Inspection·June 24, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based 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.On 06/24/25, MA C's medication cart had 3 clear medication cups with no names on them with , but resident medications were pre popped from the medication blister pack in the cups. These findings could place residents at risk of receiving the wrong medications. Findings included: 1. Record review of an employee concern form dated 6/20/25 indicated the Administrator had received a report that medications were found in cups stacked within each other. It appeared the medication were intended to be administered and somehow forgotten. The Medical Director was notified and identified residents were put-on 24-hour monitoring for any changes, the responsible parties were notified, and in service education on Medication Administration was conducted. Classroom meetings were scheduled for 6/24/25. During an interview on 6/24/25 at 6:40 a.m. the Administrator said he had written an employee concern about medications found in a room. He said they had identified the residents and their medications. He said the nurse they thought was responsible had been terminated. They had called the physician, the families and placed the residents in question on a 24-hour monitoring. He said he had not seen the medications himself but understood there was a picture floating around. Record review of an in-service training report dated 6/20/25 indicated the topic was Medication Administration. When administering medications to residents it is your responsibility to ensure the resident takes the prescribed medications. It is the facility policy to never leave medications at (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675490 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)