Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Villa during CMS and state inspections, most recent first.
Facility Assessment was incomplete because it did not include resident acuity, diseases, conditions, physical or behavioral health needs, cognitive status, or special treatments and conditions. It also did not list the number of nurse aides needed for the day, evening, and night shifts. The Administrator stated the acuity information and CNA staffing numbers had been overlooked and that the assessment was meant to guide staffing based on resident need.
A resident with dementia, CAD, and CKD had a physician order for a urinalysis with C&S, but the facility could not find any lab results or documentation that the test was completed. The DON said he was responsible for follow-through but was unaware of the order, and the Administrator said there was no record beyond the order itself. The facility policy stated staff process lab requisitions and a nurse reviews all results.
Improper Frozen Food Storage in Walk-In Freezer: The walk-in freezer had ice buildup on the ceiling, bags of food with thick frost that were stuck together and could not be checked for dates or labels, and stacks of boxes and a cart blocking access to the shelves. A Dietary Aide said the freezer had problems for years and the food could not be assessed for freezer burn or spoilage, while the Dietary Mgr said the freezer was a disaster and that staff had only been adding food to it.
A resident with heart failure, heart disease, and hypertension was ordered carvedilol twice daily with specific BP and HR hold parameters and daily vital sign monitoring. The care plan required checking and documenting BP per MD order and holding the medication if values were below set parameters. Review of the MAR showed no BP or HR documentation for the evening carvedilol dose over an extended period, and the MAR lacked a designated area to record these vital signs for the second daily dose. The DON confirmed that untimed vital signs in nurses’ notes could not be linked to the medication administration, and a medication aide reported that although she checked BP and pulse before giving the evening dose, there was no place on the MAR to record them, resulting in incomplete clinical records contrary to facility policy.
A resident with severe cognitive impairment and dependence on staff for ADLs experienced a delay in incontinent care after a bowel movement, despite a care plan requiring assistance with toileting and hygiene every two hours and as needed. The resident was observed sitting in a wheelchair with stool-stained clothing and a noticeable odor, while a hospitality aide reported having notified a CNA about the need for changing approximately an hour earlier. The CNA went on break without informing an LVN of the resident’s need for care, and leadership later confirmed their expectation that incontinent care be completed before breaks and provided promptly, consistent with facility policy requiring necessary services to maintain grooming and personal hygiene.
The facility failed to ensure that nurse aides working more than four months were properly trained, competent, and certified within the required four-month timeframe. Two nurse aides were hired and worked full-time providing resident care, including incontinence care and bathing, before timely completion of the LTCR Nurse Aide Training and Competency Evaluation Program and without having taken or scheduled the CNA exam. The DON, Administrative Assistant, and Administrator each gave differing and incorrect timeframes for when aides must be certified, and the Administrative Assistant, who shared responsibility for tracking certification with the staffing coordinator, was unsure of the actual requirements. These practices conflicted with the facility’s written policy that prohibits using an aide for more than four months unless the aide has completed an approved training and competency evaluation program or has been deemed competent under federal regulations.
A resident with dementia and mobility issues was found to have a raised toilet seat missing an anti-slip rubber foot, causing instability. Staff interviews revealed there was no specific schedule or policy for checking the safety and function of equipment, and the issue had not been reported or documented.
A staff member was observed vaping between the nurse's station and a resident sitting area while residents were present, in violation of the facility's non-smoking policy. Interviews with staff and residents confirmed that the facility prohibits smoking and vaping inside, and that staff are only allowed to smoke in a designated outdoor area. The incident was directly observed by a surveyor, and the staff member involved denied remembering the event but acknowledged using vapes and cigarettes.
Staff, including LVNs and a medication aide, were found to have pre-popped medications from blister packs and placed them in cups labeled with resident names or left unlabeled, storing them in medication carts or leaving them in resident rooms. These actions were contrary to facility policy, which requires medications to be administered directly to residents without pre-preparation or unattended storage.
The facility failed to properly label and date food items in storage, did not ensure all staff wore required hair restraints while in the kitchen, and did not maintain cleanliness of kitchen equipment and surfaces. Observations revealed unmarked food in the cooler and freezer, staff entering the kitchen without hairnets or beard guards, and significant grease buildup on cooking equipment, with cleaning schedules not being followed or documented.
Multiple residents reported that meals were bland, repetitive, overcooked, and not served according to their preferences, with observations confirming issues such as mushy vegetables and soggy breading. Residents with various medical conditions, including cognitive impairment and malnutrition, expressed dissatisfaction with food quality and variety, and documentation showed ongoing complaints over several months. The Dietary Manager acknowledged the problems and lack of a food palatability policy, while meal observations by surveyors confirmed the deficiencies.
Two residents were placed at risk when one was found with a prohibited antimicrobial skin cleanser in her room, and another was transferred using a mechanical lift with the legs in the narrow position, contrary to facility policy and FDA best practices. Staff interviews revealed a lack of awareness regarding the proper procedures for both chemical storage and safe resident transfers.
Three residents requiring respiratory care did not have their oxygen cannulas or nebulizer masks properly covered when not in use, contrary to facility policy and professional standards. Two residents' nasal cannulas were left uncovered on oxygen concentrators, and another resident's nebulizer mask was left uncovered on a nightstand. Staff interviews confirmed responsibility for covering equipment and acknowledged infection control concerns.
A CNA failed to change gloves and perform hand hygiene during incontinent care for a resident with severe cognitive impairment and multiple chronic conditions. The CNA used the same gloved hands to handle both soiled and clean items, including the resident's clothing, bedding, and bed remote, contrary to facility policy and infection control standards. Staff interviews and policy review confirmed that proper procedures were not followed, resulting in a breach of infection prevention protocols.
A resident with severe cognitive impairment and chronic pain experienced pain after an LVN yanked her left arm during care, as witnessed by another resident. The resident reported the LVN was mean and abusive, and the incident was documented in facility records. Staff interviews provided conflicting accounts, but the facility's abuse prevention policy was not upheld in this instance.
A resident with a history of wandering was found outside the facility unsupervised, despite having a wander guard. The facility failed to investigate multiple elopements, did not document incidents, and did not notify the family or physician. Faulty alarm systems and inadequate staff response contributed to the deficiency, leading to an Immediate Jeopardy situation.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting two residents. A resident with severe cognitive impairment reported seeing roaches in her living area, while another resident with moderate cognitive impairment found roaches in his clothing. Staff interviews revealed inadequate communication and housekeeping practices, contributing to the problem. The facility's pest control measures, including monthly exterminator visits, were insufficient to address the infestation.
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks in their care. Errors included incorrect weight coding, missing documentation of wounds and treatments, and unrecorded diagnoses of anxiety, depression, and medication use. Interviews with staff emphasized the importance of accurate MDS coding for individualized care plans and appropriate staffing.
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. This included unaddressed weight loss, wound care, and medication management for residents with significant health issues.
The facility failed to provide palatable, attractive, and safe food for seven residents, leading to complaints about the taste, lack of seasoning, and improper cooking. Despite measures to address meal preferences, residents continued to express dissatisfaction with the food quality.
The facility failed to maintain an infection prevention and control program, leading to multiple deficiencies in catheter and incontinent care. Staff did not change gloves or sanitize hands appropriately, risking the spread of infections among residents with severe medical conditions.
The facility failed to provide a homelike environment by not replacing missing slats from a resident's window blinds, causing discomfort and difficulty napping. Despite repeated requests, the issue remained unresolved for months, and the maintenance log did not list the room as needing repairs.
The facility failed to update the care plans for two residents to reflect their current medication regimens, leading to potential risks in their care. One resident's care plan incorrectly listed Eliquis instead of Aspirin, and another resident's care plan was not updated to show the discontinuation of Eliquis.
A facility failed to ensure a safe transfer for a resident with severe cognitive impairment and physical limitations. Staff members did not use a gait belt as required by policy, instead lifting the resident under her arms, which could cause harm. The DON and ADM were unaware of this practice, and staff competencies lacked proper training for two-person transfers.
A resident with anxiety, depression, and dementia was prescribed Duloxetine and Lorazepam without adequate behavior and side effect monitoring. The facility's DON and ADM acknowledged the oversight, emphasizing the importance of monitoring due to potential major side effects in the elderly. The facility's policy mandates ongoing documentation and monitoring, which was not followed in this case.
Facility Assessment Missing Resident Acuity and Staffing Details
Penalty
Summary
The facility failed to ensure its Facility Assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility. Record review of the Facility Assessment dated [DATE] showed that the Resident Acuity section did not outline the acuity of the resident population, and the Special Treatments and Conditions section did not include information concerning the resident population. The assessment also did not identify the number of nurse aides needed for the day, evening, and night shifts in the Staff Planning section under Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies. During interview, the Administrator stated he must have overlooked adding the resident acuity information and the number of nurse aides needed to provide care. He stated the Facility Assessment was intended to summarize the types of residents cared for and provide a base for how many staff were needed for different levels of acuity, and that it was a guide for staffing nurses and CNAs on each shift.
Failure to Obtain Ordered Urinalysis and Culture
Penalty
Summary
The facility failed to obtain a urinalysis with culture and sensitivity for a resident who had an order for the test entered on 12/18/25. The resident was an elderly female with diagnoses including dementia, coronary artery disease, and chronic kidney disease. Her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment, and she required supervision or touching assistance with ADLs. Her care plan, last revised on 04/13/26, noted fatigue, weakness, and confusion related to anemia and included an intervention to obtain lab reports and report them to the physician as ordered. Record review on 05/09/26 showed no lab results for the ordered urinalysis with culture and sensitivity. During interview, the DON stated he was responsible for making sure urinalysis and lab work were followed through with, but he was not aware the resident had an order and was not sure why it had not been done. The Administrator stated the facility could not find the urinalysis results and could not determine whether the resident had refused or what had happened, noting there was no documentation except the order. The facility policy stated the physician orders diagnostic and lab testing, staff process test requisitions and arrange for tests, and a nurse reviews all results.
Improper Frozen Food Storage in Walk-In Freezer
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. During observation in the walk-in freezer, there was a thin ice buildup on the ceiling, and bags of food on the left top shelf had thick frost buildup and were stuck together into one lump, preventing staff from pulling them apart to check dates or labels. In the center of the freezer, three stacks of boxes approximately 5 to 6 feet high were placed on top of plastic milk crates, along with a cart holding boxes, and these items blocked access to the freezer shelves. During interviews, a Dietary Aide said the freezer had problems for years and that one person could not clean it by themselves; she also stated the food on the shelves was covered with frost, frozen together, and could not be checked for dates, and she could not tell whether the food was bad or good. The Dietary Manager said the freezer was a disaster, that they had only been adding food to it, and that she was aware of the frost buildup and the inability to pull the bags apart to check for dates or labels. The DON and Administrator both stated that food should be rotated, unpacked, labeled, stored in the right order, and kept accessible, and the Administrator said there should not be any boxes in the freezer and expected it to be defrosted.
Incomplete Documentation of Vital Signs for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident receiving antihypertensive medication with specific vital sign parameters. The resident, an older adult with diagnoses including heart failure, heart disease, and hypertension, had an admission MDS showing a BIMS score of 9, indicating moderate cognitive impairment, and required substantial staff assistance for most ADLs. The resident’s care plan identified hypertension with associated risks and included interventions to administer antihypertensive medications as ordered, check and document blood pressure per MD order, and hold medication and notify the MD per facility protocol if blood pressure was below ordered parameters. Physician orders and the Nursing MAR for the month showed an order for carvedilol 3.125 mg by mouth every 12 hours at 8 AM and 8 PM, with instructions to hold the medication for systolic blood pressure less than 105, diastolic blood pressure less than 60, and heart rate less than 60, and to monitor vital signs daily. However, review of the MAR from 3/01/26 through 3/19/26 revealed no documentation of blood pressure or heart rate for the 8 PM carvedilol dose. The DON acknowledged that there was no place on the MAR to document a second set of vital signs for the 8 PM dose and that, although some vital signs appeared in nurses’ notes, they were not timed, so it was not possible to determine their relationship to the medication administration. A medication aide who typically worked the 2 PM to 10 PM shift stated that when administering medications with blood pressure and pulse parameters, she documented those vital signs on the MAR and that, if a medication was ordered more than once daily, there should be a place to document vital signs with each administration. She confirmed that there was no place on this resident’s MAR to document blood pressure or pulse for the 8 PM carvedilol dose, even though she reported checking them before administration. She further stated that if blood pressure and pulse were not documented, it was as if they were not checked, and there would be no way to tell if the medication was given within the physician’s parameters. The facility’s medication administration policy required medications to be administered as prescribed and for vital signs to be checked and verified, if necessary, prior to administration, underscoring the incomplete documentation for this resident’s evening carvedilol doses.
Failure to Provide Timely Incontinent and ADL Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and assistance with activities of daily living (ADLs) to a dependent resident. The resident was an elderly female with Alzheimer’s disease, dementia, and anxiety disorder, with a Comprehensive MDS showing a severely impaired BIMS score of 5 and a need for substantial/maximal assistance with toileting, dressing, and personal hygiene. Her care plan required assistance from one staff member for toileting every two hours and as needed, with incontinent care after each episode. On the cited date, surveyors observed the resident sitting in her wheelchair with pajama pants stained brown from the crotch area and a noticeable stool odor; she was fidgeting and trying to grab clean clothes from her bed, and her verbalizations were incomprehensible. A hospitality aide present in the room stated the resident had a bowel movement and that she had informed a nursing assistant about an hour earlier that the resident needed to be changed. Further interviews revealed that the nursing assistant who had been caring for the resident was on break and had not informed the LVN that the resident required incontinent care before leaving. The LVN stated that the nursing assistant should have reported the need for care so that the LVN or another CNA could provide it, and acknowledged that residents not being provided incontinent care promptly could result in skin breakdown. The DON and the Administrator both stated their expectation that resident care, including incontinent care, be provided before staff go on break and that such care be provided promptly, with managers responsible for oversight. The facility’s policy on quality of life and ADL care for dependent residents required that residents unable to carry out ADLs receive necessary services to maintain grooming and personal hygiene. The resident’s family member also reported that they often observed the resident’s clothing soaked in urine, indicating ongoing concerns with timely incontinent care.
Failure to Ensure Nurse Aides Met Training and Certification Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides working more than four months were trained, competent, and certified within the required four-month timeframe, as required by OBRA and the facility’s own policy. Record review showed that NA D was hired on 01/03/2024 and completed the LTCR Nurse Aide Training and Competency Evaluation Program on 12/31/2024, indicating she worked full-time providing resident care such as incontinence care and bathing before timely completion of the program. NA B was hired on 11/12/2024 and completed the same training program on 02/16/2025, also working full-time and providing similar resident care during this period. Both aides reported they had not tested to become CNAs and did not have test dates scheduled. Interviews with facility leadership revealed confusion and incorrect understanding of the required certification timeframe. The DON stated that nurse aides had up to one year to get certified, while the Administrator stated that nurse aides had two years from completion of skills training to become certified. The Administrative Assistant, who along with the staffing coordinator was responsible for ensuring aides were certified within required timeframes, reported uncertainty about what those timeframes were and noted that the facility had been without a staffing coordinator until the day of the interview. These actions and inactions occurred despite a written facility policy stating that no individual would be used as a nurse aide for more than four months unless competent and having completed an approved training and competency evaluation program, or otherwise deemed competent under the federal requirements.
Failure to Maintain Safe Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition for one resident who used a raised toilet seat. Observation revealed that the raised toilet seat was missing an anti-slip rubber foot on one of its legs, causing the seat to rock when weight was applied. The resident, who had dementia, COPD, anxiety, and moderate cognitive impairment, required supervision for transfers and used a walker as her primary mode of mobility. The care plan identified her as being at risk for falls and included the use of a raised toilet seat as an intervention. Interviews with facility staff indicated there was no specific schedule for checking equipment for function and safety. The maintenance director relied on staff to report broken equipment via clipboards and checked these twice daily, but there was no record of the missing anti-slip foot. The DON stated that the maintenance director was responsible for monthly equipment checks and completing work orders, but the administrator confirmed there was no policy regarding the functioning of essential equipment.
Staff Member Vaped Indoors in Violation of Facility Non-Smoking Policy
Penalty
Summary
A staff member was observed vaping inside the facility, specifically between the nurse's station and the resident sitting area, while residents were present. The staff member, when questioned, denied remembering the incident but acknowledged using vapes and cigarettes, and stated that staff were not allowed to vape inside the facility. Multiple interviews with other staff members, including CNAs, LVNs, the DON, and the Regional Nurse, confirmed that the facility is a non-smoking environment and that staff are only permitted to smoke in a designated area outside the building. The facility's policy explicitly prohibits smoking, including electronic cigarette products, inside the building for both residents and visitors. Despite the facility's non-smoking policy, the incident of vaping occurred in a common area, exposing residents and staff to vape fumes. Interviews with residents and staff indicated no prior issues with vaping inside the facility, and staff expressed varying levels of awareness regarding the risks associated with vaping indoors. The event was directly observed by a surveyor, and the staff member involved was identified and questioned about the incident.
Improper Pre-Popping and Storage of Medications by Staff
Penalty
Summary
The facility failed to ensure proper pharmaceutical services were provided, specifically in the dispensing and administration of medications by staff. Multiple instances were observed where medications were pre-popped from blister packs and placed into medication cups, which were then either left unattended in resident rooms or stored in medication carts prior to administration. On one occasion, five clear medication cups containing different residents' medications were found in a resident's room, with the medications intended for administration but apparently forgotten. Further observations revealed that staff, including LVNs and a medication aide, had pre-popped medications for multiple residents and stored them in labeled or unlabeled cups within medication carts. One LVN had 15 cups with different resident names and medications, while another had two cups with resident names written on the bottom. The medication aide had three cups with medications but no resident names. Staff members acknowledged during interviews that they were aware pre-popping medications was not permitted and that medications should not be dispensed prior to the time of administration. Record reviews confirmed that the facility's policy required medications to be administered safely and timely, with verification of the right resident, medication, dosage, time, and route before administration. The policy also stated that medications should not be left at the bedside or pre-prepared for later administration. These practices were not followed, as evidenced by the observations and staff admissions.
Failure to Maintain Food Safety Standards in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, as evidenced by multiple observations and interviews. In the walk-in cooler and freezer, numerous food items were found without proper labeling or dating, including foam bowls with unknown contents, plastic containers with unidentified meats, and bags of various unmarked food items. The dietary manager acknowledged that the staff responsible for labeling and dating had been absent, and the replacement staff did not follow proper procedures. The lack of labeling and dating was confirmed by both observation and staff interviews, with the dietary manager stating that undated food could be served past its safe period and that all food should be labeled and dated according to policy. Additionally, the facility did not ensure that all staff entering the kitchen wore appropriate hair restraints. The Activity Director Assistant was observed entering the kitchen without a hairnet while food was being prepared and admitted to doing so daily, unaware of the requirement. Two male dietary aides were also observed assisting with meal service without facial hair coverings, despite having mustaches and chin hair. Both aides stated they did not wear facial hair coverings, with one citing discomfort and the other only wearing a mask when ill. The dietary manager confirmed that all staff, including non-dietary personnel, were expected to wear hairnets and beard guards in the kitchen, and that this had been communicated previously. The facility also failed to maintain cleanliness of kitchen equipment and surfaces. Observations revealed a significant greasy buildup on the oven doors, knobs, backsplash, and the shelf above the stove, with drops of grease hanging over areas where food was being prepared. The cleaning schedule, which required daily and weekly cleaning of kitchen equipment, was posted but showed no documentation of completed cleaning tasks for the observed period. The dietary manager confirmed that all equipment should be cleaned daily and that the lack of cleaning could result in contamination. These failures were corroborated by facility policies and training records, which outlined the requirements for food labeling, staff hygiene, and sanitation practices.
Failure to Provide Palatable and Attractive Food to Residents
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at an appetizing temperature for the majority of residents reviewed. Multiple residents reported that the food was bland, mushy, overcooked, and repetitive, with some stating that their dislikes and preferences were not honored. Observations confirmed that vegetables were often overcooked and watery, and fried foods were tough or soggy. Residents also reported that the same foods, such as chicken, instant mashed potatoes, and green beans, were served repeatedly, and that meal variety and texture were lacking. Resident interviews revealed dissatisfaction with the quality and presentation of meals, with several residents stating that the food was not appealing or fit to eat. Some residents with moderate to severe cognitive impairment, as well as those with diagnoses such as dementia, stroke, heart failure, depression, and malnutrition, expressed that their dietary needs and preferences were not being met. Grievance logs and resident council minutes documented ongoing complaints about food quality, temperature, lack of variety, and failure to honor dislikes, with issues persisting over several months. During meal observations, surveyors and the Dietary Manager noted that food items such as country fried steak and Brussel sprouts were not prepared to an acceptable standard, with soggy breading and mushy vegetables. The Dietary Manager acknowledged awareness of the complaints and agreed with the observations but stated there was no food palatability policy in place. Despite in-service education and discussions with dietary staff, the issues with food quality and resident satisfaction remained unresolved at the time of the survey.
Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents. In the first instance, a resident with moderate cognitive impairment and a diagnosis of dementia was found to have an antimicrobial antiseptic skin cleanser in her room on two separate observations. The resident was unaware of who placed the bottle in her room or its intended use. Interviews with staff, including an LVN, the Director of Nurses, and the Administrator, confirmed that such items are prohibited in resident rooms due to the risk of harm, especially for residents with cognitive impairment. Despite this, the item remained in the resident's room, and facility policies provided did not specifically address the prohibition of such chemicals in resident rooms. In the second instance, a resident with severe cognitive impairment, hemiplegia, and a history of falls required two-person assistance with mechanical lift transfers. During an observed transfer, CNA B and CNA C did not maintain the mechanical lift legs in the wide position while moving the resident from his wheelchair to the bed. CNA B was unsure of the purpose of spreading the lift legs and routinely moved the resident with the lift legs in the narrow position. CNA C and the DON both stated that the lift legs should be in the wide position for stability and safety, as per facility policy and FDA best practices. The Administrator also confirmed that the staff did not follow the correct procedure, which could have compromised the resident's safety. Record reviews showed that CNA B had previously demonstrated satisfactory performance in mechanical lift procedures, which included keeping the lift legs in the wide position during transfers. Facility policy and FDA guidance both require the lift base to be at its maximum open position to ensure stability and prevent accidents. Despite this, the observed transfer did not adhere to these protocols, and the staff involved were not fully aware of the safety rationale behind the procedure.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required such care, as evidenced by observations, interviews, and record reviews. Specifically, two residents who used oxygen concentrators did not have their nasal cannula tubing covered with a bag when not in use, and one resident's nebulizer face mask was left uncovered on a nightstand. These actions were inconsistent with professional standards of practice, the residents' care plans, and the facility's own policy on oxygen administration. For the two residents with oxygen concentrators, both had physician orders for oxygen therapy and required maximal assistance with activities of daily living. During observations, their nasal cannulas were found uncovered and, in one case, nearly touching the floor. Both residents were cognitively impaired and typically wore oxygen, but the unused cannulas on their concentrators were not protected as required. The third resident, who was cognitively intact and required supervision with activities of daily living, had a nebulizer and mask sitting on her nightstand without a protective bag. Staff interviews confirmed that nurses and aides were responsible for ensuring respiratory equipment was covered when not in use, and acknowledged that failure to do so could lead to infection control issues. The facility's policy required safe handling and storage of respiratory equipment, but this was not followed in these instances.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices during incontinent care for a resident with severe cognitive impairment, multiple chronic conditions, and total incontinence. The CNA, after performing perineal care, did not change gloves or perform hand hygiene before handling clean items such as the resident's clothing, clean brief, clean incontinent pad, bedding, and bed remote. This sequence of actions was observed directly and confirmed through interviews with staff, who acknowledged that the CNA did not adhere to established protocols for glove use and hand hygiene. The resident involved was an elderly individual with diagnoses including dementia, heart disease, diabetes, hemiplegia, and cerebrovascular disease, and was always incontinent of urine and bowel. The care plan identified a risk for skin breakdown due to incontinence. During the observed care episode, the CNA used the same gloved hands that had been in contact with soiled areas to touch the resident's shoulder, hip, clothing, bedding, and other clean items, and also failed to perform hand hygiene after removing soiled gloves and before donning new ones. Interviews with another CNA, the Director of Nursing (DON), and the Administrator confirmed that the expected practice was to change gloves and perform hand hygiene when moving from a dirty to a clean area, and before handling clean items. Facility policies reviewed also required hand hygiene and glove changes at appropriate points during resident care. The CNA's failure to follow these procedures was acknowledged by the staff involved and was documented as not meeting the facility's infection control standards.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when a licensed vocational nurse (LVN) yanked the resident's left arm during care. The resident, an elderly female with diagnoses including parkinsonism, dementia with severe cognitive impairment, osteoarthritis, and chronic pain, required maximal assistance with activities of daily living. The incident was reported to have caused pain in the resident's left arm, which was already affected by chronic conditions, and was witnessed by another resident who described the action as abusive. Interviews and record reviews confirmed that the resident expressed feeling hurt and described the LVN as being mean and abusive, specifically mentioning repeated yanking of her left arm. The witness corroborated the account, stating that the LVN yanked the resident's arm in an abusive manner while administering pain medication. The resident reported ongoing pain in her arm following the incident, although she acknowledged pre-existing pain in that area. The facility's documentation included an incident report and a subsequent x-ray, which did not reveal acute injury but did confirm severe osteoarthritis in the affected shoulder. Staff interviews revealed differing perspectives on the incident, with the LVN denying any intent to harm and stating she was careful due to the resident's known pain. Facility leadership acknowledged the resident's sensitivity to her shoulder and noted that the witness supported the resident's account. The facility's abuse prevention policy requires protection of residents from all forms of abuse, but the actions described in the report indicate a failure to uphold this standard for the resident involved.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a history of wandering. The resident, who was severely cognitively impaired and required supervision for various activities, was found approximately 50 feet away from the facility entrance around 4:00 AM. Despite having a wander guard and being identified as an elopement risk, the facility did not prevent the resident from leaving unsupervised. The facility did not investigate the resident's three separate elopements that occurred over several months. There was no documentation of these incidents in the resident's chart, nor were the family or physician notified. Staff interviews revealed that the resident had been found outside the facility on multiple occasions, yet these incidents were not properly reported or documented. The facility's alarm systems were found to be faulty, with issues in the wander guard system and door alarms that could turn off prematurely. Despite these problems, the facility did not take appropriate actions to address the risks, and staff failed to follow protocols for documenting and reporting elopements. This lack of action and oversight led to the identification of an Immediate Jeopardy situation.
Removal Plan
- Regional Nurse provided in-service training to Administrator on identifying an elopement, the importance of training staff to document any elopements, notifications required when elopements occur, the importance of facility investigating each elopement and placing intervention to prevent reoccurrence, the importance of facility elopement screening and assessments being completed accurately to determine wanderguard placement or potential secure unit placement, how to report an elopement to HHSC.
- In-services to all staff were initiated. Training will be conducted by administrator, ADONS, and Regional nurses. Topics covered include facility revised elopement policy. Policy addresses required assessments, documentation to complete, and notifications employees should contact.
- All in servicing will be completed. No employee will be allowed to work until in servicing is completed.
- Elopement policy will be included in new hire training packets.
- All resident's elopement screens and care plans were updated to ensure accuracy. Facility will follow elopement screen assessment guidelines for identifying level of risk. Facility screening tool provides a risk level numerical value based on key questions. All high-risk residents will be placed on Wander guard System. Audit and updates were completed by unit managers and ADONS.
- All residents that are on wanderguard will be identified in a binder at the nurse's station, with resident demographics (face sheet) to identify each. Completed by Unit managers and ADONS.
- Resident #1 was assigned a designated sitter until secure unit placement can be arranged.
- Facility adopted a new Elopement policy. The updated policy clearly defines steps for employees to take during an elopement. The new policy directs staff on necessary notifications to make, and all documents to complete. Incident reports and medical record entry are covered as well.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the environment of two residents. Resident #1, a female with severe cognitive impairment and multiple health issues, reported seeing roaches in her bathroom and around her living area. Her roommate corroborated these sightings, noting frequent bug activity in their shared space. Similarly, Resident #2, a male with moderate cognitive impairment, expressed concerns about roaches in his clothing and room. Observations confirmed the presence of roaches in Resident #2's room, with numerous insects seen on the sink and walls. Interviews with staff revealed systemic issues in pest control management. CNA KKK, who had been with the facility for three months, noted occasional roach sightings and attributed some of the problem to inadequate housekeeping practices. The Maintenance Supervisor acknowledged receiving verbal reports of roaches but did not consistently communicate these issues to the Administrator. The Director of Housekeeping admitted to seeing roaches in various facility areas and relied on verbal communication with the Maintenance Supervisor rather than maintaining a log of sightings. The lack of a structured deep cleaning schedule further contributed to the problem. The facility's pest control measures were insufficient, as evidenced by the exterminator's monthly visits not addressing the infestation effectively. The exterminator recommended keeping areas clean but did not provide specific instructions for deep cleaning or furniture management. The Administrator was unaware of the roach problem, despite expectations for a clean environment. The facility's policy on pest control, dated 2020, outlined measures to eradicate pests, but these were not effectively implemented, leading to an unsanitary environment for residents.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate MDS assessments for four residents, leading to potential risks in their care and services. For Resident #61, the MDS was inaccurately coded with a weight of 262 pounds, despite a recorded weight of 255.4 pounds. Additionally, the MDS did not reflect the presence of a wound on the resident's left lower extremity, which was being treated as per physician orders. The care plans for Resident #61 also lacked documentation for the wound and weight loss, despite ongoing treatments and observations confirming these conditions. Resident #51's MDS was not coded to include diagnoses of anxiety and depression, despite these conditions being documented in the resident's medical records and care plans. Similarly, Resident #12's MDS did not reflect the use of the antidepressant Duloxetine, which was prescribed and administered regularly as per the physician's orders. The care plan for Resident #12 also failed to mention the use of this medication, despite its documented administration. For Resident #13, the MDS did not include active diagnoses of major depressive disorder and anxiety disorder, even though these conditions were documented in the resident's medical records and care plans. The resident was receiving medications for these conditions, but the MDS only reflected a diagnosis of bipolar disorder. Interviews with the MDS Coordinator, DON, and ADM highlighted the importance of accurate MDS coding for developing individualized care plans and ensuring appropriate staffing and care levels. The facility's policy on MDS accuracy emphasized the need for assessments to accurately reflect residents' statuses, as required by federal regulations.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #61, a 62-year-old male with diagnoses including wound infection, diabetes mellitus, and atrial fibrillation, did not have a care plan for his wound or weight loss despite significant weight reduction and specific wound care orders. Observations confirmed the presence of an open lesion on his left lower extremity, which was not addressed in his care plan. Resident #77, an elderly male with bladder cancer, diabetes mellitus, and obstructive uropathy, experienced weight loss that was not care planned. His quarterly MDS indicated moderate cognitive impairment and a need for supervision with eating, but no interventions were documented to address his weight loss. Similarly, Resident #12, an elderly female with depression and heart failure, had no care plan for her use of an antidepressant and diuretic, despite these medications being prescribed and administered regularly. Resident #30, an elderly female with hypothyroidism and heart failure, also lacked a care plan for her diagnoses and use of a diuretic. Her quarterly MDS indicated severe cognitive impairment and a need for maximal assistance with activities of daily living, yet her care plan did not reflect her medical conditions or medication regimen. Interviews with the MDS Coordinator, DON, and ADM revealed that care plans were not consistently updated or individualized, leading to potential risks for the residents involved.
Failure to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature for seven residents. Multiple residents reported that the food tasted horrible, lacked flavor, and was sometimes improperly cooked. One resident mentioned that the chicken served was raw and bleeding, while another stated that the eggs were overcooked. Several residents expressed that they had to buy their own food due to the poor quality of the meals provided by the facility. The dietary manager acknowledged that the food needed more seasoning and flavoring, and residents had repeatedly requested different salt and seasoning mixes, which had not been provided by the facility. During a test tray sampling, the survey team and dietary manager found that the noodles were sticky and flavorless, the green beans were bland, and the chicken fried steak was soggy, although the gravy had good seasoning. The dietary manager confirmed the lack of seasoning in the food. Residents also reported that the food was often too soft and lacked variety, with some meals being mixed up, such as lunch and dinner. The facility's policies indicated that residents should be provided with nourishing, palatable, and well-balanced meals that meet their daily nutritional and special dietary needs, but these standards were not being met. Interviews with the Director of Nursing (DON) and the administrator revealed that they were aware of the food complaints but believed the food quality had improved. The DON mentioned that he had not received direct complaints from residents and that the facility monitored residents' weights to prevent weight loss. The administrator stated that a staff member inquired about residents' meal preferences daily and that alternate meals were available. Despite these measures, residents continued to express dissatisfaction with the food quality, indicating ongoing issues with the facility's meal services.
Infection Control Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies in the care provided to residents. Specifically, the treatment nurse did not change her gloves or sanitize her hands appropriately while providing catheter care to a resident with multiple diagnoses, including sepsis and cellulitis. This failure was observed during an interview and record review, where the nurse admitted to not following proper procedures, which could have led to further infections for the resident. Another incident involved a CNA who did not change her gloves or perform hand hygiene correctly while providing incontinent care to a resident with severe cognitive impairment and chronic obstructive pulmonary disease. The CNA acknowledged her mistake during an interview, stating that she realized she should have changed her gloves but did not do so until later in the procedure. This lapse in infection control practices was confirmed by the DON, who emphasized the importance of universal precautions in preventing the spread of infections. A third deficiency was observed when a CNA did not change her gloves or sanitize her hands after removing a foley catheter stabilizer device from a resident with chronic kidney disease and urinary retention. The CNA admitted to being nervous and not following proper procedures, which included putting a dirty towel back into clean water. This was corroborated by an LVN who assisted during the procedure and confirmed that such actions could lead to urinary tract infections. The facility's policies and skills check-offs did not adequately address the need for changing gloves during these procedures, contributing to the observed deficiencies.
Failure to Maintain Homelike Environment by Not Replacing Window Blinds
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident by not replacing missing slats from the window blinds. The resident, who is [AGE] years old and has severe cognitive impairment, expressed that the missing slats allowed sunlight to enter the room, making it difficult for her to nap and causing discomfort. Despite the resident's repeated requests for the blinds to be fixed, the issue remained unresolved for months. The Maintenance Supervisor confirmed that the maintenance log did not list the resident's room as needing blind slats replaced, although other rooms had their blinds fixed. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that facility policies require maintaining a homelike environment, which includes ensuring that window blinds are functional. The facility's policy on Quality of Life - Homelike Environment emphasizes the importance of providing a comfortable and personalized setting for residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plans for two residents were not updated to reflect their current medication regimens. Resident #12's care plan incorrectly indicated that she was prescribed Eliquis, while her records showed she was actually taking Aspirin. Similarly, Resident #13's care plan was not updated to reflect the discontinuation of Eliquis, which had been stopped on 04/08/24. Resident #12, an elderly female with a diagnosis of paroxysmal atrial fibrillation, had a care plan that indicated she was taking Eliquis, a blood thinner. However, her physician orders and medication administration records (MAR) showed that she was actually prescribed Aspirin. This discrepancy was not corrected in her care plan, which could lead to inappropriate care interventions. Resident #13, another elderly female with a history of gastrointestinal hemorrhage, had her Eliquis discontinued, but this change was not reflected in her care plan. Interviews with the MDS Coordinator, DON, and ADM revealed that they were aware of the importance of accurate and updated care plans for individualized resident care. They acknowledged that failing to update care plans could lead to residents not receiving appropriate care. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and timely updates, but this was not adhered to in these cases.
Improper Transfer Technique Used by Staff
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that two staff members, a CNA and an LVN, performed a safe two-person transfer for a resident with severe cognitive impairment and physical limitations. The resident, who required maximal assistance for transfers and was dependent on others for mobility, was transferred without the use of a gait belt, contrary to the facility's policy and the resident's care plan. Instead, the staff members lifted the resident from under her arms, a technique known as 'chicken winging,' which is not approved and could cause harm to the resident's arms and shoulders. The resident involved was an elderly female with diagnoses including dementia and age-related osteoporosis. Her care plan indicated that she required substantial assistance and was at risk for falls due to her medical conditions. Despite this, during an observed transfer, the staff did not use a gait belt and instead lifted her under her arms, which is against the facility's policy. The CNA involved stated that she believed using a gait belt was less safe for this resident, despite the policy requiring its use. The LVN also confirmed that the resident refused the mechanical lift, but did not authorize the omission of the gait belt. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the improper transfer technique being used. Both confirmed that the facility's policy mandates the use of a gait belt for all transfers unless otherwise care planned. The DON emphasized that 'chicken winging' could cause damage to the resident's arms and shoulders, and the ADM acknowledged that improper transfers could lead to falls and injuries. The review of staff competencies showed that the CNA and LVN had not been checked off for two-person transfers, highlighting a gap in training and adherence to safety protocols.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that Resident #12's drug regimen was free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #12, an elderly female with diagnoses including anxiety disorder, depression, and dementia, was prescribed Duloxetine for depression and Lorazepam for anxiety. However, there were no orders for behavior or side effect monitoring for these medications, as confirmed by the resident's medical records and MAR. The care plan also did not indicate the use of an antidepressant, despite the prescription of Duloxetine. The Director of Nursing (DON) acknowledged the oversight and emphasized the importance of monitoring due to the potential major side effects of psychotropic medications on the elderly population. The Administrator (ADM) also confirmed that the nursing staff was responsible for ensuring medication and side effect monitoring, and that failure to do so could lead to unrecognized side effects and ineffective treatment outcomes. During interviews, both the DON and ADM highlighted the necessity of behavior and side effect monitoring to assess the efficacy of the medications and to report any adverse effects to the medical doctor (MD). The facility's Psychotic Medication policy from 2017 mandates ongoing documentation, including root cause analysis of behavioral indicators, monitoring for efficacy and adverse consequences, and documentation of target behaviors each shift. The lack of adherence to these protocols for Resident #12 indicates a significant lapse in the facility's medication management practices, potentially compromising the resident's therapeutic outcomes and safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 42 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Haven Retreat | 0.2 mi | ★★★★★ | 1 | 0 |
| Focused Care At Linden | 13.8 mi | ★★★★★ | 10 | 1 |
| Vivian Healthcare Center | 19.7 mi | ★★★★★ | 0 | 0 |
| Avir At Citizens Trail | 23 mi | ★★★★★ | 28 | 0 |
| The Springs Of Texarkana | 23.4 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.