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Deficiency Records for Golden Years Center For Rehab and Healthcare
A list of the most recent deficiencies for Golden Years Center For Rehab and Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Golden Years Center For Rehab and 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-04-22 | 2024-07-08 | 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 | 2024-04-22 | 2024-07-08 | N |
| Provide or obtain dental services for each resident. | Health | 2024-04-22 | 2024-07-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-22 | 2024-07-08 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-04-22 | 2024-07-08 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-04-22 | 2024-06-03 | 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 | 2024-04-22 | 2024-06-03 | 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 | 2024-04-22 | 2024-06-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-22 | 2024-06-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-22 | 2024-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-22 | 2024-06-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-22 | 2024-06-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-22 | 2024-06-03 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-04-22 | 2024-06-03 | 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 | 2024-04-22 | 2024-06-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-04-22 | 2024-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-22 | 2024-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-04-22 | 2024-06-03 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-04-22 | 2024-06-03 | 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 | 2024-04-22 | 2024-06-03 | 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 | 2024-04-22 | 2024-06-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-04-22 | 2024-06-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-22 | 2024-06-03 | N |
| Dispose of garbage and refuse properly. | Health | 2024-04-22 | 2024-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-22 | 2024-06-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-04-22 | 2024-06-03 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-04-22 | 2024-06-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Meet other general requirements. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-22 | 2024-06-03 | 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 | 2024-04-22 | 2024-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-04-22 | 2024-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-19 | 2024-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-01 | 2023-04-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-01 | 2023-04-14 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-26 | 2023-02-26 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-14 | 2023-01-26 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-08-26 | 2022-10-10 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-08-26 | 2022-10-10 | 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 | 2022-08-26 | 2022-10-10 | 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 | 2022-08-26 | 2022-10-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-26 | 2022-10-10 | 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 | 2022-08-26 | 2022-10-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-26 | 2022-10-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-08-26 | 2022-10-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-08-26 | 2022-10-10 | 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 | 2022-08-26 | 2022-10-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-26 | 2022-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-26 | 2022-10-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-08-26 | 2022-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-26 | 2022-10-10 | N |
| Keep all essential equipment working safely. | Health | 2022-08-26 | 2022-10-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-26 | 2022-10-10 | 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 | 2022-08-26 | 2022-10-10 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-08-26 | 2022-10-10 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-26 | 2022-10-10 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-08-26 | 2022-10-10 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-12-06 | 2020-01-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-12-06 | 2020-01-18 | 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 | 2019-12-06 | 2020-01-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-06 | 2020-01-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-06 | 2020-01-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-06 | 2020-01-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-06 | 2020-01-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-06 | 2020-01-18 | 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 | 2020-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-06 | 2020-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-06 | 2020-01-18 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-06 | 2020-01-18 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-12-06 | 2020-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-06 | 2020-01-18 | 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 | 2019-12-06 | 2020-01-18 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-12-06 | 2020-01-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-06 | 2020-01-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-06 | 2020-01-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-06 | 2020-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-06 | 2020-01-18 | N |
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