Golden Acres Manor

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 30, 2026

  Based on record review, review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to ensure residents remained free from abuse for 3 of 16 sampled residents (Resident #47, #56, and #57) who exhibited and/or were subjected to physical/verbal abuse. Failure to prevent resident-to-resident physical/verbal abuse resulted in hitting, emotional distress (crying), and fear. These actions placed all residents at risk for serious injury, pain, and mental/emotional harm. Findings include: Review of the facility policy titled Abuse and Neglect Policy and Procedure occurred on 07/29/26. This undated policy stated, . each resident has the right to be free from abuse, . […]

• Actual harm, isolatedF684Jul 30, 2026

  Based on observation, record review, resident and staff interview, the facility failed to ensure that 1 of 1 sampled resident (Resident #1) with a non-pressure skin wound received treatment and care in accordance with professional standards of practice. Failure to perform regular wound monitoring and assessments and document the progression of a wound resulted in delayed healing and worsening of the wound. Findings include: Observation on 07/28/26 at 8:52 a.m. showed an open area on Resident #1's mid-back. Resident #1 stated, They think it [the open area] is from the sling [ceiling lift sling]. During an interview on 07/30/26 at 10:42 a.m., Resident #1 stated she has had the open area for about a month. Review of Resident #1's medical record occurred on all days of survey. […]

• Actual harm, isolatedF686Jul 30, 2026

  Based on record review, review of facility policy, and staff interviews, the facility failed to provide appropriate treatment and services to prevent the development of a pressure ulcer for 1 of 1 closed record (Resident #65) with pressure ulcers. Failure to ensure adequate monitoring and assessment by a provider resulted in the worsening of a facility acquired pressure ulcer. Findings Include: Review of the facility policy titled Pressure Injury Prevention and Management occurred on 07/29/26. The policy, dated 02/23/18 stated, . […]

• Actual harm, isolatedF689Jul 30, 2026

  1. Based on record review, review of facility policy, and staff interview, the facility failed to provide adequate supervision and/or assistance for 1 of 5 sampled residents (Resident #5) who experienced frequent falls. Failure to provide adequate supervision, assistance, and interventions to prevent falls, resulted in two transfers to the emergency room, pain, lacerations and abrasions, and lethargy. Findings include: Review of the facility policy titled Fall Policy occurred on 07/30/26. This policy, dated 2017, stated, . Falls will be discussed in morning meetings. Immediate interventions are discussed as well as any other possible contributing factors that may be mitigated by additional interventions. […]

• No harm, potential for more than minimal, patternF600Apr 30, 2026

  Based on record review, review of the facility reported incident (FRI) investigations, observations, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 5 of 5 sampled residents (Resident #2, #3, #4, #5, #6) who were subjected to verbal and physical abuse by Resident #1. Failure to protect residents from verbal and physical abuse may result in injury, fear, anxiety, mental anguish, emotional distress and resulted in retaliatory abuse to Resident #1.Findings include:Review of the facility policy titled Resident to Resident Altercation occurred on 04/30/26. This policy, dated 04/20/26, stated, . Resident to Resident Altercations can include: Verbally aggressive behaviors 1. Screaming 2. Cursing . […]