Golden Palms Rehabilitation and Retirement

In the surveyor’s words

From the most serious findings on record at Golden Palms Rehabilitation and Retirement, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 resident (Resident #1) reviewed for accidents. The facility failed to ensure an exit door was secured to prevent elopement. Resident #1 eloped from the facility on 9/19/24 and was found by hospital security guards. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 9/19/24 and ended on 10/3/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm, and death. […]

• Actual harm, isolatedF689Jun 25, 2024

  Based on interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's environment remained free of hazards. On 06/19/24 at around 4:00pm - 6:00pm Resident #1 was found by the ADON with altered mental status and a bottle of rubbing alcohol that was 1/4 empty on a dresser at the foot of his bed after Medical Records staff had found 2 bottles of alcohol in residents room earlier in the morning. This deficient practice could place the residents at risk for harm, or serious injury. […]

• No harm, potential for more than minimal, patternF584Apr 15, 2026

  Based on observations, interviews, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 8 of 19 resident A-Beds (1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A) reviewed for environment.The facility failed to ensure resident rooms 1201-A, 1202-A, 1205-A, 1207-A, 1209-A, 1211-A, 1213-A, and 1215-A had a covering or door on their closets. This deficient practice could place residents at risk of their personal belongings being seen, touched, or stolen. […]

• No harm, potential for more than minimal, patternF727Dec 10, 2025

  Based on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 13 ([DATE]th,10th, 23rd, 24th, and 31st, [DATE]th, 7th, and 21st, and [DATE]th, 18th, 19th, 25th, and 26th, 2025) of 90 days reviewed for RN hours, for the period from [DATE], through [DATE].The facility failed to have any RN coverage on weekends for [DATE]st, [DATE]th, 18th, 19th, 25th, and 26th, 2025.The facility failed to have less than 8 hours of RN coverage on weekends for [DATE]th,10th, 23rd, and 24th, and [DATE]th, 7th, and 21st, 2025.This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide. […]

• No harm, potential for more than minimal, patternF692May 8, 2025

  Based on interviews and record review, the facility failed to offer a therapeutic diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for 1 (Resident #1) of 3 residents reviewed for diets. The facility failed to administer Resident #1 with liquid protein (on 02/28/25, 03/02/25, 03/03/25, 03/04/25, 03/08/25, 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/14/25, 03/16/25, 03/17/25, 03/19/25, 03/20/25, 03/21/25, and 03/24/25) and Nepro (on 02/28/25, 03/01/25, 03/03/25, 03/04/25, 03/06/25, 03/07/25, 03/09/25, 03/12/25, 03/13/25, 03/15/25, and 03/24/25) supplements as ordered by her physician. […]