Golden Villa

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jan 31, 2025

  Based 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. […]

• Immediate jeopardy, patternF692Mar 4, 2023

  46062 Based 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. […]

• Immediate jeopardy, isolatedF678Feb 16, 2024

  Based 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… […]

• Immediate jeopardy, isolatedF755Mar 4, 2023

  Based 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. […]

• Actual harm, isolatedF697Mar 4, 2023

  Based 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 [DATE] from the hospital. […]