Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Golden Creek Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found multiple medication carts unlocked and unattended in common areas while containing prescription drugs, OTC medications, and narcotics. An LVN walked past three unlocked carts at the nurses’ station without securing them, and later another cart was observed unlocked with no staff nearby while two residents were in wheelchairs within the area. On a separate hall, an LVN was in a resident’s room with the door partially closed while the assigned medication cart remained unattended and unlocked in the hallway. In interviews, LVNs, the ADON, DON, and Administrator all acknowledged that policy requires carts to be locked when not in use or out of sight and that the assigned nurse is responsible for securing them, yet they could not explain why the carts were left unlocked. The facility’s written policy confirms that all drug compartments, including carts, must be locked when not in use and that unlocked medication carts are not to be left unattended.
A resident with Parkinson’s disease, multiple sclerosis, depression, and other comorbidities, who was dependent on staff for toileting and dressing, received incontinent care from a CNA while the room door was open and the privacy curtain was not used, leaving the resident exposed from the waist down. The resident, who was cognitively intact, reported that night-shift staff often left the door open during care and that this was upsetting, and he wanted the door closed and curtain pulled during all incontinent care. The CNA and facility leadership (ADON, DON, Administrator) all acknowledged that policy and resident rights require privacy during perineal and incontinent care, including closing doors and using privacy curtains, but the observed care did not follow these requirements.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
A resident did not receive appropriate care to maintain or improve ROM and mobility, and the facility did not ensure interventions were provided unless a decline was medically justified.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Surveyors observed unsanitary food storage and preparation practices, including cooked food placed near sanitation chemicals, repeated buildup of grime and residue in ice machines, and improper use and placement of cleaning towels and sanitizer buckets near food and clean dishes. Staff interviews revealed inconsistent cleaning routines, lack of documentation for equipment cleaning, and unclear maintenance reporting processes, all in violation of facility policies for kitchen sanitation and food safety.
Unlocked and Unattended Medication Carts with Accessible Drugs
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication carts were locked and medications secured in accordance with facility policy and accepted professional standards. During an early morning observation, three medication carts (MC #1, MC #2, and MC #3) were found along the wall at the nurses’ station, all unlocked, while containing residents’ prescription drugs, over-the-counter medications, and narcotics stored in a locked box within the carts. A nurse (LVN B) walked past all three carts without locking them, leaving the medications accessible. Further observations showed that MC #3 remained unlocked at the nurses’ station with no staff nearby, while two residents in wheelchairs were approximately 50 feet away from the cart. Later, on another hall, LVN B was observed inside a resident’s room with the door cracked open, while the assigned medication cart was left unattended and unlocked in the hallway. These observations demonstrated repeated instances where medication carts were not secured when the responsible nurse was not in direct attendance. In interviews, LVN B and LVN C both acknowledged they had been trained on medication storage and understood the policy that medication carts must be locked when not in use or when out of the nurse’s sight. LVN B stated he left the carts unlocked because he believed he was monitoring them, and admitted the carts should have been locked. LVN C reported he left MC #3 unlocked for several minutes while on a locked unit and could not see the cart from behind the secured door, acknowledging that someone could access the medications when the cart was left alone. The ADON, DON, and Administrator each confirmed that facility policy requires medication carts to be locked when unattended, that the assigned nurse or medication aide is responsible for locking the cart, and that monitoring is done through observation, but they could not explain why the nurses left the carts unlocked. Review of the written Storage of Medications Policy confirmed that all drug compartments, including carts, must be locked when not in use and that unlocked medication carts are not to be left unattended. The report states that this failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure privacy during personal care for one cognitively intact male resident who was dependent on staff for toileting hygiene and dressing. The resident, diagnosed with Parkinson’s disease, multiple sclerosis, protein-calorie malnutrition, type 2 diabetes with hyperglycemia, major depressive disorder, and muscle weakness, had a care plan that directed staff to reduce distractions and close the door during interactions. Despite these documented needs and interventions, a CNA provided incontinent care to this resident with the room door open and without pulling the privacy curtain, leaving him nude from the waist down and visible from the hallway. During interviews, the CNA acknowledged she had been trained on resident rights and knew that privacy during incontinent care required knocking, pulling the privacy curtain, and closing the door, and that all staff were responsible for providing privacy. She stated she had no reason for not providing privacy to this resident. The resident reported that staff on the night shift often left his door open when providing care and stated that he wanted staff to pull the curtain and close the door every time he received incontinent care, adding that it upset him when this was not done. Facility leadership, including the ADON, DON, and Administrator, all confirmed their understanding that staff were required by policy to provide privacy during incontinent care by closing doors and pulling privacy curtains. They each stated that the staff member providing care was responsible for ensuring privacy and acknowledged that failure to do so could cause the resident to feel embarrassed or not feel good. Review of the facility’s Perineal Care Policy and Resident Rights Policy showed that providing privacy is a required step in perineal care and that residents are guaranteed privacy and confidentiality, including privacy during personal care. Despite these policies and stated expectations, the observed care to this resident did not comply with the privacy requirements.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover the resident's assessed needs.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that the resident received necessary interventions to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. This lack of appropriate care was observed and cited during the survey.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Food Service Sanitation and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations and staff interviews. During kitchen inspections, surveyors observed a stainless-steel stockpot filled with cooked mashed potatoes placed near a red sanitation bucket containing used cleaning towels and sanitation chemicals. The commercial ice machine and the commercial countertop water and ice dispenser machine were found to have significant brown and white residue buildup, including slime and small white particles in drainage areas. These unsanitary conditions were repeatedly observed on multiple days, with the ice machine's interior and exterior surfaces showing persistent dirt, grime, and slime. Dietary staff were seen using cleaning towels from the red sanitation bucket to wipe down food preparation counters, with the towels being repeatedly dipped into the bucket and causing splashes near areas where food was being prepared. The red sanitation bucket was consistently kept on top of the food preparation counter, in close proximity to both food and clean dishes, despite staff acknowledging that spillage or splashes from the bucket could be harmful if they came into contact with food or dishes. Staff interviews revealed that the cleaning water in the buckets was changed each shift, but the placement of the bucket was not considered a concern by the dietary manager, even though other staff kept similar buckets under counters away from food and clean dishes. The facility's cleaning and maintenance practices for kitchen equipment were inconsistent and inadequately documented. The dietary manager stated that deep cleaning of the commercial ice machine was performed monthly but was not logged, and maintenance staff reported only performing work on the ice machine every six months. There was confusion and lack of clarity regarding the process for reporting and tracking maintenance issues, with verbal requests being made in morning meetings and not always entered into the maintenance software. Requested documentation of work orders and invoices for ice machine servicing was not provided. Facility policies required that equipment and food contact surfaces be maintained in a clean and sanitized condition, but these standards were not met, as evidenced by the observed accumulation of soil residues and improper storage of cleaning materials.
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Illustrative
What surveyors actually found near you
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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.
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Illustrative
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Nursing homes near Navasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Navasota Nursing & Rehabilitation | 0.6 mi | ★★★★★ | 11 | 2 |
| Accel At College Station | 17.6 mi | ★★★★★ | 8 | 1 |
| Fortress Nursing And Rehabilitation | 18.3 mi | ★★★★★ | 3 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 18.9 mi | ★★★★★ | 10 | 3 |
| High Hope Care Center Of Brenham | 23.8 mi | ★★★★★ | 9 | 0 |
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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.