Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Age Operations during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Alzheimer's Disease eloped from the facility and was found alone outside near a main road during inclement weather. The facility did not identify or address the resident's elopement risk, and staff were unaware of the resident's absence until notified by a passerby. This failure to monitor and protect the resident resulted in neglect.
A resident with severe cognitive impairment and multiple medical conditions was able to leave the facility unsupervised and was found outside near a main road in his wheelchair during inclement weather. Staff were unaware of the resident's absence until notified by a passerby, and the resident was brought back inside without injury. The incident was cited as a failure to provide adequate supervision to prevent accidents.
Two residents did not have comprehensive care plans addressing their specific medical needs. One resident with respiratory failure and an order for oxygen therapy lacked a care plan for oxygen use and monitoring. Another resident who returned from the hospital after a toe amputation did not have a care plan for surgical site care. Staff confirmed these omissions and cited issues with remote care plan updates and staff availability.
A nurse failed to follow proper wound care protocols during a pressure ulcer dressing change for a resident with multiple medical conditions. The nurse applied ointment directly from the tube to the wounds, placed the tube on bed linens and in her pocket, and did not use a barrier as required by facility policy. After the procedure, the nurse removed gloves and left the room without immediately washing hands, increasing the risk of cross-contamination. Staff interviews confirmed that these actions did not meet infection control standards.
Two residents with respiratory and cardiac conditions did not receive oxygen at the flow rates ordered by their physicians. Observations found one resident receiving a higher flow rate and another a lower flow rate than prescribed. Nursing staff confirmed the discrepancies and adjusted the oxygen settings after discovery. The DON acknowledged that oxygen should be administered according to physician orders.
A registered nurse failed to follow infection control protocols by not sanitizing hands or wearing gloves while removing and applying a transdermal medication patch for a resident. The nurse handled the patch with bare hands and did not perform hand hygiene before or after the procedure, contrary to facility policy. The DON confirmed that proper hand hygiene and glove use are required for such medication administration.
A resident did not receive timely medication administration as required by the facility's policy. The resident's 8:00 AM medications were given at 10:15 AM, outside the allowed time frame. The RN responsible was still in training and admitted to frequent delays. The DON was unaware of the issue.
A resident with moderate cognitive impairment sustained a head laceration after being transferred by a single CNA using a mechanical lift, contrary to facility policy requiring two staff members. The CNA did not wait for assistance due to a busy morning, leading to the resident sliding out of the lift and falling.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and severe cognitive impairment successfully eloped from the facility. The resident, who was mobile with a device and had diagnoses including Alzheimer's Disease, hyperlipidemia, hypertension, and atherosclerotic heart disease, was admitted with a BIMS score of 6 out of 15, indicating severe cognitive impairment. The resident's Elopement Risk Assessment on admission noted cognitive impairment and wandering behaviors, but did not indicate a risk for elopement, and the Baseline Care Plan did not document a history of wandering or elopement. The incident was discovered when a passerby observed the resident alone outside in a wheelchair, in a grassy area near a main road, during rainy weather. The passerby contacted the facility, and staff were alerted to the resident's absence. A housekeeper on break noticed the resident in a ditch and called for help, at which point a CNA assisted in returning the resident to the facility. The facility was unaware of the resident's absence until notified by the passerby, and staff interviews confirmed that the resident was alone outside and unaccounted for until this external notification. The facility's policy on abuse, neglect, and exploitation requires protection of residents' health, welfare, and rights, including the identification, assessment, care planning, and monitoring of residents with behaviors that might lead to neglect. In this case, the failure to identify and address the resident's risk for elopement, combined with a lack of monitoring, resulted in the resident leaving the facility unsupervised and being exposed to potential harm.
Failure to Prevent Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's Disease, was able to leave the facility unsupervised. The resident, who was awaiting discharge and had a BIMS score indicating severe cognitive impairment, was found outside the facility in his wheelchair, in a grassy area near a main road, during rainy weather. The incident was captured on video by a passerby and posted to social media, and the facility was first alerted to the resident's absence by a phone call from the passerby. Review of the resident's records showed that, although he was assessed as cognitively impaired with decreased safety awareness and disturbances in judgment, his elopement risk assessment did not indicate a risk for elopement, and his baseline care plan did not document a history of wandering or elopement. The care plan did note the need to evaluate for unsteady gait and maintain a safe environment. Staff interviews revealed that the resident was discovered outside by a housekeeper on break, who then called for help. A CNA responded and, along with the housekeeper, brought the resident back inside. The facility did not know the resident was missing until notified by the passerby. Interviews with facility staff, including the DON, BOM, and Administrator, confirmed that the resident was outside unsupervised and that staff were unaware of his absence until external notification. The resident was assessed after being brought back inside and was found to have no injuries. The deficiency was cited under F689 for failure to provide adequate supervision to prevent accidents, resulting in a successful elopement.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two of three residents reviewed, as required by facility policy. For one resident with diagnoses including acute respiratory failure with hypoxia, hydrocephalus, and mild cognitive impairment, there was a physician order for continuous oxygen therapy to maintain oxygen saturation above 90%. However, the resident's care plan did not address respiratory concerns, the use of oxygen, or monitoring of oxygen saturation. Staff interviews confirmed that the care plan lacked these elements and that care plans are updated remotely by corporate MDS staff. For another resident with Type 2 Diabetes Mellitus, dementia, emphysema, and abnormal gait, who had recently returned from the hospital after a left great toe amputation, there was no care plan addressing the surgical site. Progress notes documented the amputation and the need for specific wound care, but staff confirmed that no care plan was in place for the amputation. The absence of a care plan was attributed to the MDS nurse not being present at the time of the resident's hospital stay and return.
Improper Pressure Ulcer Dressing Change and Cross-Contamination Risk
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow proper standards of practice during a pressure ulcer dressing change for a resident with a history of acute respiratory failure, hydrocephalus, and mild cognitive impairment. The RN entered the resident's room, sanitized her hands, and donned gloves before applying ointment directly from the tube to both buttocks wounds using her gloved hands. The RN then placed the ointment tube on the bed linens and later in her pocket, actions which were not in accordance with the facility's policy requiring a clean field and the use of barriers to prevent cross-contamination. After completing the dressing change, the RN removed her gloves, exited the room while holding a cup and the dirty gloves, discarded the gloves in the dining room trash, and delivered the cup to the kitchen before returning to the resident's room to wash her hands. Interviews with staff confirmed that the ointment tube was not handled in a sanitary manner and that a barrier should have been used. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) both acknowledged that the nurse should have used a barrier for the ointment and sanitized or washed her hands before leaving the resident's room. The facility's policy specifically required the use of a clean field and no-touch techniques to minimize infection risk, which were not followed during this observed dressing change.
Failure to Administer Oxygen at Ordered Flow Rates
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards by not ensuring that two residents received oxygen at the flow rates specified in their physician orders. For one resident with multiple cardiac and respiratory diagnoses, including heart failure, asthma, and acute ischemic heart disease, the physician ordered oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 90%. However, observations revealed the oxygen concentrator was set at 2.5 liters per minute on two separate occasions. A registered nurse confirmed the discrepancy and adjusted the flow rate to the correct setting. For another resident with acute respiratory failure and mild cognitive impairment, the physician ordered oxygen at 2 liters per minute via nasal cannula to keep oxygen saturation above 90%. Observations showed the oxygen concentrator was set at 1.5 liters per minute during two checks. The registered nurse acknowledged the incorrect setting and adjusted it accordingly. The Director of Nursing confirmed that staff are expected to follow physician orders for oxygen administration and that deviations from ordered flow rates are a concern.
Failure to Follow Hand Hygiene and Glove Use During Transdermal Patch Administration
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow proper infection prevention and control protocols during the administration of a transdermal medication patch for a resident. According to facility policy, staff are required to wash their hands prior to administering medication, avoid touching medication with bare hands, and wash hands again after administration. During an observed medication pass, the RN sanitized her hands before entering the resident's room and administered oral medications. However, she removed the old transdermal patch and applied a new one to the resident's arm with bare hands, without washing or sanitizing her hands before or after the procedure, and without wearing gloves as required by policy. The RN later confirmed in an interview that she did not sanitize her hands or wear gloves during the process, citing difficulty in removing the patch with gloves and issues with the new patch sticking to gloves. The Director of Nursing (DON) also stated in an interview that nurses are expected to wash or sanitize their hands before and after medication administration and to wear gloves if required for specific medications. The failure to adhere to these protocols was directly observed and confirmed by staff interviews.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure timely administration of medications for a resident, identified as R6, as observed during a survey. The facility's policy on medication administration requires that medications be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. However, on the morning of June 10, 2024, a surveyor observed that R6 received their 8:00 AM dose of oxybutynin chloride and sennosides-docusate sodium at 10:15 AM, which was outside the allowed time frame. R6 had active orders for these medications to be administered at specific times throughout the day, as documented in their Medication Administration Record (MAR). Interviews conducted during the survey revealed that the Director of Nursing (DON) was unaware of any medications being administered late. Additionally, RN1, who administered the medications to R6, stated that she was still in training and was slower with medication administration, resulting in frequent delays. RN1 admitted to not knowing how many medications were administered late, particularly on the B Hall, where she worked. This deficiency highlights a lapse in adhering to the facility's medication administration policy, leading to untimely medication delivery for R6.
Failure to Follow Mechanical Lift Transfer Protocol
Penalty
Summary
The facility failed to ensure that two staff members assisted with a mechanical lift transfer for a resident, resulting in the resident sustaining a laceration to the back of their head. The facility's policy, titled Safe Resident Handling/Transfers, mandates that two staff members must be utilized when transferring residents with a mechanical lift. However, during an incident, only one staff member was present, leading to the resident falling and hitting their head on the floor. The resident involved had a medical history that included neurocognitive disorder with Lewy bodies, chronic embolism and thrombosis, and other conditions, and was dependent on staff for transfers. On the day of the incident, the resident attempted to be transferred from the bed to a wheelchair by a single CNA, who acknowledged that she did not wait for assistance due to a busy morning. The resident held the bar of the mechanical lift instead of crossing their arms, causing them to slide out of the lift and fall, resulting in a head injury.
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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 Inman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inman Healthcare | 0.3 mi | ★★★★★ | 0 | 0 |
| Lake Emory Post Acute Care | 1.1 mi | ★★★★★ | 3 | 0 |
| Magnolia Manor - Inman | 1.1 mi | ★★★★★ | 3 | 0 |
| Rosecrest Rehabilitation And Healthcare Center | 4 mi | ★★★★★ | 0 | 0 |
| Valley Falls Terrace | 7.2 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.