Health inspection·November 13, 2025

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to follow established policy regarding smoking areas and smoking safety for the 1 of 1 facility reviewed for smoking. The facility failed to ensure NA A did not smoke a vape in the facility on 11/13/25 while standing beside the nurse's station. This failure could place residents and staff at risk of unsafe smoking and injury.Findings include:During an observation on 11/13/25 at 11:24 AM, NA A vaped while standing between the nurse's station and the resident sitting area where residents were sitting at the time. When NA A vaped a cloud of fumes went in the air around her. NA A turned around as the vape fumes went in the air and observed this surveyor standing around from her and rushed down the hallway. During an interview on 11/13/25 at 11:33 AM, NA A said she did not remember, and she did not believe that she did vape when she was standing at the nurses. NA A said she did utilize vapes, and she smoked cigarettes, but the facility did not allow the staff to vape in the facility. NA A said she was not an expert at what the risk was for vaping in the facility. During an interview on 11/13/25 at 11:35 AM, the Regional Nurse said the facility was a smoke free facility and she had manager go find NA A and write her up and begin in-servicing with the staff. During an interview on 11/13/25 at 3:10 PM, CNA B said she was not aware of any staff smoking or using vapes in the facility and the facility is a non-smoking facility. CNA B said none of the residents smoke at the facility. CNA B said if she was aware of any staff using vapes in the facility she would have reported it to the administrator. During an interview on 11/13/25 at 3:15 PM, Resident #1 and Resident #2, who resided on the hall NA A worked on, said they have never had any issues with the vapes being used by staff or residents in the facility. During an interview on 11/13/25 at 3:19 PM, LVN C said she had not had any problems with any staff vaping recently but when she first started about a year ago, she was unsure of some hearsay of staff using vapes. LVN C said she had no problems since. LVN C said the facility was a non-smoking facility. LVN C said she was sure there was a risk for using a vape around residents, but she honestly was not sure what the risk was. During an interview on 11/13/25 at 3:21 PM, LVN D said she was not aware of the vape being used but the staff was allowed to go outside to the shed to smoke and use them. She said the failure placed a risk for residents breathing in the fumes and causing problems. During an interview on 11/13/25 at 3:23 PM, the DON said he has never had anyone use a vape in the facility. The DON said no residents smoked and if they do smoke, they offer the patch or try to get them relocated to the sister facility. The DON said facility staff are allowed to smoke but out back in the designated smoking area. The DON said the failure of staff vaping in the facility placed a risk for the infection control spread through the fumes for staff and other residents. During an interview on 11/13/25 at 3:32 PM, the Regional Director of Operations said no staff should be using any smoking products in the facility. The Regional Director of Operations said the facility did have a designated place for the staff to smoke in the back of the facility. The Regional Director of Operations said the failure of staff vaping in the facility could have aggravated breathing for the residents. Record review of the undated facility policy Smoking Area indicated: Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675490 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Villa 1104 S William St Atlanta, TX 75551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)