Atlanta, TX

Golden Villa

3-star overall rating with 2-star inspections with $122,216 in total fines with 9 recent health deficiencies

1104 S William St, Atlanta, TX

(903) 796-0290

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Caring Healthcare Group

Operator or chain grouping

Approved since

1995-05-26

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.35

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.22

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.93

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

4.50

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.57

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.13

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.19

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.00

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.40

CMS adjusted RN staffing hours

Adjusted total hours

5.05

CMS adjusted total nurse staffing hours

Case-mix index

1.22

Higher values indicate more complex resident acuity

RN turnover

30%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,779

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.57

Composite VBP score used to determine payment impact.

Payment multiplier

0.9829

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 18.39% · Performance 21.46% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 8.25% · Performance 10.89% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.37

Baseline 47.19% · Performance 45.83% · Measure score 4.37 · Achievement 4.37 · Improvement 0.11

Adjusted total nurse staffing

4.66

Baseline 4.07 hours · Performance 4.40 hours · Measure score 4.66 · Achievement 4.66 · Improvement 1.45

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.68%	10.72% 2 pts worse	No Different than the National Rate · Eligible stays 120 · Observed rate 15.83% · Lower 95% interval 9.35%
Discharge to community	41.37%	50.57% 9.2 pts worse	No Different than the National Rate · Eligible stays 59 · Observed rate 37.29% · Lower 95% interval 31.97%
Medicare spending per beneficiary	1.79	1.02 0.8 pts worse
Drug regimen review with follow-up	88.61%	95.27% 6.7 pts worse	Numerator 70 · Denominator 79
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 79
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	3.8%	2.29% 1.5 pts worse	Numerator 3 · Denominator 79 · Adjusted rate 3.77%
Healthcare-associated infections requiring hospitalization	10.89%	7.12% 3.8 pts worse	No Different than the National Rate · Eligible stays 69 · Observed rate 17.39% · Lower 95% interval 7.04%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 161
Staff flu vaccination coverage	5.6%	42% 36.4 pts worse	Numerator 7 · Denominator 125
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	88%	95.95% 8 pts worse	Numerator 44 · Denominator 50
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	93.94%	25.2% 68.7 pts better	Numerator 31 · Denominator 33

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	2.1 0.4 pts better	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.7	2.1 0.6 pts worse	1.8 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.2 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.3% 3.3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.7%	2.7% 1 pts better	11.4% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 2.8% · Q4 1.4% · 4Q avg 1.7%
Percentage of long-stay residents who lose too much weight	1.0%	3.3% 2.3 pts better	5.4% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 1.4% · 4Q avg 1.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	20.2%	18.9% 1.3 pts worse	19.6% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 19.4% · Q3 20.5% · Q4 17.8% · 4Q avg 20.2%
Percentage of long-stay residents who received an antipsychotic medication	5.6%	10.8% 5.2 pts better	16.7% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 8.8% · Q3 3.6% · Q4 3.4% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	2.6%	15.4% 12.8 pts better	16.3% 13.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 3.5% · Q4 1.6% · 4Q avg 2.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.0%	16.1% 5.1 pts better	14.9% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 6.9% · Q3 12.3% · Q4 6.8% · 4Q avg 11.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	1.0%	15.0% 14 pts better	19.8% 18.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents with pressure ulcers	2.5%	4.2% 1.7 pts better	5.1% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.1% · Q3 4.1% · Q4 2.3% · 4Q avg 2.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	19.0%	12.0% 7 pts worse	12.0% 7 pts worse	Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 17.6% · Expected 10.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	19.8%	25.9% 6.1 pts better	23.9% 4.1 pts better	Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 17.6% · Expected 21.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-04 · Fire 2025-06-04

9 health deficiencies

Top issue: Environmental (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-05-01 · Fire 2024-05-01

10 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-03-04 · Fire 2023-03-04

17 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-01

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-29

F · Potential for more than minimal harm 2023-03-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-26

E · Potential for more than minimal harm 2023-03-04

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-04-05

E · Potential for more than minimal harm 2023-03-04

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-04-26

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-09

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2025-12-10

D · Potential for more than minimal harm 2025-11-13

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2025-11-14

E · Potential for more than minimal harm 2025-06-24

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-06-05

E · Potential for more than minimal harm 2025-06-04

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-06-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-06-04

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-06-04

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-06-05

D · Potential for more than minimal harm 2025-06-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-05

K · Immediate jeopardy 2025-01-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-02-01

D · Potential for more than minimal harm 2025-01-31

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2025-02-01

E · Potential for more than minimal harm 2024-05-01

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-05-02

E · Potential for more than minimal harm 2024-05-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-05-02

E · Potential for more than minimal harm 2024-05-01

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-05-02

E · Potential for more than minimal harm 2024-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-02

D · Potential for more than minimal harm 2024-05-01

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-05-02

D · Potential for more than minimal harm 2024-05-01

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-05-02

D · Potential for more than minimal harm 2024-05-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-05-02

D · Potential for more than minimal harm 2024-05-01

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-05-02

J · Immediate jeopardy 2024-02-16

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2024-02-17

D · Potential for more than minimal harm 2024-02-16

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-02-17

E · Potential for more than minimal harm 2023-10-27

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-11-24

K · Immediate jeopardy 2023-03-04

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-03-05

J · Immediate jeopardy 2023-03-04

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-03-05

G · Actual harm 2023-03-04

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-03-05

E · Potential for more than minimal harm 2023-03-04

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-03-05

E · Potential for more than minimal harm 2023-03-04

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-03-05

E · Potential for more than minimal harm 2023-03-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-03-05

E · Potential for more than minimal harm 2023-03-04