Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Acres Manor during CMS and state inspections, most recent first.
A resident with dementia, restlessness, agitation, and a documented history of entering others’ rooms, rummaging, and exhibiting verbal and physical behaviors was involved in multiple abusive encounters with other residents. In separate incidents, this resident hit another resident in a TV lounge after handling that resident’s bag, punched a resident on the chin/cheek while following behind with a walker, grabbed another resident’s arm near the TV leading to mutual hitting and a fall onto a recliner occupied by a third resident, kicked a resident while being escorted to dinner, and lifted a resident’s chair cushion while searching for a wallet, leading to a profane verbal exchange. Several of the involved residents had impaired cognition, while others had intact cognition but histories of mood and behavioral issues. Staff interviews showed limited description of immediate protective actions when witnessing resident-to-resident aggression, and an administrator noted that the aggressive resident had not been evaluated by psychiatry for an extended period. The facility failed to prevent repeated verbal and physical abuse among residents, resulting in retaliatory abuse toward the aggressive resident.
Surveyors identified unsanitary conditions in the kitchen, including expired sanitizer test strips, dust and dirt accumulation on kitchen equipment, and improper storage of resident cold packs next to food items in a unit freezer. Staff confirmed these practices did not meet facility policy or professional standards.
Staff failed to consistently perform hand hygiene after removing gloves, before applying new gloves, and before touching clean surfaces or equipment during personal care for multiple residents, including those with pressure ulcers and other care needs. Reusable equipment such as mechanical lifts was not always disinfected after use, and staff sometimes exited rooms or handled resident items without proper hand hygiene, contrary to facility policy.
A resident with severe cognitive impairment was financially exploited by a staff member, who altered and cashed checks for amounts far exceeding the agreed purchase price of items. The staff member admitted to making up prices and was unaware of the resident's vulnerable status due to dementia. The incident was discovered after the resident's family noticed significant financial discrepancies.
A resident with benign prostatic hyperplasia and intact cognition reported that staff did not regularly assist with urinary incontinence care during the evening and night, despite requesting help every 3-4 hours. Documentation showed scheduled check and change times, but the care plan did not reflect the resident's preferences. Two administrative nurses confirmed the care plan was not updated or individualized to meet the resident's current needs.
Nursing staff did not clarify or accurately transcribe a new medication order for a resident, resulting in a discrepancy between the medication card and the MAR for Metoprolol. Additionally, a nurse failed to correctly prime an insulin pen for another resident, not following manufacturer instructions. Administrative staff confirmed that medication orders should be clarified when discrepancies are found.
A resident with a diagnosis of PTSD and a history of physical and sexual abuse did not receive an assessment for past traumas or identification of known triggers. The care plan only addressed general mood observations and lacked a trauma-specific plan, and staff confirmed these assessments and plans were not completed.
The facility failed to maintain sanitary conditions in food storage and preparation. Observations revealed unlabeled and undated food items in the freezer and cooler, including spaetzeles, corn, sausage crumbles, and meat patties. Additionally, the cooling process for leftover soup was not properly monitored, as temperatures were not checked after removal from the steam table. This failure to adhere to facility policy and professional standards poses a risk of foodborne illness.
Failure to Prevent Repeated Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from verbal and physical abuse by another resident with known behavioral issues. Facility policies on resident-to-resident altercations and abuse/neglect defined verbally aggressive behaviors such as screaming and cursing, and physically aggressive behaviors such as hitting, kicking, grabbing, pushing, and rummaging through others’ property, and affirmed residents’ right to be free from verbal, physical, and mental abuse. Resident #1 had documented diagnoses including dementia, restlessness, and agitation, with a care plan noting a history of entering other residents’ rooms, rummaging, and exhibiting verbal and physical behaviors. Despite this, Resident #1 was involved in multiple altercations with other residents over a short period. In one incident with Resident #3, video and investigation documentation showed Resident #3 sitting in a recliner in a common TV area while Resident #1 was near other recliners. Resident #3 told Resident #1 to leave electrical cords alone, then got up and approached Resident #1. Resident #1 began to handle Resident #3’s bag on the recliner, after which Resident #3 hit Resident #1 on the left side of the head, and Resident #1 hit Resident #3 on the left arm. Resident #3 had a history of depression, anxiety, mental disorder, mild cognitive disorder, and prior verbal and physical behaviors, with an MDS indicating intact cognition. In another incident with Resident #4, video review and notes showed Resident #4 ambulating with a walker past the nurse’s station into the TV area, followed closely by Resident #1. Resident #1 was seen standing directly behind Resident #4, appearing to make a comment; Resident #4 swatted at Resident #1, and Resident #1 then struck Resident #4 on the left chin/cheek area. A progress note documented that Resident #1 punched Resident #4 when Resident #4 did not respond to Resident #1’s attempt to engage in conversation. Additional altercations involved Resident #2, #5, and #6. In the incident with Resident #2, video review showed Resident #1 standing in front of the TV fidgeting with the control box, then later walking over to Resident #2 and grabbing her arm as if to guide her away from the TV. Resident #2 responded by hitting Resident #1’s left arm, and Resident #1 hit her back on the right arm; both then grabbed each other, fell onto a recliner occupied by another resident, and staff intervened. Resident #2’s MDS indicated severely impaired cognition, and she sustained transient red marks on her head and upper inner arm. In another event, the activity director was walking residents to dinner when Resident #1 kicked Resident #5, who was walking in front, and then chuckled; Resident #5, who also had severely impaired cognition, recalled being kicked and stated the other resident was “not 100 percent.” In a separate episode with Resident #6, staff heard Resident #6 yelling profanities at Resident #1, who was lifting her chair cushion looking for his wallet; Resident #1 raised his voice and called her an explicit name, and Resident #6 prepared to remove her shoe to use toward him before staff intervened. Resident #6, with intact cognition, later stated that Resident #1 wanted to hurt her and that he had hit her friend (Resident #4) for no reason. Staff interviews further illustrated gaps in protecting residents from abuse. One staff member, when asked what she would do if she witnessed a resident hit another resident, stated she would get the RNs and “try to get a hold of someone,” without describing immediate protective interventions. An administrative staff member reported that Resident #1 had not been seen by psychiatry since 2024, despite his documented dementia with psychotic disturbances and ongoing behavioral issues. Across these events, the facility did not prevent repeated verbal and physical altercations initiated or escalated by Resident #1 toward other residents, which led to retaliatory physical and verbal abuse by those residents toward Resident #1.
Failure to Maintain Sanitary Kitchen and Food Storage Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment as required by professional standards and facility policy. Observations revealed the use of expired quaternary ammonia sanitizer test strips, with an expiration date of December 2023, and accumulations of dust and dirt on the hood above the oven, the grate below the front door of a reach-in refrigerator, and on four fans located on two condenser units in the walk-in cooler. Dietary staff were unable to confirm the last cleaning date for the hood, and acknowledged that the test strips should not be expired and that the dust and dirt should be cleaned from the equipment. Additionally, on the Prairie Unit, two resident cold packs intended for use on the body were found stored next to food items in the freezer. An administrative nursing staff member confirmed that resident cold packs should not be stored in the food freezer and identified a separate refrigerator designated for these items. These failures were identified through observation, review of facility policy, and staff interviews.
Failure to Follow Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to established infection prevention and control protocols during personal care activities for several residents. Observations revealed that certified nurse aides (CNAs) did not consistently perform hand hygiene after removing gloves, before applying new gloves, or before touching clean surfaces and equipment. In multiple instances, CNAs handled soiled items, then touched clean briefs, oxygen cannulas, clothing, and other surfaces without proper hand hygiene. For example, after providing perineal care and removing soiled gloves, CNAs applied new gloves or handled resident equipment without sanitizing their hands. Additionally, staff failed to disinfect reusable equipment, such as mechanical lifts, after use. In one case, a CNA exited a resident's room with a mechanical lift and placed it in the hallway without sanitizing it. Another CNA transported a resident to a lounge after care without performing hand hygiene upon exiting the room. These actions were not in accordance with the facility's infection prevention and hand hygiene policies, which require hand hygiene between resident contacts, after handling contaminated objects, and before and after glove use. The residents involved included individuals with specific care needs, such as a resident with a pressure ulcer and a history of skin breakdown. The observed deficiencies occurred during routine personal care activities, including perineal care, transfers using mechanical lifts, and handling of oxygen equipment. An administrative nurse confirmed that staff were expected to follow hand hygiene protocols and sanitize equipment as outlined in facility policy.
Failure to Protect Resident from Misappropriation of Funds by Staff
Penalty
Summary
A facility failed to protect a resident with severe cognitive impairment from misappropriation of funds by a staff member. The incident involved the resident providing a staff member with a signed blank check for a purchase, which the staff member then altered and cashed for a significantly higher amount than agreed upon. The staff member also obtained a second check from the resident, which was similarly altered for a higher amount. Photocopies of the altered checks were obtained by the facility, and the staff member admitted to making up the prices and being unsure of the amounts received. The resident's family discovered the financial discrepancies and reported them to the facility. The staff member involved acknowledged selling items to the resident and admitted to not knowing the actual value of the items sold. The staff member also stated they were unaware of the resident's vulnerable status due to dementia. The facility's review of the incident confirmed the misappropriation of funds from the resident's account.
Failure to Update Care Plan for Urinary Incontinence Preferences
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect a resident's current needs and preferences regarding urinary incontinence care. According to the facility's policy, care plans should be periodically reviewed and updated by a team of qualified persons as the resident's condition changes or based on clinical judgment and resident needs. Record review showed that the resident, who has benign prostatic hyperplasia with lower urinary tract symptoms and intact cognition, expressed concerns that staff did not assist him regularly with urinary incontinence care during the evening and night. He specifically requested assistance at least every 3-4 hours and as needed. Documentation for the resident indicated check and change times at 11:00 p.m., 2:00 a.m., and 4:00 a.m., but the current care plan only stated that staff should provide extensive assist with incontinence care upon demand, not disturb at night, and change at night upon request. The care plan did not reflect the resident's stated preferences for urinary incontinence care. Two administrative nurses confirmed that staff failed to update and individualize the care plan to address the resident's current needs and preferences.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
Nursing staff failed to follow professional standards of practice during medication administration for two residents. In one instance, a nurse prepared a medication card labeled Metoprolol Succinate ER 50 mg for a resident, while the Medication Administration Record (MAR) listed Metoprolol Tartrate 50 mg. The nurse identified the discrepancy between the medication card and the MAR at the time of administration, did not administer the medication, and stated she would follow up on the issue. Upon further review, the nurse confirmed that although the resident had been receiving the correct medication and dose, the order was not clarified when written and was incorrectly transcribed as tartrate instead of succinate on the MAR. In another instance, a nurse prepared an insulin pen for a different resident and was observed holding the pen horizontally instead of upright while priming it, contrary to the manufacturer's instructions. Administrative staff confirmed that nursing staff are expected to clarify medication orders when discrepancies arise. These actions demonstrate a failure to clarify, accurately transcribe, and reconcile new physician's orders, as well as a failure to follow proper technique for insulin administration.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to assess a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for past traumas and to identify known triggers, as required by facility policy. Record review showed that the resident had a documented history of physical and sexual abuse and neglect, as noted in a psychiatry note. Although the care plan referenced mood alterations and PTSD, it only included general observations for changes in psychosocial or mood state and did not document an assessment of past traumas, identification of potential triggers, or the development of a trauma-specific care plan. An administrative nurse confirmed that staff did not complete a trauma assessment, identify triggers, or create a trauma care plan for the resident.
Failure to Maintain Sanitary Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions in the kitchen used for all residents, staff, and visitors. During an observation of the main kitchen, it was found that several food items in the walk-in freezer, including spaetzeles, corn, pre-cooked sausage crumbles, and meat patties, were not labeled or dated. Additionally, the meat patties had a manufacturer's use-by date that had already passed. In the walk-in cooler, a container of sliced banana bread was also found without a label or date. Furthermore, leftover homemade soup was stored in styrofoam cups in an upright freezer without proper labeling. The facility's policy requires that all foods not stored in their original packaging must be labeled with contents and dated. However, the staff failed to adhere to this policy. Additionally, the cooling process for leftover soup was not conducted according to professional standards. The soup was removed from the steam table at a high temperature and placed in the cooler without further temperature checks to ensure safe cooling. An administrative dietary staff member confirmed that the staff did not obtain food temperatures to ensure safe cooling, which is a critical step to prevent microbial growth and potential foodborne illness.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carrington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Home Of The Good Shepherd | 19.3 mi | ★★★★★ | 3 | 0 |
| Smp Health - St Aloisius | 39.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.