Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Acres Living And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow the facility’s hand hygiene policy while assisting multiple residents with meals. A Speech Therapist touched her hair twice and continued feeding a resident with severe cognitive impairment and dysphagia without using hand sanitizer. An LVN touched her hair while feeding a dependent resident with vascular dementia and dysphagia and did not sanitize her hands, then moved directly to assist another resident with Alzheimer’s disease and a cognitive communication deficit without performing hand hygiene between residents or before returning to the first. The DON confirmed staff were expected not to touch their hair while feeding and to sanitize hands between residents, and the facility’s policy required hand hygiene before and after assisting with meals.
Surveyors found that staff failed to maintain resident dignity during assisted feeding when a Speech Therapist and an LVN stood over two residents with severe cognitive impairment and dysphagia while feeding them their entire meals. One resident had multiple conditions including MDD, dementia, and anxiety, with a care plan calling for a calm, quiet mealtime setting, while the other had vascular dementia and schizoaffective disorder and was fully dependent on staff for eating. The Speech Therapist acknowledged knowing that standing while feeding was a dignity issue but did so anyway, and the LVN reported not knowing she should sit while feeding. The DON stated staff were expected to sit at the same level as residents when feeding and confirmed there was no feeding policy in place.
The facility failed to provide necessary nail care for four residents who were unable to perform activities of daily living, resulting in long and dirty fingernails. Despite residents expressing a desire for assistance, staff did not consistently offer or monitor nail care, contrary to facility policy. This deficiency was observed in residents with varying levels of cognitive impairment and dependence on staff.
The facility failed to provide adequate respiratory care for three residents on oxygen therapy. One resident's room lacked an 'Oxygen in Use' sign, while another resident's nasal cannula tubing and humidity bottle were not changed weekly as required. Additionally, a third resident's nasal cannula tubing was not labeled or dated, increasing the risk of infection. Staff acknowledged these oversights and the potential risks involved.
The facility's kitchen failed to meet food safety standards by not labeling and dating food items in the walk-in freezer and by an employee not following proper hand hygiene during meal preparation. Unlabeled frozen popcorn shrimp were found, and an employee continued food prep after touching a personal phone without changing gloves. Both the Dietary Manager and the employee acknowledged the importance of these protocols to prevent contamination.
A facility failed to maintain an effective infection control program, with a CNA not performing hand hygiene between glove changes during incontinence care for a resident, and a CMA not disinfecting a blood pressure cuff between checks on two residents. Both staff members acknowledged their lapses, which were contrary to the facility's infection prevention policies. The DON confirmed the need for proper hand hygiene and equipment sanitization to prevent infection spread.
A resident with severe cognitive impairment and total dependence on staff was unable to reach the call light while in bed, as it was placed on the nightstand. This oversight was contrary to the resident's care plan and facility policy, which require the call light to be within reach to prevent falls and ensure timely assistance. Staff interviews confirmed the importance of this protocol to avoid risks such as falls and injuries.
A resident with an indwelling catheter was at risk for urinary tract infections due to improper catheter care by a CNA, who placed the catheter drainage bag on the bed above the bladder level, causing urine to back up in the tubing. Despite being aware of the correct procedure, the CNA expressed concern about pulling the tubing, leading to this deficiency. The resident had medical conditions including reflux uropathy, diabetes mellitus, and Alzheimer's disease, which increased her risk for infections.
The facility failed to ensure that the call light system was accessible in resident bathrooms, affecting several residents. Observations showed that call light pull strings were improperly positioned, either hanging over toilet paper dispensers or intertwined on grab bars, making them inaccessible, especially if residents were on the floor. Interviews confirmed the improper placement and the potential risk, with the facility's policy requiring call devices to be within reach.
A resident with severe cognitive impairment reported being raped, but the facility failed to report the allegation to the state within the required two-hour timeframe. The LVN attempted to notify the Administrator, who was the Abuse Coordinator, but there was a delay in communication. The incident was reported to the state later in the afternoon, contrary to the facility's policy for immediate reporting.
A resident's call light system was found hanging from the wall with exposed wiring, causing fear of use despite it functioning. The resident, with a history of falls and other health issues, did not report the issue, assuming staff were aware. Interviews revealed staff were unaware of the problem, and maintenance requests were not properly communicated, leading to a delay in addressing the issue.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene during meal assistance. Surveyors observed a Speech Therapist feeding a resident with severe cognitive impairment and dysphagia who had a care plan addressing potential nutritional problems and the need for a calm, quiet setting at mealtimes. During this feeding, the Speech Therapist touched her hair twice and continued feeding without using hand sanitizer, contrary to the facility’s hand hygiene policy, which requires hand hygiene before and after assisting a resident with meals. Another resident with vascular dementia, dysphagia, and schizoaffective disorder was care planned as dependent on staff for eating and requiring substantial/maximal staff assistance. An LVN was observed feeding this resident, touched her own hair, and did not use hand sanitizer before continuing to feed the resident, despite having sanitizer gel available. The LVN later acknowledged she did not use hand sanitizer while feeding this resident and stated she was not aware she had touched her hair at the time. The same LVN then moved from assisting the second resident to assist a third resident, an elderly female with Alzheimer’s disease and a cognitive communication deficit who was care planned for potential nutritional problems and ordered a regular diet with thin liquids. The LVN did not sanitize her hands between residents or prior to returning to assist the second resident. The DON stated that staff were expected not to touch their hair while feeding residents and to sanitize their hands between assisting residents, and confirmed that these actions placed the involved residents at risk of infection. The facility’s hand hygiene policy, dated August 2024, identified hand hygiene as the primary means to prevent the spread of infections and required use of alcohol-based hand rub or soap and water before and after assisting a resident with meals.
Failure to Maintain Dignity During Assisted Feeding
Penalty
Summary
The deficiency involves the facility’s failure to treat residents with respect and dignity and to provide care in an environment that promotes quality of life during mealtimes. Surveyors observed that during a lunch meal, a Speech Therapist stood while feeding one resident and an LVN stood while feeding another resident for the entirety of their meals. The facility’s DON stated that staff were expected to sit at the same level as residents when feeding them, and also acknowledged that the facility did not have a feeding policy. The Speech Therapist admitted she had known for over a year that standing while feeding a resident was a dignity issue, but chose to stand because the dining room was full and she wanted to provide the meal quickly, and she did not request a chair. The first resident was an older female with major depressive disorder, type 2 diabetes, dementia, dysphagia, and anxiety disorder. Her MDS showed severe cognitive impairment with a BIMS score of 00, and her care plan for potential nutritional problems and functional decline due to dysphagia included providing a calm, quiet setting at mealtimes with adequate eating time. The second resident was an older female with vascular dementia, dysphagia, and schizoaffective disorder, whose MDS indicated she was severely impaired and dependent on staff for eating, with a care plan focus on ADL self-care performance deficit and an intervention requiring substantial/maximal staff assistance with eating. The LVN who fed the second resident while standing stated she was not aware she should not stand while feeding and acknowledged that the resident could have felt intimidated. The DON and staff interviews confirmed that residents were at risk of choking and not having a dignified experience during their meals when staff stood over them while feeding.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents who required assistance with personal hygiene, including nail care. Resident #17, who had moderate cognitive impairment and required maximal assistance, was found with long and dirty fingernails. Despite expressing a dislike for his nails being long and dirty, he did not inform the staff about his needs. Resident #91, with intact cognition but requiring extensive assistance, had long fingernails pressing into his palm, posing a risk for skin breakdown. He expressed a desire for nail care and intended to ask the nurse for assistance. Similarly, Resident #28, with severe cognitive impairment and total dependence on staff, had long and dirty fingernails, some of which were chipped. He also expressed a desire for his nails to be trimmed and cleaned. Resident #255, who was totally dependent on staff due to severe cognitive impairment, was found with short fingernails but with dirt underneath, indicating a lack of proper hygiene maintenance. Interviews with staff, including LVNs and the DON, revealed that nail care was not consistently offered or monitored, despite being recognized as a responsibility of the nursing staff. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain grooming and personal hygiene, but this was not adhered to, leading to the observed deficiencies.
Deficiencies in Respiratory Care for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen therapy. For one resident, the facility did not display an 'Oxygen in Use' sign on the resident's doorway, which is necessary to alert staff and visitors of the oxygen therapy and prevent the introduction of flammable materials. Both a CNA and an RN acknowledged the absence of the sign and recognized the importance of having it for safety and emergency purposes. Another resident's nasal cannula tubing and humidity bottle were not changed in a timely manner, as required by the physician's orders. The tubing and bottle were dated 10 and 11 days prior to the observation, respectively, despite the requirement for weekly changes. An LVN confirmed the oversight and noted that such delays could lead to breathing problems and infection control issues. For the third resident, the nasal cannula tubing was not labeled or dated, which is necessary to ensure timely changes and prevent infection. An LVN admitted to assuming the tubing was dated by another nurse and acknowledged the risk of infection due to the lack of labeling. The DON confirmed the expectations for signage and equipment changes, noting that the facility lacked a specific policy for oxygen signage but followed standard nursing protocols.
Food Safety and Hand Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The first deficiency involved the improper labeling and dating of food items in the facility's walk-in freezer. Specifically, three large bags of unidentified food items were found without any labels or dates. The Dietary Manager confirmed that these items were frozen popcorn shrimp and acknowledged that it was the cooks' responsibility to ensure all food items were labeled with a received date and a use-by date. The second deficiency was related to inadequate hand hygiene practices during meal preparation. An employee, referred to as [NAME] A, was observed preparing chicken salad sandwiches while wearing gloves. During the preparation, [NAME] A touched a personal phone and then continued to mix the chicken salad without changing gloves or performing hand hygiene. This action was contrary to the facility's infection control policy, which requires handwashing and sanitizing between tasks to prevent contamination. Interviews with the Dietary Manager and [NAME] A revealed that both were aware of the facility's policies regarding food labeling and hand hygiene. The Dietary Manager expressed that all kitchen employees were expected to follow these protocols to prevent cross-contamination and foodborne illnesses. [NAME] A admitted to the error and acknowledged the importance of proper hand hygiene and food labeling to ensure resident safety.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff members. In the first incident, a CNA did not perform hand hygiene between glove changes while providing incontinence care to a resident. This resident, who was moderately cognitively impaired and always incontinent of bladder and bowel, was at risk due to the CNA's failure to wash hands after removing dirty gloves and before donning clean ones. The CNA acknowledged the lapse, attributing it to nervousness and lack of sanitizer. In the second incident, a CMA did not disinfect a blood pressure cuff between checks on two residents. Both residents had moderate cognitive impairments and were being monitored for hypertension. The CMA, who had recently started working at the facility, admitted to not having wipes available to sanitize the equipment, recognizing the risk of germ transfer between residents. The Director of Nursing (DON) confirmed the expectation for staff to perform hand hygiene before and after care, and between glove changes, to prevent infection spread. The facility's policies on hand hygiene and infection prevention were not adhered to, as evidenced by the staff's actions during resident care. The DON stated that random checks would be conducted to monitor compliance with infection control practices.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had access to the call light system while lying in bed, which is a necessary accommodation for resident needs and preferences. This deficiency was identified during an observation where the resident, who was trying to get up to use the bathroom, was unable to reach the call light placed on top of the nightstand. The resident, a male with severe cognitive impairment and total dependence on staff for activities of daily living, was at risk due to this oversight. The resident's care plan specifically included the intervention to keep the call light within reach to prevent falls and ensure timely assistance. Interviews with facility staff, including an LVN and the DON, confirmed that the call light should always be within reach of residents to prevent risks such as falls and injuries. The staff acknowledged the responsibility to ensure the call light is accessible before leaving the room. The facility's policy also mandates placing the call device within the resident's reach and reporting any defects immediately. Despite these protocols, the call light was not within reach, posing a risk to the resident's safety and ability to communicate with caregivers.
Improper Catheter Care Increases UTI Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident who was incontinent of bladder, which could lead to an increased risk of urinary tract infections. During an observation, it was noted that a CNA placed the resident's urinary catheter drainage bag on the bed by the resident's feet during incontinent care, which is above the level of the bladder. This action caused urine to back up in the tubing toward the resident's bladder. The resident, who had a moderately impaired cognition and required maximal assistance with activities of daily living, had an indwelling catheter and was at risk for urinary tract infections due to her medical conditions, including reflux uropathy, diabetes mellitus, and Alzheimer's disease. The facility's policy and the resident's care plan both required that the catheter bag be kept below the level of the bladder to prevent urine from backing up and to reduce the risk of infection. Despite being aware of this requirement, the CNA expressed concern about pulling the tubing, which led to the improper placement of the catheter bag. The Director of Nursing confirmed that the catheter should be maintained below the bladder level to prevent urine from backing up and increasing the risk of infection. The CNA had previously been verified as competent in catheter care, according to the facility's skills verification checklist.
Inaccessible Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the call light system was accessible to residents in the bathrooms and bathing areas, affecting seven residents. Observations revealed that the call light pull strings were improperly positioned, either hanging over toilet paper dispensers fixed six feet from the floor or intertwined on grab bars, making them inaccessible to residents, especially if they were lying on the floor. This deficiency was noted in shared toilets between adjacent rooms in a female secured unit. Interviews with the Maintenance Supervisor and the Director of Nursing (DON) confirmed the improper placement of the call light pull strings. The Maintenance Supervisor demonstrated that the pull strings were too long, causing them to lay on the floor, and acknowledged the potential for serious problems. The DON emphasized that call lights should always be within reach of residents, even if they are on the floor, to ensure they can call for assistance when needed. The facility's policy requires that call devices be placed within the resident's reach before leaving the room, highlighting a failure to adhere to this policy.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required timeframe. The Abuse Coordinator was informed of the allegation at 8:25 AM but did not report it to the State Agency until 2:25 PM, exceeding the mandated two-hour reporting window. This delay in reporting could place residents at risk of abuse and neglect. The resident involved was an elderly female with severe cognitive impairment, requiring assistance with personal hygiene and supervision with toilet transfers. She was occasionally incontinent and had a history of dementia and muscle weakness. On the morning of the incident, the resident reported to a family member and a nurse that she had been raped the previous night, which led to her being taken to the hospital for evaluation. Interviews with staff revealed a breakdown in communication and reporting procedures. The LVN attempted to notify the Administrator, who was the Abuse Coordinator, but was unable to reach him immediately. The Administrator claimed to have learned about the incident later in the morning and reported it to the state in the afternoon. The facility's policy required immediate reporting of abuse allegations, but this was not adhered to in this case.
Deficiency in Call Light System Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident due to the malfunctioning call light system in the resident's room. The call light wall mount was observed to be hanging from the wall with exposed electrical wiring, which made the resident afraid to use it, despite it still functioning. The resident had not reported the issue, assuming staff were aware since they had been in the room for other maintenance concerns. The resident's care plan emphasized the importance of having the call light within reach due to her risk of falls and other health conditions, including cerebrovascular disease, hemiplegia, and vascular dementia. Interviews with facility staff revealed a lack of awareness and communication regarding the maintenance issue. The CNA assigned to the resident's hall was unaware of the call light's condition, and the engineer technician responsible for maintenance had not noticed the problem during a recent visit to the room. The charge nurse recalled an aide mentioning a call light issue but could not identify who reported it. The facility's policy required maintenance issues to be entered into an electronic system, but this was not done, leading to a delay in addressing the problem. The administrator was also unaware of the issue until informed by the engineer technician.
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 792 citations issued within 25 miles in the last 12 months — including the 35 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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Leaves | 2.6 mi | — | 0 | 0 |
| Villages Of Lake Highlands | 2.6 mi | — | 3 | 1 |
| Le Reve Rehabilitation & Memory Care | 2.8 mi | — | 17 | 3 |
| Palomino Place | 3.2 mi | — | 11 | 0 |
| Christian Care Communities And Services Mesquite | 3.3 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golden Acres Living And Rehabilitation Center.
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 August 2026) and official state health department websites.