Golden Villa

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 8 medication carts (200 Hall Medication Cart and 300 Hall Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure the 200 Hall Medication Cart and the 300 Hall Medication Cart were properly secured when Medication Aide A left the facility and left them unlocked and unattended on 06/12/2026. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility. The facility failed to include any resident disease, conditions, physical and behavioral health needs, cognitive status, and acuity of the resident population as well as the number of staff to care for the resident population on the Facility Assessment. This failure could affect residents by not having the necessary resources to ensure appropriate care was provided.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of 1 of 5 (Resident #1) residents reviewed for laboratory services. The facility failed to obtain a urinalysis with culture and sensitivity (a laboratory test that grows and identifies bacteria or yeast in a urine sample to diagnose a urinary tract infection. The sensitivity test is then performed on the cultured germs to determine which specific antibiotic, or antifungal medication will effectively treat the infection) for Resident #1 per physician's order placed on 12/18/26. This failure could place residents at risk of delays in treatment, and/or deterioration in condition

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure frozen food items were stored properly in their walk-in freezer. This failure could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1 of 14 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to document the blood pressure and heart rate for parameters established by the physician for administering Resident #1's carvedilol (blood pressure medication) 8 PM dose from 3/1/26-3/19/26. This failure could place residents receiving blood pressure medications at risk of experiencing unsafe drops in blood pressure and heart rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for quality of life. The facility failed to provide Resident #1 incontinent care, after she had an episode of bowel incontinence on 02/11/2026. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual completed a training and competency evaluation program for 2 of 3 Nurse Aides (NA B and NA D) reviewed for nursing services. The facility failed to ensure NA B and NA D were certified within the required time of four months. This failure could place residents at risk for receiving inappropriate care from an individual whose skill level was not known.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 4 resident raised toilet seat reviewed for essential equipment (Resident #1). Resident #1's raised toilet seat had a missing anti-slip rubber foot. This failure could result in resident falls and injury while the raised toilet seat. Record review of an undated face sheet, revealed Resident #1 was a [AGE] year-old female that admitted on [DATE]. Resident #1 had diagnoses of dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and problem-solving), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and anxiety. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow established policy regarding smoking areas and smoking safety for the 1 of 1 facility reviewed for smoking. The facility failed to ensure NA A did not smoke a vape in the facility on 11/13/25 while standing beside the nurse's station. This failure could place residents and staff at risk of unsafe smoking and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure staff provided pharmaceutical services such as dispensing and administering all drugs to meet the needs of each resident for 3 of 4 staff reviewed for pharmacy services. (LVN A, LVN B, and MA) 1. On 06/20/25, 5 clear medication cups were found with 5 different residents' medications in a resident's room. 2. On 06/24/25, LVN A's medication cart had 15 clear medication cups with 15 different resident names written on them and their medications pre- popped from the medication blister pack in those cups. 3. On 06/24/25, LVN B's medication cart had 2 paper medication cups with two different resident names written on the bottom of the cups with pre popped medication from the medication blister pack in those cups. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to ensure all food items were labeled and dated in the walk-in cooler and the walk-in freezer. 2. The facility ensure that the Activity Director Assistant wore a hair net when entering the kitchen and 2 male staff members wore facial hair coverings while assisting with meal preparation. 3. The facility failed to the shelf above the stove top and parts of the oven were clean. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 7 of 8 residents (Resident's #9, #11, #33, #42, #49, #57, and #84) reviewed for palatable food. The facility failed to provide food that was palatable and attractive to Resident #9, #11, #33, #42, #49, #57, and #84 who complained the food was bland, mushy, and overcooked, and the same foods were served over and over. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #17) reviewed for resident abuse. The facility failed to ensure Resident #17's was free from abuse when LVN J yanked Resident #17's left arm on 05/22/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's environment remained free of accidents and hazards for 2 of 21 residents (Resident #38 and Resident #4) reviewed for accident hazards. 1. The facility failed to prevent Resident #38 from having antimicrobial antiseptic skin cleanser in her room. 2. The facility failed to ensure CNA B performed a safe mechanical lift transfer for Resident #4. This failure could place residents at risk for injury, harm, and impairment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 8 residents (Resident #10, Resident #26 and Resident #83) reviewed for respiratory care and services. 1. The facility failed to cover the nasal cannula tubing with a bag on an oxygen concentrator machine that was not in use for Resident #10 and Resident #83. 2. The facility failed to cover the face mask with a bag on nebulizer machine that was not in use for Resident #26. This failure could place residents at risk for developing respiratory complications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Residents #4) reviewed for infection control practices. The facility failed to ensure CNA B did not contaminate Resident #4, Resident #4's clothing, clean brief, clean incontinent pad, bedding, and bed remote after CNA B had performed incontinent care. These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility did not prevent Resident #1 who had a history of wandering from leaving the facility unsupervised. On or about 07/28/2024, Resident #1 was found approximately 50 feet away from the entrance of the facility around 4:00 AM. The facility failed to ensure Resident #1 received adequate supervision to prevent elopement. The facility failed to investigate resident #1's three separate elopements that occurred in July 2024, October 2024, and January 25, 2025. The facility failed to put interventions in place to prevent Resident #1 from eloping. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 4:48 PM. on 01/30/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so the facility was free from pests and rodents for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of roaches. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 4 of 19 residents reviewed for MDS accuracy. (#61, #51, #12, and #13) 1. The facility failed to code the MDS with an accurate weight for Resident #61. 2. The facility failed to code the wound and wound treatment for Resident #61. 3. The facility failed to code the diagnoses of anxiety and depression for Resident #51. 4. The facility failed to ensure Resident #12 use of an antidepressant (are prescription medicines to treat depression), Duloxetine, was reflected on her MDS. 5. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 19 residents (Resident #61, Resident #77, Resident #30 and Resident #12) reviewed for comprehensive person-centered care plans. 1. The facility failed to implement a nutritional care plan with interventions for Resident #61's weight loss and implement a wound care plan with interventions for Resident #61's open lesion to his left lower extremity. 2. The facility failed to implement a nutritional care plan with interventions for Resident #77's weight loss. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature for 7 (Residents #30, #33, #36, #44, #45, #63, and #82) of 89 residents reviewed for palatable food. 1. The facility did not provide meals services in a manner to ensure palatable food served was appetizing to residents. 2. The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #30, #33, #36, #44, #45, #63 and #82, who complained the food served did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents reviewed for foley catheter care (Resident #31 and #47) and 1 of 2 residents reviewed for incontinent care (Resident #13) infection control practices. 1. The treatment nurse did not change her gloves when going from dirty to clean when providing catheter care to Resident #31. The treatment nurse did not sanitize or wash her hands after performing catheter care when she changed her gloves. 2. The facility failed to ensure CNA F changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #13. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 19 residents reviewed for environment. (Resident #4) The facility failed to replace missing slats from Resident #4's window blinds. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 19 residents (Residents #12 and Resident #13), reviewed for care plans. The facility failed to revise and update Resident #12's comprehensive care plan for the type of blood thinner she was prescribed. Resident #12's care plan indicated she was prescribed Eliquis (is an anticoagulant drug (blood thinner) that helps prevent blood clots) instead of Aspirin (help prevent another heart attack or clot-related stroke). The facility failed to revise and update Resident #13's comprehensive care plan to reflect she was no longer prescribed Eliquis, discontinued on 04/08/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #43) and 2 of 4 staff (CNA F and LVN H) reviewed for transfer. The facility failed to ensure CNA F and LVN H performed a safe 2 person transfer for Resident #43. This failure could place residents at risk of injury from accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 1 (Resident # 12) of 5 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #12 had behavior monitoring (monitor activities and mood) for her prescribed Duloxetine (antidepressant; is used to treat depression and anxiety). 2. The facility failed to ensure Resident #12 had behavior monitoring for her prescribed Lorazepam (antianxiety; is a prescription medication that's used for anxiety, insomnia, and seizures) 3. The facility failed to ensure Resident #12 had side effects monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) for her prescribed Duloxetine. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (Resident #1) residents reviewed for CPR. 1. The facility failed to ensure staff utilized the AED (automated external defibrillator, is a medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to the heart in attempt to re-establish an effective rhythm) when Resident #1 was found unresponsive and not breathing because the facility staff could not locate the AED pads (Automated External Defibrillator pads are an essential part of the AED machine. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 2 Residents (Resident #2) reviewed for PRN (as needed) pain medication administration. The facility failed to ensure the documentation of Resident #2's prn (as needed) pain medications were documented in the MAR. This failure could place residents at risk of delayed pain medication administration, or over medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for residents who were unable to carry out activities of daily living for 1 of 5 resident reviewed for ADLs. (Resident #1) The facility failed to provide Resident #1 with her scheduled showers and hair washing. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 24 residents (Resident #55 and Resident #90) reviewed for nutrition/weight loss. 1. The facility failed to provide Resident #55 with physician prescribed dietary supplements. Subsequently, Resident #55 developed a pressure wound and low albumin levels. 2. The facility failed to implement dietician recommendations for Resident #90, resulting in significant weight loss. An Immediate Jeopardy (IJ) situation was identified on 03/01/2023 at 4:30 p.m. Th Administrator was notified, and a POR (plan of removal) was requested. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #98) and 2 of 4 medication storage location (medication storage #1 and #2) reviewed for pharmacy services. 1. The facility failed to clarify the open-ended order for Lovenox (an anticoagulant medication used to prevent blood clots) therapy when Resident #98 returned from his hospital admissions on 1/25/23 and again on 2/7/23. 2. The facility failed to have system in place to ensure appropriate medication reconciliation was performed for Resident #98. 3. The facility failed to have a system in place to ensure accurate duration of anticoagulant therapy for Resident #98. 4. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 24 residents (Resident #160) reviewed for pain management. 1. The facility failed to take timely and appropriate intervention when Resident #160 complained of pain on 2/26/23 and 2/27/23. 2. The facility failed to ensure Resident #160's medication orders were accurately entered when she returned to the facility on 2/20/23 from the hospital. These failures could place residents at risk for unnecessary pain, discomfort and decreased quality of life. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS was completed for 6 of 24 reviewed for MDS accuracy. (#55, #35, #33, #66, and #69 ) The facility failed to accurately document Resident #55's anticoagulant usage The facility failed to accurately document Resident #35's opioid usage. The facility failed to accurately document Resident #33's opioid usage. The facility failed to accurately document Resident # 66's fall with injury, antibiotic usage, and diagnosis of UTI. The facility failed to accurately document Resident # 69's falls and rejection of care behaviors. These failures could place residents at risk for not receiving needed care and services.

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 24 residents (Resident #55, Resident #66, Resident #35, and Resident #33) reviewed for comprehensive person-centered care plans. The facility failed to implement a nutritional care plan with interventions for Resident #55. The facility failed to develop a care plan and implement care plan interventions for Resident #66's falls. The facility failed to develop a care plan for Resident #35's fractured wrist and opioid use. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to ensure CNA A was not filling cups with ice using an ice scoop and directing the ice from the scoop into her hand and then into the drinking glass 2. CNA was handling cups by the rim while serving residents. These deficient practices could place residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 5 of 8 residents reviewed antibiotic use. (Resident #7, Resident #60, Resident #62, Resident #66, Resident #110) 1. The facility failed to ensure the appropriate use of antibiotics to treat infections for Residents #66 and #7. 2. The facility failed to add a diagnosis to support use for prescribed antibiotics for Resident #60, #62, #66, and #110. 3. The facility failed to follow their policy to use the Suspected UTI SBAR form to communicate concerns with the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 30 residents reviewed for dignity. (Resident #86) The facility failed to provide privacy for Resident #86 during feeding tube administration. This failure placed residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview, observation and record review, the facility failed to make prompt efforts to resolve grievances for 1 of 24 residents (Resident #29) reviewed for grievances. The facility failed to file a grievance report and investigate when Resident #29's Representative reported to the SW that CNA BB cut Resident #29's hair without the Resident Representative's permission. This deficient practice of not resolving grievances promptly could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were secure during transportation to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident # 93) The facility did not ensure a wheelchair was secured while transporting Resident # 93. Resident # 93 was struck by an unsecure wheelchair during transport. This failure could place residents who travel in the facility van at risk of an accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who had a urinary catheter, received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed for catheter care. (Resident #66). Resident #66 was not provided with a secure anchored in place indwelling urinary catheter and Resident #66's urine collection bag was placed on the floor. These failures could place residents at risk for urinary tract infections, pain, confusion, and sepsis (infections that spread to the blood).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 2 resident reviewed for feeding tube management. (Resident #86) 1. The facility failed to flush Resident #86's gastrostomy tube with water before administering enteral feeding. 2. The facility failed to prevent air from entering Resident #86's gastrostomy tubing during enteral feeding and flushes. These failures placed residents at risk for clogged tubing, trapped air, vomiting, and aspiration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rates were not 5 percent or greater. There were 4 errors out of 25 opportunities, which resulted in a 16 percent medication error rate which involved 1 of 5 residents (Resident #55) reviewed for medication administration. 1. The facility failed to ensure Resident #55 received her Pro-stat (indicated for increased protein needs in low volume related) at 8:00 p.m. instead of 10:00 a.m. 2. The facility failed to ensure Resident #55 received her Alprazolam (used to treat anxiety and panic disorders) on time. 3. The facility failed to ensure Resident #55 had hold parameters for her Metoprolol (a beta-blocker that affects the heart and circulation (blood flow through arteries and veins) which was held with no order or notification to the MD. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 24 residents (Resident #98) reviewed for clinical records. The facility failed to ensure LVN U did not document a nursing progress note on Resident #98 on 3/2/23, when Resident #98 was not in the facility. This failure could place residents at risk for inaccurate assessments and monitoring.