Golden Pavilion Healthcare

In the surveyor’s words

From the most serious findings on record at Golden Pavilion Healthcare, in the surveyor’s own words.

• Actual harm, patternF692Mar 17, 2023

  Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for four of eight sampled residents (Resident 1, 3, 4, and 6) when: 1. The facility failed to ensure a Registered Dietitian (RD) evaluated and reassessed Residents 1,3, 4, and 6's nutritional status to recommend nutritional interventions, after unplanned severe and continuous weight loss. a. Resident 1 experienced progressive weight loss from ,d+[DATE] to ,d+[DATE], with a total weight loss of 39.6 pounds (lbs.- a unit of measurement) (20 percent of body weight) with no implemented interventions to address the unplanned weight loss during this period. b. […]

• Actual harm, isolatedF689Jul 22, 2026

  Based on observation, interview, and record review, the facility failed to prevent an avoidable fall for one of one sampled resident (Resident 1) when Resident 1 fell off the bed to the floor.This failure resulted in Resident 1's fall with fractures to the left humerus (the long bone in the upper arm that goes from the shoulder to the elbow) and left distal femur (lower part of thigh bone found behind the kneecap [bone located at the front of the knee]).Review of Resident 1's admission Record indicated, Resident 1 was readmitted on [DATE], with diagnoses including unspecified injury of left and right thigh, type 2 diabetes (a disease that occurs when your blood sugar is too high), muscle weakness, and history of transient ischemic attack (TIA, a mini-stroke caused by temporary blockage of… […]

• Actual harm, isolatedF684Jun 9, 2026

  Based on interview and record review, the facility failed to ensure five of 35 sampled residents (Residents 27, 50, 223, 175, and 32) received necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, residents' choices, and the facility's policies and procedures when the facility failed to: 1a. Implement Resident 27's ordered bowel protocol, as evidenced by no PRN ( pro re nata - as needed) constipation medications being administered during a seven day period without a bowel movement (BM).1b. […]

• Actual harm, isolatedF693Dec 4, 2025

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received tube feeding (a method of delivering liquid nutrition, fluids, and medication directly into the digestive system through a feeding tube when a person cannot eat or drink enough by mouth) in accordance with physician order, the comprehensive person-centered care plan, and the resident's goals when Resident 1's tube feeding rate was increased from 60 to 200 mL/hr (milliliters per hour, which is a unit of measurement for a flow or infusion rate). This failure resulted in Resident 1 transferring to a local acute care hospital and eventually passing away due to aspiration pneumonia (a lung infection. […]

• Actual harm, isolatedF740Jan 17, 2023

  Based on interview and record review, the facility failed to address suicidal ideation (thinking about wanting to end one's own life) when the facility did not re-assess Resident 2's verbalization I no longer wish to be here on 9/8/22, and the facility did not create and implement a care plan for suicidal ideation for one of three residents reviewed. This failure resulted in Resident 2's suicide attempt on 9/21/22, by using scissors to cut his neck. Findings: 1. During review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including generalized anxiety (persistent worry and fear) disorder, depression (elevation or lowering of a person's mood), and paraplegia (paralysis of the lower body), and previous suicide attempt. […]