 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-03-11 | 2021-04-13 | 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 | 2021-03-11 | 2021-04-13 | 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 | 2021-03-11 | 2021-04-13 | N |
| 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. | Health | 2021-03-11 | 2021-04-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-11 | 2021-04-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-11 | 2021-04-13 | 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 | 2021-03-11 | 2021-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-11 | 2021-04-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-11 | 2021-04-13 | N |
| Use approved construction type or materials. | Fire Safety | 2021-03-11 | 2021-04-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-03-11 | 2021-04-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-11 | 2021-04-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-11 | 2021-04-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-11 | 2021-04-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-03-11 | 2021-04-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-11 | 2021-04-07 | 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 | 2021-03-11 | 2021-04-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-11 | 2021-04-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-30 | Not Fixed | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-11 | Not Fixed | N |
