Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Harmony Care At Golfcrest during CMS and state inspections, most recent first.
Surveyors found multiple environmental and sanitation deficiencies on two halls, including unsecured baseboards, peeling paint, broken blinds, non-functioning overbed lighting, and an uncovered electrical outlet between beds. Several resident rooms and bathrooms had dirty floors with trash, dust, food crumbs, overflowing trash containers, and soiled privacy curtains, as well as a bathtub and shower area containing a dirty shower chair, disposable brief, wet tissue, and broken sheetrock. Cords and antennas were observed on floors, and one room had black buildup under a window. Resident care equipment, including a G-tube feeding pole, an air mattress and its pump, and an O2 concentrator, were visibly soiled with dried beige and dark substances. Staff interviews confirmed housekeeping and maintenance routines, but at the time of observation, the environment and equipment did not meet the facility’s own policy for a safe, clean, and homelike setting.
The facility failed to maintain an effective pest control program on two of three halls, where surveyors observed dead flies, live flies on a resident’s forehead, gnats in bathrooms, and both dead and live roaches on room floors. Several residents reported that flies, gnats, and roaches were always present in their rooms, even though a pest control company regularly treated the building. Maintenance staff described routine walkthroughs and pest treatments, but record review showed that rooms later found with roaches and gnats were not included on a recent treatment list, despite a facility policy requiring an ongoing program to keep the building free of insects and rodents.
A resident with Alzheimer’s disease, multiple comorbidities, and significant ADL dependence repeatedly refused showers and requested bed baths instead, with multiple refusals documented in progress notes and shower sheets. The resident reported problems getting showers and stated he was not bathed as often as he would like, while staff described episodes where the resident initially agreed to a shower, then yelled and refused once in the shower chair or on the shower bed, subsequently requesting a bed bath and calling his daughter to report not receiving a shower. Despite staff awareness of this ongoing pattern and the facility’s policy requiring the IDT to revise care plans as conditions or information changed, the comprehensive care plan did not include any problem, goal, or interventions addressing the resident’s shower refusals, constituting a failure to review and revise the care plan accordingly.
A resident who was fully dependent on staff for ADLs and had multiple chronic conditions did not receive timely incontinent care, as night shift staff repeatedly failed to respond to her call light over an extended period. The resident was left in soiled conditions for hours, experienced verbal abuse, and felt neglected and belittled. Despite complaints from the resident, her family, and other staff, management denied awareness of the issue, and incident reports did not document the neglect.
Three residents with cognitive and physical impairments were able to smoke unsupervised and without required smoke aprons, outside of scheduled smoking times, due to lapses in staff supervision and inconsistent enforcement of facility policy regarding the storage of smoking materials. Staff interviews confirmed that residents sometimes accessed cigarettes and lighters on their own, and that these practices were known to administration but not consistently addressed.
A CNA failed to properly handle soiled linens for two residents on enhanced barrier precautions, placing a wet Hoyer sling and bedsheet in a trash bin instead of the linen barrel for one resident, and attempting to reuse a blanket that had been on the floor for another. These actions did not comply with infection control policies requiring proper handling of contaminated linens to prevent the spread of infection.
A resident with severe physical and cognitive impairments was found without a functioning call light at the bedside, as the device was missing its push button component. Multiple staff members, including the DON, CNAs, and maintenance, were unaware of the issue prior to observation, despite facility policy requiring regular checks and maintenance of call systems. The deficiency was identified through observation and interviews, with no prior documentation of the broken call light.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A medication aide failed to administer a phosphate binder (Sevelamer) with meals as ordered for a resident with end stage renal disease on dialysis. The medication was given without food, contrary to pharmacy label instructions and facility policy, resulting in a deficiency in pharmaceutical services.
A nurse left a medication cart unlocked and unattended in a hallway outside an open resident room. The cart contained various resident-labeled medications, with controlled substances secured in a separate locked compartment. The nurse admitted to forgetting to lock the cart after being called away, and the DON confirmed that staff are responsible for ensuring medication carts are locked and accessible only to authorized personnel.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two red biohazard-labeled containers without lids were found outside the facility, containing deteriorated red bags and trash. Staff interviews revealed no knowledge of the containers' origin or contents, and the containers were not part of the facility's approved medical waste disposal process.
The facility failed to implement an effective infection control program, as CNAs were observed transporting soiled linen without clear trash bags, and personal care equipment was improperly stored. Interviews confirmed staff awareness of proper procedures, but these were not consistently followed, posing a risk of cross-contamination.
The facility failed to maintain a safe and sanitary environment in two resident halls, with issues such as non-functioning lights, broken fixtures, peeling paint, and strong odors. The Maintenance Supervisor, new to the role, was unaware of some issues but planned to address them. These deficiencies contradict the facility's policy of providing a clean and homelike environment.
The facility failed to maintain an effective pest control program, leading to the presence of roaches and gnats in two halls. Observations revealed live and dead roaches in resident rooms, and interviews with residents confirmed persistent pest issues. The pest control company increased visit frequency, but recent treatments did not include all affected rooms.
A resident with hypertension was given Metoprolol despite blood pressure readings below the physician-ordered parameters. The medication was administered on several occasions when the resident's blood pressure was too low, contrary to the prescribed instructions. Interviews with nursing staff revealed inconsistencies in medication administration and documentation, with one LVN admitting to possible documentation errors and another emphasizing the importance of checking vital signs before administration. The DON confirmed the medication should not have been given under these conditions.
The facility's kitchen failed to meet food safety standards, with unsealed and undated food items found in the pantry, and a dented can stored improperly. Staff interviews confirmed that these practices could lead to foodborne illnesses, affecting 89 residents.
A medication aide administered blood pressure medications to a resident despite their blood pressure being below the physician's recommended parameters. Initially, the aide denied administering the medications, claiming they were discarded, but later admitted to the error. The facility's policy requires holding medications if vitals are out of parameters and notifying the nurse and physician.
The facility did not submit complete and accurate direct care staffing information to CMS for the first quarter of fiscal year 2024. An outside HR company was responsible for the submission, but due to a lapse, the contract was terminated. The Administrator was unaware of the issue until the survey team highlighted it. This deficiency meant the facility did not accurately report staffing levels, impacting the ability to meet residents' needs.
Environmental and Sanitation Deficiencies on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, functional, and homelike environment on two of three halls, specifically the 100 and 200 halls. Surveyor observations on multiple dates found numerous environmental issues in resident rooms and common areas. In several rooms, baseboards were not affixed to the walls, there was peeling paint behind beds, and broken blinds were present in the hallway between the two halls. One room had an overbed light that did not illuminate when turned on, and another room had an uncovered electrical outlet between two beds. Nightstands in some rooms had peeling strips on the front, and one bed had a worn sheet with brown stains. Additional observations showed significant cleanliness and sanitation problems. One bathroom contained a dirty bathtub with blackened strips, a dirty shower chair, a disposable brief, wet tissue paper, and a box with gloves, along with broken sheetrock at the base of the shower pipe. Multiple rooms had dirty floors with trash, dust, food crumbs, and dirt, including rooms where trash containers were filled and overflowing. Some rooms had antennas and cords or electric cords lying on the floor. One room had an accumulation of black material in the corner under the window, and another had stained floors, trash on the floor, and soiled privacy curtains with a dark dry substance on them. Surveyors also identified unclean resident care equipment. In one room, a G-tube feeding pole was soiled with copious amounts of dried beige substance similar in color to the enteral feeding in the bag at the bedside. The resident’s air mattress had stains, and the pump at the foot of the bed was soiled with dried dark brown drips and dried beige streaks and drips of unknown substances. The O2 concentrator at the bedside had drips of dried beige substance down the sides and back. Staff interviews confirmed that housekeeping was responsible for room cleaning and that environmental rounds were conducted, but at the time of survey, the rooms and equipment remained in the deficient conditions described. The facility’s own policy stated residents were to be provided a safe, clean, and homelike environment with clean linens and adequate lighting, which was not met in these observed instances.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to keep two of three halls (Hall 100 and Hall 200) free of pests, resulting in multiple resident rooms containing roaches, flies, and gnats. During observations on 1/15/2025 between 11:30 a.m. and 2:00 p.m., surveyors noted dead flies in one resident room and flies and gnats in that room’s bathroom, a live fly on a resident’s forehead in another room, and dead roaches on the floors of additional rooms. In other rooms, flies were observed flying in the room, live gnats were present in the bathroom, and both dead and live roaches were seen on the floor. Interviews with five unidentified residents on 1/15/2026 revealed that flies, gnats, and roaches were consistently present in their rooms, and that although a pest control company treated the building, the pests continued to return. The Assistant Maintenance staff member reported that pest control had been in the facility a few days prior, treating for roaches, gnats, flies, and ants, and that they typically conducted morning walkthroughs, checked the maintenance log, and spoke with residents to address concerns. The Maintenance Supervisor stated he performed morning building walkthroughs several days a week and used a fly wipe that appeared to decrease flies. Record review of pest control receipts showed multiple treatment dates and indicated that rooms identified with roaches and gnats during the survey were not included on the list of rooms treated on 01/08/2026, despite an existing policy stating the facility shall maintain an effective pest control program to keep the building free of insects and rodents.
Failure to Revise Care Plan for Repeated Shower Refusals
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to address ongoing refusals of showers. A male resident with diagnoses including hypertension, diabetes, Alzheimer’s disease, anxiety, depression, malnutrition, and diaper dermatitis was admitted in mid-January 2026. His quarterly MDS showed a BIMS score of 11, indicating moderately impaired decision-making, and documented no behaviors under the behavior section. Functionally, he required varying levels of assistance with ADLs, including maximal assistance for shower/bath and personal hygiene, and was incontinent of bladder with a colostomy. Despite these needs, his care plan dated late December 2025 did not include any problem, goal, or interventions related to shower or bathing refusals; it only reflected that he was to receive showers/bed baths at least twice per week as documented on shower sheets and CNA point-of-care tasks. Surveyor review of progress notes and shower sheets showed multiple instances where the resident refused showers and requested bed baths instead, with refusals documented on several specific dates in early January 2026. During observation, the resident was alert, oriented, able to make his needs known, and appeared groomed with no lingering odor. In interviews, he reported having problems getting a shower, stating that he usually received a bed bath but wanted a shower where staff could soap him up and wash him off, which he felt could not be done in bed. He also stated that he was bathed but not as often as he would like, that he had specific bathing days but did not always receive them when he wanted, and that he expected staff to know when he wanted a shower. Staff interviews confirmed awareness of the resident’s pattern of refusing showers. The MDS Coordinator acknowledged knowing that the resident often refused showers and stated it should have been addressed in the care plan, characterizing its omission as a human oversight. A CNA described that the resident would initially agree to a shower, be placed in the shower chair, then start screaming and yelling that he did not want a shower and preferred a bed bath, after which he would call his daughter and say he did not get a shower. ADONs reported they were aware the resident always refused showers and believed he was care planned for shower refusals, explaining that he would be placed on the shower bed, then refuse to go to the shower room and request a bed bath instead, and later call his daughter stating he needed a shower. The facility’s own care plan policy required ongoing assessment and revision of care plans as resident conditions or information changed, and for the IDT to develop a comprehensive, person-centered care plan with measurable objectives and timeframes, but this was not carried out for this resident’s shower refusal behavior.
Failure to Provide Timely Incontinent Care and Respond to Call Lights
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The resident, who had multiple medical diagnoses including congestive heart failure, hypertension, diabetes, stroke, COPD, and parkinsonism, was totally dependent on staff for most ADLs, including incontinent care. The care plan for this resident specified that call lights should be within reach and answered promptly, but this intervention was not consistently followed. Over a period of several months, the resident's call light was repeatedly ignored or not acknowledged by the 3rd shift nursing staff, particularly for incontinent care needs. Documentation and interviews revealed that the resident was left in soiled conditions for extended periods, sometimes for several hours, and that staff would enter the room, turn off the call light, and leave without providing care. The resident and her family member reported multiple instances of neglect, including verbal abuse and dismissive behavior from staff, and these concerns were corroborated by the resident's roommate and a CNA. Despite these ongoing issues, management staff and the administrator denied receiving complaints or being aware of the neglect, and incident reports did not reflect the call light concerns. The resident expressed feelings of neglect, belittlement, and shame as a result of the staff's actions and inactions. Interviews with other staff members confirmed that complaints about call lights not being answered, especially on the night shift, were known but not always reported or addressed. The facility's policy required staff to treat residents with kindness, respect, and dignity, but this was not upheld in the care provided to the resident during the period in question.
Failure to Supervise Smoking and Secure Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and safe storage of smoking materials for three residents with cognitive impairments and other medical conditions. On the morning of 12/18/2025, three residents were observed smoking unsupervised in the designated smoking area, outside of scheduled smoking times, and without the required use of smoke aprons. Interviews with the residents confirmed that they sometimes smoke on their own before the official smoking times, and that they occasionally obtain cigarettes from other residents. Staff interviews revealed that residents are not supposed to smoke unsupervised or keep their own smoking supplies, but these practices were not consistently enforced, particularly during night shifts when no designated smoking times were scheduled. The residents involved had significant medical histories, including dementia, cognitive communication deficits, schizoaffective disorder, hemiplegia, heart disease, diabetes, and neuropathy. Their care plans and smoking assessments indicated the need for supervision while smoking, the use of smoke aprons, and secure storage of smoking materials at the nurse's station. Despite these documented interventions, the residents were able to access cigarettes and lighters and smoke without staff supervision or protective equipment. Staff interviews confirmed awareness of the risks and the facility's policy, but also acknowledged that residents sometimes circumvented these rules, and that administration was aware of previous incidents of unsupervised smoking. Facility policy required that residents only smoke in designated areas under staff or family supervision, and that all smoking materials be stored securely at the nurse's station. However, observations and interviews demonstrated that these policies were not consistently followed, particularly during overnight hours. Staff reported redirecting residents when found smoking unsupervised and notifying management, but lapses in supervision and secure storage of smoking supplies persisted, resulting in residents being able to smoke unsupervised and without appropriate safety measures.
Failure to Follow Infection Control Procedures for Soiled Linens
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection control procedures for two residents who required enhanced barrier precautions due to their complex medical conditions. For one resident with a history of sepsis, quadriplegia, tracheostomy, stage 4 pressure ulcer, and gastrostomy, the CNA did not place the resident's soiled Hoyer transfer sling and bed sheets in the designated linen barrel after use. Instead, these items were found stuffed inside the resident's bedside rubbish bin, wet and saturated with liquid. The licensed vocational nurse (LVN) and director of nursing (DON) confirmed that these linens did not belong in the trash bin and that improper handling could be a source of infection, especially given the resident's vulnerability. In a separate incident, the same CNA was observed in another resident's room, where a navy-blue blanket was found bundled on the floor at the foot of the bed. The resident, who had diagnoses including acute and chronic respiratory failure, colostomy, tracheostomy, gastrostomy, and peripheral vascular disease, was dependent on staff for all activities of daily living and also required enhanced barrier precautions. The CNA picked up the blanket from the floor, shook it out, and attempted to place it back on the resident's bed before being stopped by the surveyor. When questioned, the CNA acknowledged that the blanket could be placed in the dirty linen barrel but initially attempted to reuse it. Both residents were on enhanced barrier precautions due to their wounds and indwelling medical devices, as indicated by physician orders and facility policy. The facility's infection control policies required that soiled linens be handled in a manner that prevents contamination and the transfer of microorganisms. The CNA's actions in both cases did not comply with these procedures, as confirmed by interviews and observations documented in the report.
Failure to Provide Functioning Call Light System at Bedside
Penalty
Summary
The facility failed to ensure that a resident had access to a functioning call light system at the bedside, as required for requesting staff assistance. During observation, it was noted that the call light device available to the resident was missing the push button component, leaving only the outer casing. The resident, who was nonverbal, dependent on staff for all activities of daily living, and had significant medical conditions including quadriplegia, tracheostomy, and a stage 4 pressure ulcer, was unable to use the call system to summon help. Interviews with facility staff, including the Administrator, DON, CNAs, LVN, HR/Payroll Director, and Maintenance Director, revealed that none were aware that the call light in the resident's room was nonfunctional prior to the surveyor's observation. Staff acknowledged that the expectation is to check call lights regularly and ensure they are within reach and operational for all residents. The Maintenance Director reported conducting weekly checks of call lights and keeping spare parts available, but there was no documentation of a broken call light for this resident in the maintenance binder. Record review confirmed that the facility's policy requires each resident to have a means to call staff for assistance from their bed, and that the call system must remain functional at all times. Despite these policies and routine checks, the deficiency occurred due to a lack of awareness and failure to identify and address the nonfunctional call light for a resident with severe impairments and high care needs.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Administer Phosphate Binder with Meals as Ordered
Penalty
Summary
A deficiency occurred when a medication aide (MA-B) failed to administer Sevelamer, a phosphate binder prescribed to control high phosphorus levels in a resident with end stage renal disease (ESRD) on dialysis, according to the pharmacy label instructions. The medication was ordered to be given with meals, but MA-B administered three tablets of Sevelamer to the resident without food during a morning medication pass. The medication administration record (MAR) and pharmacy label both specified that the medication should be taken with meals, yet this instruction was not followed. The resident involved was a male with a history of bilateral shin fractures, ESRD requiring dialysis, osteoarthritis, anxiety, and dependence on renal dialysis. At the time of the incident, the resident was observed with dry skin and was seen scratching his body, and he confirmed that he typically takes Sevelamer with meals. The nurse in charge was unaware that the medication had been given without food, and facility policy required verification of medication orders and adherence to label instructions. The failure to administer the medication as ordered constituted a lapse in pharmaceutical services for the resident.
Unattended and Unlocked Medication Cart
Penalty
Summary
A nurse failed to ensure that the medication cart on the 200 Hall was locked when left unattended. During an early morning observation, the medication cart was found in the hallway outside an open resident room, visibly unlocked and unattended. The cart contained various medications labeled for residents, including over-the-counter drugs, while controlled substances were secured within a separate locked compartment inside the cart. The nurse assigned to the cart stated she was called away and forgot to lock it, acknowledging that facility protocol requires the cart to be locked when unattended to prevent unauthorized access. The Director of Nursing confirmed that the assigned nurse or medication aide is responsible for securing the cart and restricting access to authorized personnel only.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Improper Storage and Disposal of Biohazard Waste Containers
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment by not properly disposing of waste in the appropriate receptacles. Observations revealed two red, cylindrical, 32-gallon containers labeled 'Infectious Waste: Biohazard' located outside the facility, one near the generator and another near a storage shed. Both containers were without lids and contained red bags of unknown origin, water, and various trash items. Some of the red bags were deteriorated, indicating prolonged exposure to the elements. The containers appeared to have been outside for an extended period, and the contents could not be clearly identified due to the condition of the bags. Interviews with facility staff, including the ADON/IP, Administrator, and Maintenance Director, revealed a lack of awareness regarding the presence and use of these biohazard containers outside the building. The ADON/IP stated that biohazard bags were only used for residents in isolation and were supposed to be stored and picked up from the Medical Waste room inside the facility. Neither the Administrator nor the Maintenance Director knew how long the containers had been outside or what they contained, with the Maintenance Director suggesting they may have been there for years. The containers were not part of the facility's approved waste disposal process.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by improper handling of soiled linen and patient care equipment. Observations revealed that CNAs were transporting dirty linen and soiled briefs across the hallway without using clear trash bags, which is against the facility's infection control policy. Personal care basins and bed pans were found on the bathroom floor without labels or protective plastic bags, posing a risk of cross-contamination between residents sharing the rooms. Interviews with CNAs and the Director of Nursing (DON) confirmed that staff were aware of the proper procedures but failed to implement them. CNA D admitted to not having clear plastic bags available during incontinent care, which could lead to contamination. The DON acknowledged that staff had been in-serviced on infection control measures, including the proper disposal of soiled items and labeling of personal care equipment, but these practices were not consistently followed. The facility's policies emphasize the importance of handling soiled items to prevent the spread of infections, yet these guidelines were not adhered to, potentially affecting all residents in the facility.
Environmental Deficiencies in Resident Halls
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents on two of the three halls reviewed for environmental concerns. Observations revealed several issues, including a non-illuminating overhead light in a bathroom, baseboards coming off the walls, broken sheet racks, peeling paint, and lifting floor tiles in various rooms. Additionally, there were strong urine and feces odors in some rooms, with visible brown stains and smears that resembled feces on the toilet and floor, contributing to an unsanitary environment. Interviews conducted during the survey indicated a lack of awareness and prompt action from the maintenance staff. A resident reported the bathroom light issue, and the Maintenance Supervisor, who was new to the position, was unaware of the problem. He mentioned plans to address the concerns and check the maintenance logs daily. The facility's policy emphasizes providing a safe, clean, and homelike environment, but the observed deficiencies suggest a failure to adhere to these standards, potentially affecting the residents' quality of life.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and gnats in two of the three halls reviewed. During the survey, live and dead roaches were observed in multiple rooms, including on residents' overbed tables and floors. Interviews with residents revealed that roaches were a persistent issue, with residents resorting to using their own spray to manage the problem. The facility's pest control company had been visiting monthly, but due to ongoing issues, the frequency was increased to weekly visits for four weeks before returning to a monthly schedule. The grievance log indicated a recent complaint about insects on a resident's plate, although the location was not specified. The pest control records showed treatments for various pests, including roaches, spiders, and ants, but the rooms identified with pest issues during the survey were not included in the recent treatment list. The facility's pest control policy stated an ongoing program to keep the building free of insects and rodents, but the observations and resident reports indicated that the program was not effectively implemented.
Medication Administration Error Due to Non-Adherence to Physician's Orders
Penalty
Summary
The facility failed to ensure that a resident's medication, Metoprolol, was administered according to the physician's orders. The resident, who had a diagnosis of essential hypertension, was prescribed Metoprolol Tartrate 25mg to be taken orally every 12 hours, with specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) was less than 70, or heart rate (HR) was less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were below the specified parameters, including instances where the SBP was 83/51 and 105/67. Interviews with the nursing staff revealed discrepancies in medication administration and documentation. One LVN stated that she was not responsible for administering the medication at the specified times and emphasized the importance of checking blood pressure before administering the medication. Another LVN acknowledged the possibility of incorrect documentation, despite being aware of the resident's tendency for low blood pressure. The Director of Nursing (DON) confirmed that the medication should not have been given when the blood pressure was below the parameters, as it could lead to adverse effects such as dizziness and potential falls.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, which could potentially place 89 residents at risk for foodborne illness. During an observation, it was noted that food items in the pantry were not properly sealed or dated. Specifically, a 16 oz bag of tortilla chips was found open, unsealed, and undated, while an 80 oz bag of instant oatmeal was dated but not sealed. Interviews with the Dietary Manager and staff revealed that all kitchen staff were responsible for ensuring food items were sealed and dated, and the Dietary Manager would double-check these items. The staff acknowledged that improperly sealed or dated food could lead to food poisoning for residents. Additionally, a dented can of apples was found stored with non-dented cans, contrary to safety protocols. The Dietary Manager confirmed that dented cans should be stored separately to prevent potential exposure to botulism. Staff interviews indicated that everyone in the kitchen was responsible for checking for dented cans, and shifts were expected to double-check each other's work. The facility's policy and FDA guidelines were reviewed, highlighting the importance of proper food storage and handling to prevent serious health hazards.
Medication Administration Error Due to Non-Adherence to Physician Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A medication aide (MA L) administered Doxazosin and Amiodarone to a resident with a blood pressure reading of 100/65, which was below the physician's recommended parameters of holding the medication if the systolic blood pressure (SBP) was less than 110 and diastolic blood pressure (DBP) was less than 60. Despite the resident's blood pressure being outside the safe range, MA L proceeded with the administration of the medications. Upon observation, MA L initially denied administering the medications and claimed to have discarded them in the resident's trash bin, which was not observed. The Assistant Director of Nursing (ADON) was informed of the situation and assessed the resident for adverse side effects. The ADON confirmed that the medications were not found in the trash bin, and MA L later admitted to administering them. The Director of Nursing (DON) reiterated that medications should be held if vitals are out of parameters and that the medication aide should have notified the nurse to inform the physician.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the first quarter of the fiscal year 2024. This deficiency was identified during a review of the facility's staff roster and the CMS PBJ Staffing Data Report, which indicated that no data was submitted for the quarter. The facility's policy required staffing information to be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. However, the facility did not meet this requirement for the specified period. Interviews revealed that an outside third-party HR company was responsible for submitting the payroll and PBJ data, but due to a lapse in submission, the contract with this company was terminated in February 2024. The Regional Director of Clinical Operations acknowledged the risk of not submitting the PBJ data, as it meant the facility was not accurately reporting staffing levels. The Administrator, who began working at the facility in March 2024, was unaware of the issue until it was brought up by the survey team. The failure to submit the PBJ data was recognized as a deficient practice, as it did not accurately reflect the staffing component necessary to meet residents' needs.
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 739 citations issued within 25 miles in the last 12 months — including the 72 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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Afton Oaks Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 12 | 7 |
| Avir At Courtyard | 2 mi | ★★★★★ | 8 | 0 |
| Avir At Golfcrest | 2.5 mi | ★★★★★ | 1 | 1 |
| Garden Terrace Healthcare Center Of Houston | 4.6 mi | ★★★★★ | 8 | 1 |
| The Methodist Hospital Snf | 5.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Harmony Care At Golfcrest.
100% money-back within 48 hours.
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.