Golfview Nursing Center

In the surveyor’s words

From the most serious findings on record at Golfview Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 4, 2022

  Based on observations, interviews and record review, the facility failed to provide the supervision needed for one resident (#1) while outdoors in excessively hot weather of 15 residents sampled who were identified as cognitively impaired and able to self-propel in a wheelchair or ambulate freely around the facility. Resident #1 was outdoors in the facility's enclosed unshaded courtyard on Sunday, 07/24/22 between 2:00 p.m. and 4:15 p.m. when the maximum temperature was 95 degrees Fahrenheit (F), and the heat index was between 93- and 106-degrees F. Resident #1 was cognitively impaired with multiple medical diagnoses and known by facility staff to frequently wheel himself outside to the courtyard in his wheelchair but was unable to return inside independently. […]

• Actual harm, isolatedF627Jul 2, 2025

  Based on record review and interviews, the facility failed to permit a resident to return to the facility after a hospital stay for one resident (#1) of three sampled residents reviewed for discharge process. Resident #1 was eligible for discharge from the hospital on [DATE] and as of 06/27/2025, the facility notified the hospital Resident #1 was not accepted back at the facility. Findings included:A review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] and was discharged on 05/17/2025 to an acute care hospital. […]

• No harm, potential for more than minimal, widespreadF842May 16, 2024

  Based on interview, record review, and facility policy review, the facility failed to maintain complete medical records for 24 current residents out of a total resident census of 47. The findings included: On 5/14/24 at 3:00 PM, a beneficiary notice was requested for Resident # 21. On 5/15/24 at 10:07 AM, the Interim Nursing Home Administrator (NHA) stated the facility could not provide Resident #21's beneficiary notice because the facility did not have access to the resident's full medical record. The Interim NHA stated the facility did not have access to the previous electronic medical record system used by the facility, which is where this document would be held. […]

• No harm, potential for more than minimal, patternF812May 16, 2024

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included: proper storage and labeling in the upright freezer, proper cleanliness and temperature of the walk-in cooler, and proper cleanliness and labeling of one (Station #2) of two nourishment refrigerators. This had the potential to affect 47 residents receiving food service from the kitchen. The findings included: On 05/14/24 at approximately 09:00 AM, an initial tour of the kitchen revealed the upright freezer had several open bags of vegetables in the freezer door with no date. One of the bags was observed to be punctured. Additional bags of frozen food items were also undated on the shelves. […]

• No harm, potential for more than minimal, isolatedF585Dec 30, 2025

  Based on interviews and record reviews, the facility did not provide prompt efforts to resolve a grievance for one (Resident #1) of two residents reviewed. Findings include: An observation on 12/30/2025 at 12:28 P.M. of Resident #1's privacy curtain in her room revealed three ants moving on the curtain. An interview was conducted on 12/20/2025 at 12:31 P.M. with Resident #1. Resident #1 said that she had filed a formal grievance on 12/22/2025 regarding ants in her room. Resident #1 provided a photo of the grievance that was written by her on 12/22/2025. A review of the facility provided grievance log for December 2025 revealed the facility did not have a grievance listed for Resident #1. An interview was conducted on 12/30/2025 at 1:15 P.M. with Staff D, Social Services (SS). […]