Health inspection·February 11, 2026

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete care before she went on her break. NA B said she went to break before 11, checked on Resident #1 before she went to break, and Resident #1 did not need incontinent care. NA B said incontinent care should be provided promptly because it could cause bed sores or the residents' skin could be bad. During an interview on 02/11/2026 at 5:29 PM, the DON said his expectations were that before any break was completed the residents care should be provided. The DON said Resident #1 should have been provided incontinent care when Hospitality Aide A reported to NA B she needed it. The DON said not providing prompt incontinent care could result in the residents having skin issues and it could also be a dignity issue. During an interview on 02/11/2026 at 5:50 PM, the Administrator said his expectations were incontinent care should be provided before the staff went on break. The Administrator said he expected incontinent care to be provided promptly, and all staff should be assisting with ensuring it happened. The Administrator said managers were supposed to provide oversight to ensure incontinent care was being provided. The Administrator said not providing incontinent care promptly could result in skin breakdown. Record review of the facility's policy dated, 11/28/2017, titled, QUALITY OF LIFE ADL CARE PROVIDED FOR DEPENDENT RESIDENTS, indicated, To appropriately address resident and facility practices that would affect the resident's ability to attain and maintain his/her highest practicable well-being. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Event ID: Facility ID: 675490 If continuation sheet Page 2 of 4 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 02/11/2026 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)

F 0728 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual completed a training and competency evaluation program for 2 of 3 Nurse Aides (NA B and NA D) reviewed for nursing services. The facility failed to ensure NA B and NA D were certified within the required time of four months. This failure could place residents at risk for receiving inappropriate care from an individual whose skill level was not known. Findings included: Record review of the undated Employee Data Calendar for NA D indicated NA D's date of hire was 01/03/2024. Record review of NA D's Certificate of Completion for the LTCR Nurse Aide Training and Competency Evaluation Program indicated it was completed on 12/31/2024. Record review of the undated Employee Data Calendar for NA B indicated NA B's date of hire was 11/12/2024. Record review of NA B's Certificate of Completion for the LTCR Nurse Aide Training and Competency Evaluation Program indicated it was completed on 02/16/2025. During an interview on 02/11/2026 at 2:25 PM, NA D said she worked at the facility full-time and provided care to the residents such as incontinent care and bathing. NA D said she could not remember when she completed her NA training, but it was sometime last year. NA D said she had not tested to become a CNA, and she did not have a test date scheduled. During an interview on 02/11/2026 at 2:27 PM, NA B said she worked full-time and provided care to the residents such as incontinent care and bathing. NA B said she did not remember when she completed her NA training. NA B said she had not taken the test to become a CNA, and she did not have a test date scheduled. During an interview on 02/11/2026 at 5:39 PM, the DON said the Administrative Assistant was responsible for ensuring the NAs were certified when they were supposed to. The DON said the NAs had up to one year to get certified. The DON said it was important for the NAs to be certified within the required timeframe to ensure they were competent. During an interview on 02/11/2026 at 5:44 PM, the Administrative Assistant said she and the staffing coordinator were responsible for ensuring the NAs were certified within the required timeframes. The Administrative Assistant said they had been without a staffing coordinator, and one was hired today. The Administrative Assistant said she was not sure what the required timeframe was for the NAs to get certified. The Administrative Assistant said it was important for the NAs to become certified within the required timeframe to ensure the residents were receiving the proper care and their training was correct. During an interview on 02/11/2026 at 5:58 PM, the Administrator said the DON and the Administrative Assistant kept a spreadsheet to ensure the NAs were certified within the required timeframe. The Administrator said the NAs had two years to become certified from when they completed their skills training. The Administrator said it was important for the NAs to be certified within the required timeframe because they would be required to repeat the NA class and would not be allowed to continue to work as NAs. Record review of the facility's policy revised, September 2011, titled, Nurse Aide Qualifications and Training Requirements, indicated, Nurse Aide is defined as any individual providing nursing or nursing-related services to residents in our facility who is not a licensed health professional. 3. In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities. 4. Our facility will not use any individual as a nurse aide for more than four (4) months full-time, temporary, per diem, or other basis, unless: a. That individual is competent to provide nursing and nursing related services; and b. That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or c. That individual has been deemed competent as provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 3 of 4 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 02/11/2026 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)

F 0728 in S483.150(a) and (b) of the Requirements of Participation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675490 If continuation sheet Page 4 of 4