Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Goldthwaite Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found multiple food safety and hand hygiene failures in the kitchen and dining areas. Expired cereal, expired chocolate topping, and used cooking oil were observed, along with unlabeled and undated items in a resident refrigerator. Staff were also observed failing to wash or sanitize hands during puree preparation and before serving drinks and meal trays to residents, despite training and stated expectations for proper hand hygiene.
Call lights were not kept within reach for several residents with cognitive and mobility impairments. A resident with dementia and Parkinson’s disease, a resident with stroke-related deficits, a resident with intracranial injury and dementia, and a resident with severe cognitive impairment all had call lights placed out of reach or inaccessible, and some stated they did not know where the call light was or how to contact staff for help. A restroom call light was also found without a string attached.
A facility failed to maintain a clean, comfortable, and homelike environment in 2 shared restrooms and 2 resident rooms. Observations found overflowing trash, urine in a toilet bowl, a wet towel on the floor, dirty light switches, a filthy call light string, stained walls, damaged grout/caulking, dust-covered vent fans, and missing insect screens on resident room and hallway windows; staff interviews confirmed maintenance and housekeeping concerns and noted the hall 3 shower was still in use.
Failure to disinfect a BP cuff between residents during medication administration. An MA used the cuff on one resident and then on several other residents without cleaning it in between. The MA said she was frequently in-serviced on infection control but did not recall the policy on disinfecting the cuff between residents. RN C, the DON, and the ADM all stated reusable medical equipment should be disinfected between residents, and the facility policy referenced CDC and OSHA disinfection standards.
A facility failed to keep working call systems accessible in two shared restroom areas. In one restroom, the call light by the toilet had no pull string attached, and in another, the call light string could not be reached from the shower. Staff, including an RN, LVN, CNA, DON, and MTD, acknowledged that residents needed call lights within reach from the toilet, shower, and floor, and maintenance logs did not document the missing cords.
Controlled Substance Reconciliation Failure: A resident with stroke, DM2, epilepsy, and pain was prescribed Tylenol #3 twice daily, and the MAR showed no missed doses. Staff reported the card was received and placed in the med cart, but later the resident was found out of the medication. The MA, charge nurse, DON, and ADM gave differing accounts of cart access and counts, and the facility could not determine what happened to the card or show a reliable reconciliation system for controlled meds.
A resident with traumatic brain injury, schizophrenia, and significant behavioral symptoms was admitted and quickly exhibited escalating verbal aggression, threats, and disruptive behaviors that frightened other residents and families. The ADM directed the LBSW to arrange transfer under emergency detention to a behavioral hospital, and the resident was transported with court-approved paperwork. However, review of the chart showed no physician order for discharge, no discharge assessment or summary, and no physician documentation of the basis for the facility-initiated transfer/discharge, despite facility policy and federal requirements that a physician document the basis when safety is endangered by a resident’s clinical or behavioral status. The MD later stated she routinely signs discharge summaries and would have signed one if asked, while the ADM and DON acknowledged they were unaware of the need for physician-signed discharge documentation, resulting in an incomplete and noncompliant medical record for this discharge episode.
Surveyors found that food items in the kitchen, including refrigerated and shelf-stored products, were not consistently labeled, dated, or covered according to facility policy and professional standards. Staff interviews confirmed awareness of proper procedures, but observations revealed expired and improperly labeled food items, indicating a lapse in daily food safety checks and adherence to established protocols.
A resident with multiple mental health diagnoses was admitted without the PASRR Level I assessment reflecting their mental illness, and no referral was made for a Level II evaluation. Despite receiving psychiatric services, the facility accepted a negative PASRR Level I from the hospital and did not follow policy requirements for further screening or referral.
A resident with PTSD and other mental health diagnoses did not have trauma triggers identified or addressed in their care plan, despite receiving psychiatric services and having intact cognition. Facility staff were unaware that trauma-informed interventions were missing, and no specific actions were taken to ensure culturally competent, trauma-informed care as required by facility policy.
A COTA at an LTC facility engaged in inappropriate and abusive behavior with multiple residents, including sexual abuse and inappropriate physical contact. Despite warnings and disciplinary actions, the facility failed to prevent further incidents, leading to a pattern of abuse and neglect. Residents reported feeling uncomfortable and unsafe, and the facility's policies on abuse prevention and reporting were not adequately enforced.
A facility failed to prevent abuse and inappropriate conduct by a COTA, who engaged in a sexual relationship with a resident and inappropriate physical contact with others during therapy. Despite staff awareness of rumors and unusual behavior, the facility did not investigate or report the allegations promptly, placing residents at risk.
A COTA at the facility engaged in inappropriate relationships and conduct with multiple residents, including a romantic and sexual relationship with one resident and inappropriate physical contact during therapy sessions. Despite being aware of rumors and allegations, the facility administration failed to investigate or report the conduct, resulting in a deficiency in ensuring residents were free from abuse.
The facility failed to maintain food safety and sanitation standards, with issues such as improperly labeled and dated food, expired ingredients, and unsanitary conditions in the kitchen. Staff were observed handling food improperly and not wearing hairnets, increasing the risk of contamination. The dietary manager acknowledged these lapses, attributing them to oversight and staff nervousness.
The facility failed to ensure complete and valid DNR documentation for several residents, with missing physician and witness signatures leading to potentially invalid orders. Interviews revealed a lack of staff training and awareness, risking residents' end-of-life care decisions.
The facility failed to update comprehensive care plans within seven days after MDS assessments for several residents, risking delayed treatment and care. The DON and MDS Coordinator were responsible for care plans, but inconsistencies in the process led to non-compliance with facility policy and guidelines.
A facility failed to complete a timely MDS assessment for a resident with moderate cognitive impairment, resulting in an outdated care plan. The MDS was completed 18 days after the ARD, exceeding the 14-day requirement. The resident had diagnoses including dementia and hypertension.
A resident was admitted to the facility without a PASRR Level 1 screening being completed prior to admission. The screening, which identifies mental illness and eligibility for additional services, was completed 30 days after admission. The MDS Coordinator acknowledged the delay, and the DON confirmed the absence of a specific PASRR policy, relying instead on HHSC guidelines.
Two CNAs failed to follow proper hand hygiene protocols during incontinent care for a resident, as observed in a survey. They did not wash their hands or use ABHR upon entering the room or during the care process, and supplies were improperly placed on the resident's mattress. The CNAs did not change gloves between cleaning different areas, and no hand hygiene was performed before exiting the room. The DON confirmed the expectation for consistent hand hygiene, and competency assessments indicated the CNAs were deemed competent, yet their actions did not align with these standards.
Food Storage and Hand Hygiene Failures in Kitchen and Dining Areas
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional food safety standards in its only kitchen. During the initial kitchen tour, surveyors observed 3 sealed cereal containers on dry storage shelves that had a received date of 03/05/2026 and a shelf life of 30 days, 1 chocolate topping bottle in the walk-in refrigerator with an open date of 04/23/2026 and an expiration date of 05/02/2026, and used oil in a 20-quart pot dated 05/04/2026 sitting beside the stove top. In the dining room, a standalone refrigerator contained 5 food items that were all unlabeled and undated. Interviews with dietary leadership showed that the DS acknowledged the cereal containers had been refilled on 05/06/2026 and were not labeled with the correct dates, that the chocolate topping was expired and should have been discarded, and that the oil had been used several times and should have been discarded after the first use. The DS also stated the dining room refrigerator was intended for residents' personal food items or food brought in by family or friends. The ADM stated that all staff had been trained in hand sanitation and that staff who serve food should use hand sanitizer between meal tray services. Survey observations also showed repeated failures with hand hygiene during food preparation and service. The DC was observed preparing purees without washing hands between tasks, failing to wash hands before beginning puree #1, puree #2, and puree #3, and then obtaining milk from the refrigerator without washing hands after completing the purees. The DC was later observed walking from the food preparation area to the food distribution line and failing to wash hands before serving food to plates. CNA E was observed pouring and serving drinks to 9 residents without using hand sanitation between residents. The HA was observed touching her necklace and lips, then failing to sanitize hands before continuing to serve breakfast trays and deliver trays to multiple rooms. The RD stated staff should wash hands between tasks and that residents could be at risk for illness if staff did not follow hand washing policy.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to provide reasonable accommodations by not ensuring call light devices were within reach for multiple residents. Residents #20, #24, #28, and #120 all had care plans that directed staff to keep the call light within reach and encourage use of the bell for assistance. The report also identified Resident #47 in the deficiency statement as having the call light button device out of reach, although the detailed findings focused on Residents #20, #24, #28, and #120. Resident #20 had diagnoses including dementia, anxiety disorder, and Parkinson’s disease, with a BIMS score of 03 and dependence for all ADLs. Her call light was observed hanging off the right side of the bed and out of reach, and she shook her head no when asked if she could locate it. Resident #24 had diagnoses including cerebral infarction and senile degeneration of the brain, with a BIMS score of 12 and dependent mobility. His call light was on the bedside table and he could not reach it; he stated he did not know where it was located and did not know how he would contact staff if he needed help. Resident #28 had diagnoses including intracranial injury, unspecified dementia, and anxiety disorder, with a BIMS score of 8 and partial/moderate assistance needed for transfers. His call light was hanging off the right side of the bed and out of reach, and he stated he was not aware of its location. Resident #120 had diagnoses including senile degeneration of the brain, type 2 diabetes mellitus, and anxiety disorder, with severe cognitive impairment and dependence for mobility. Her call light was found between the mattress and bedframe while she was lying in bed facing the wall, and she indicated she did not know where it was and could not use it to contact staff. The report also noted a restroom call light in hall 2 with no string attached to the metal arm.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in 2 shared resident restrooms and 2 resident rooms reviewed for cleanliness and homelike conditions. In hall 2’s shared restroom, an observation showed an overflowing trashcan with toilet paper and/or paper towels on the floor, urine still in the toilet bowl, a wet towel on the floor near the sink, and an unknown brown substance on the light switch. In hall 3’s shared restroom, observations showed brown stains on the wall beside the toilet, a call light string that was beige at the top and dark brown toward the bottom with visible wear and filth, damaged and deteriorated grout/caulking at the floor-to-wall transition, and a vent fan covered in dust. The report also noted corroded caulking and limestone tiles, and broken or missing grout in the shower area. The facility also failed to have insect screens on the outside of 2 resident room windows and 1 hallway window. One resident room window to the courtyard was open with air flowing into the room and no screen affixed to the outside, and a lotion bottle was being used to hold the window open. Another observation showed the hallway 3 window to the courtyard had no insect screen, and the resident room visible from that window also lacked a screen. Staff interviews stated maintenance was responsible for replacing call light strings, that the hall 3 shower was still in use, that the grout and caulking issues would need to be reported to maintenance, and that window screens were needed for privacy, bug prevention, and comfort. The ADM stated he had not recently checked the hall 3 restroom condition and that the facility had been attempting to obtain more window screens.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents reviewed for infection control. During observation on 5/12/2026 at 9:03 AM, MA H used a blood pressure cuff on Resident #20 and then did not disinfect the cuff before using it on or between Resident #40, Resident #48, and Resident #42 while performing medication administration. During interview on 5/12/2026 at 10:03 AM, MA H stated she was frequently in-serviced on infection control but did not recall whether the policy mentioned disinfecting the blood pressure cuff between residents, and she did not know of any issues that could occur if the cuff was not cleaned. RN C stated on 5/12/2026 at 3:16 PM that reusable medical equipment should be cleaned between residents and that failure to wipe it down could transmit infections from resident to resident. The DON stated on 5/14/2026 at 12:03 PM that staff were expected to disinfect the blood pressure cuff between residents, and the ADM stated on 4/16/2026 at 12:36 PM that staff were frequently in-serviced on infection control and that an unclean cuff could spread infection if it had germs on it. Facility policy stated environmental surfaces would be cleansed and disinfected according to current CDC recommendations and the OSHA bloodborne pathogens standard.
Call Lights Not Accessible in Shared Restrooms
Penalty
Summary
The facility failed to ensure that working call systems were available in two shared resident restrooms, including access from the floor and from the shower/bathing area. In the hall 2 shared restroom, observation showed the call light device to the left of the toilet had no string attached to the metal arm extending from the wall. In the hall 3 shared restroom, observation showed the call light string near the toilet was not reachable from the shower. Staff interviews reflected that call lights were expected to be within reach of residents and that residents could fall and need assistance. RN C stated residents should be able to reach a call light and that all staff were responsible for making sure call lights were within reach. LVN D stated call lights were to be within reach of each resident and that a resident may not get appropriate care if they could not call for help. CNA E stated she was responsible for making sure residents' call lights were within reach and that a resident could fall or get hurt if they did not have a call light in reach. Additional observations showed the hall 2 restroom call light still had no string attached on later dates. RN A stated the DON had been notified and Maintenance was getting the cord replaced, and that a resident on the floor would not have been able to reach the call light without the pull cord. The DON stated she had started working on getting the pull cord replaced and was not sure how long it had been missing. The Maintenance Director stated he would replace call light cords when reported to him, and the facility maintenance logs for the relevant period did not mention the hall 2 call light string or the hall 3 bathroom call light cord. The facility policy stated the call light should be accessible from bed, toilet, shower or bathing facility, and floor, and defective call lights should be reported promptly.
Controlled Substance Reconciliation Failure
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs in sufficient detail to allow accurate reconciliation and to ensure controlled drug records were in order. The deficiency involved one resident, a female with diagnoses including cerebral infarction due to occlusion of a small artery, type II diabetes mellitus, hypercalcemia, osteoarthritis of the left knee, history of TIA without residual effects, and epilepsy. Her MDS reflected a BIMS score of 15, indicating no cognitive impairment. Her physician ordered Acetaminophen-Codeine 300-30 mg, 1 tablet by mouth twice daily for pain, and her MAR showed no missed doses. During interview, the resident stated she received her pain medication as scheduled twice daily and had not missed doses because the facility was without Tylenol #3 for a few days. A pharmacy receipt later reviewed showed Tylenol #3 was received by the facility and signed for by an MA. The MA stated she remembered receiving the card of Tylenol #3, placing it in the medication cart for hall #1, and ensuring a controlled medication count sheet was placed in the book and the medication card was in the cart lock box. She stated she recalled the card being accounted for on subsequent shifts. Another MA stated that on one shift it was noticed the resident was out of Tylenol #3, and later she remembered seeing the card and narcotic sheet that morning but not for the evening. She stated the charge nurse and DON also had access to the cart at times, and that controlled medication counts were mostly done when handing over cart keys. The DON and ADM stated they initially thought the medication had been delayed by the pharmacy or partially supplied, later learned the facility had received a full card of Tylenol #3, and could not determine what happened to the card. The ADM stated there was no control sheet to trigger that a card was missing, and the facility policy required controlled substance inventory to be monitored and reconciled to identify loss or potential diversion.
Failure to Obtain Required Physician Documentation for Facility-Initiated Behavioral Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a facility-initiated transfer and subsequent non-readmission were properly documented in the resident’s medical record and supported by required physician documentation. A male resident with traumatic brain injury, schizophrenia, and a history of methamphetamine use was admitted with noted behavioral issues, including verbal aggression and other disruptive behaviors as documented on his admission MDS and care plan. Over the course of the weekend following admission, multiple staff documented that the resident was verbally aggressive, yelling, cursing, threatening to beat people up if he could not smoke when he wanted, slamming his hand on objects, and throwing or pushing items. Other residents and their families reported feeling scared and uncomfortable, and staff described having to keep residents in their rooms due to concern about the resident’s behavior. In response to these behaviors, the Administrator directed the LBSW to seek admission for the resident to a behavioral health hospital. The LBSW contacted the behavioral hospital, provided required information, obtained acceptance, and then went to the county courthouse to secure Emergency Detention forms signed by a judge. A county officer transported the resident to the behavioral health hospital with the emergency detention paperwork and other documents. The facility’s progress notes describe this process, but review of the resident’s medical record showed no physician order related to the resident’s discharge, no discharge assessment or summary signed by a physician, and no discharge summary or discharge order signed by a physician for the period reviewed. The facility’s own transfer/discharge policy required that when a resident is transferred or discharged because the safety of individuals in the facility is endangered due to the resident’s clinical or behavioral status, the basis for the transfer or discharge must be documented in the clinical record by a physician. The attending MD later stated she had not seen the resident in person because he was only in the facility over one weekend before being sent to the behavioral health hospital, but she had reviewed the notes and believed he was a danger to other residents. She also stated she routinely signed discharge summaries and would have signed one for this resident if she had been asked, indicating that no such request or process occurred. The Administrator and DON both acknowledged in interviews that they were still learning their roles and were unaware of all documentation requirements, with the Administrator specifically stating he did not know a physician signature was required on the documentation explaining the basis for the emergency discharge. As a result, the resident’s record lacked the required physician documentation of the basis for the transfer/discharge under the regulatory criteria, and the facility failed to ensure that the transfer/discharge was fully documented in accordance with federal requirements and its own policy. After the resident’s transfer to the behavioral health hospital, the Administrator reported that the behavioral health hospital later contacted the facility stating the resident was ready for discharge, but the clinical paperwork still reflected similar behaviors, and the facility decided not to readmit him. The Administrator stated he contacted the ombudsman, obtained a list of potentially more suitable facilities, and attempted to reach the resident’s family member (FM) to obtain permission to send referral paperwork to an alternate facility, but the FM did not return his calls. The Administrator then learned from the behavioral health hospital that the family chose to care for the resident in the community, and he stopped working on placement. Throughout this sequence, there remained no physician-signed documentation in the resident’s medical record establishing the basis for the facility-initiated discharge decision as required by regulation and facility policy, which constituted the cited deficiency.
Failure to Properly Label, Date, and Store Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage and labeling practices. During an initial tour, the walk-in refrigerator contained a box of yogurt with an expiration date, and shelves held brown bananas, an open and expired pack of tortillas, a pack of strawberry gelatin in a zip lock bag with a date, and an open, undated bag of either lemon gelatin or cake mix. Additionally, some refrigerated items that had been opened were labeled with open dates, use by dates, and expiration dates, but an opened sliced cheese package was only labeled with the open date and was missing the use by date. These observations indicated that food items were not consistently labeled, dated, or covered as required by facility policy and professional standards. Interviews with the Dietary Manager (DM), Dietary Aide (DA), and another staff member confirmed that they were trained to check for expired food and to label and date opened food items, but the observed practices did not align with this training. The DM acknowledged responsibility for daily checks and stated that a new labeling policy was being implemented. Both the DON and the Administrator stated that serving expired food could make residents sick and that it was the DM's responsibility to ensure expired food was discarded. Review of the facility's policy confirmed the requirement for all opened food to be labeled, dated, and stored properly, and for food to be covered when stored.
Failure to Accurately Complete PASRR and Refer for Level II Evaluation
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected a resident's mental health status. Specifically, a male resident with documented diagnoses of Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, Metabolic Encephalopathy, Depression, and Post Traumatic Stress Disorder was admitted without the PASRR Level I indicating the presence of a mental illness. The resident's care plan did not address his schizoaffective disorder or PTSD, and the PASRR Level I, completed by an acute care hospital, marked 'No' for both mental illness and intellectual disability, despite clear evidence of such diagnoses in the resident's records. The facility did not refer the resident to the appropriate state-designated mental health or intellectual disability authority for a Level II PASRR evaluation, as required when a mental illness is identified. Interviews with facility staff, including the MDS nurse, DON, and ADM, revealed that the negative PASRR Level I from the hospital was accepted without further review or referral, even though the resident was receiving psychiatric services twice per month through a contracted provider. Staff acknowledged that hospital PASRR screenings were often inaccurate but did not initiate a Level II screening for this resident. Additionally, the facility did not have a PASRR-specific policy available when requested, and the existing admission criteria policy outlined the requirement for Level I screening and referral for Level II evaluation if mental illness or intellectual disability is suspected. The policy also assigned responsibility for making referrals to the social worker, but this process was not followed in the resident's case.
Failure to Care Plan for Trauma Triggers in Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) received trauma-informed and culturally competent care in accordance with professional standards of practice. Specifically, the resident's comprehensive care plan did not include any goals or interventions to address or mitigate triggers related to the resident's PTSD, despite the diagnosis being documented. The resident, who also had diagnoses of schizoaffective disorder, anxiety disorder, metabolic encephalopathy, and depression, was receiving psychiatric services twice monthly and had intact cognition as indicated by a BIMS score of 15. However, there was no evidence that the care plan accounted for the resident's trauma history or potential triggers. Interviews with facility staff, including the MDS Nurse, DON, and ADM, revealed a lack of awareness and action regarding the need to identify and care plan for trauma triggers for residents with PTSD. Staff stated that while residents with PTSD were offered psychiatric services, there were no specific interventions or care plan updates addressing trauma triggers. The facility's own policy required comprehensive, person-centered care plans that are culturally competent and trauma-informed, but this was not implemented for the resident in question.
Failure to Protect Residents from Abuse by COTA
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by multiple incidents involving a Certified Occupational Therapy Assistant (COTA) identified as D. The COTA engaged in inappropriate and abusive behavior with several residents, including sexual abuse and inappropriate physical contact. Resident #1, a cognitively intact female with multiple health conditions, reported that COTA D groomed her for a relationship, leading to sexual intercourse in her room. Despite warnings and disciplinary actions against COTA D for unprofessional conduct, the facility did not prevent further incidents. Resident #2, also cognitively intact, experienced inappropriate behavior from COTA D during therapy sessions, where he removed her pants without explanation, making her feel uncomfortable. This incident was witnessed by a CNA who did not report it immediately. Additionally, Resident #3, who had previously been satisfied with the facility's care, refused to return due to COTA D's inappropriate behavior, including visiting her home and giving her inappropriate gifts. The facility's failure to act on rumors and reports of COTA D's behavior allowed these incidents to occur. Residents #4 and #5 also reported inappropriate touching by COTA D during therapy sessions. Despite these reports, the facility's administration and staff failed to take timely and effective action to prevent further abuse. The facility's policies on abuse prevention and reporting were not adequately enforced, leading to a pattern of abuse and neglect that placed residents at risk. The facility's inaction and lack of proper oversight contributed to the continuation of these abusive behaviors.
Failure to Prevent Abuse and Inappropriate Conduct by Therapy Staff
Penalty
Summary
The facility failed to adhere to its policies and procedures to prevent mistreatment, abuse, neglect, and exploitation of residents, as well as misappropriation of residents' property. This deficiency was identified through observations, interviews, and record reviews involving multiple residents. A certified occupational therapy assistant (COTA) was found to have engaged in inappropriate and unprofessional conduct with several residents, including having a sexual relationship with one resident and inappropriate physical contact with others during therapy sessions. One resident, who was cognitively intact, reported that the COTA groomed her for a relationship, which included taking her out to eat and meeting her family under the guise of therapy. The resident eventually reported that the COTA had intercourse with her in her room. Another resident reported that the COTA removed her pants during therapy sessions, which made her feel uncomfortable, although she initially did not report it due to fear. Other residents also reported inappropriate touching by the COTA during therapy sessions, including rubbing their buttocks and genitalia. The facility's failure to investigate and report these allegations promptly to the state office, as well as to protect the residents from potential abuse, was a significant oversight. Staff members, including CNAs and the Administrator, were aware of rumors and observed unusual behavior but did not take appropriate action to address the situation. This lack of action placed residents at risk of sexual abuse from facility staff, highlighting a severe breach in the facility's duty to ensure a safe environment for its residents.
Inappropriate Conduct by COTA with Residents
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by inappropriate relationships and conduct by a Certified Occupational Therapy Assistant (COTA) with multiple residents. The COTA engaged in a romantic and sexual relationship with a resident, which was not reported or investigated by the facility administration despite being aware of rumors and allegations. The COTA was also reported to have taken residents out of the facility for meals, which was not part of their therapy plan, and engaged in inappropriate physical contact with residents during therapy sessions. The facility's administration was alerted to the inappropriate relationship between the COTA and a resident but failed to investigate or report the allegations. The COTA was given warnings for not following professional boundaries and for providing therapy outside the prescribed plan of care. Despite these warnings, the COTA continued to engage in inappropriate conduct, including taking residents out for meals and engaging in physical contact that was not part of the therapy plan. The facility's failure to act on these warnings and allegations resulted in multiple residents being subjected to inappropriate conduct by the COTA. Interviews with residents and staff revealed that the COTA engaged in inappropriate conduct with multiple residents, including taking off a resident's pants during therapy, fondling a resident, and giving a resident inappropriate gifts. Staff members observed the COTA taking residents out for meals and engaging in behavior that was not part of the therapy plan but did not report these observations to the administration. The facility's failure to investigate and address these allegations and observations resulted in a deficiency in ensuring residents were free from abuse.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed that food items in the freezer and cooler were not properly labeled or dated, with several items not in their original packaging. Additionally, the kitchen prep area was found to be cluttered with personal items and expired food products, including spices and baking ingredients. Containers for bulk food items such as flour and rice were noted to be grimy and sticky, with unsecured lids and additional bags placed on top of loose contents. During meal service, a staff member was observed handling food with gloved hands that had previously touched various kitchen surfaces without washing or changing gloves. This included picking up biscuits with her hands instead of using tongs, which she acknowledged could lead to cross-contamination and illness. The dietary manager, who was present, confirmed that the staff member was aware of the proper procedures but attributed the lapse to nervousness. The dietary manager also admitted to being out of the facility, which contributed to the oversight of these issues. Furthermore, staff members were observed not wearing hairnets in the kitchen, which they attributed to forgetfulness. The dietary manager acknowledged the importance of wearing hairnets to prevent hair from contaminating food and kitchen surfaces. The facility's policies, dated 2012, clearly outlined the requirements for sanitation, food handling, and infection control, including the use of hairnets, proper labeling and dating of food, and maintaining cleanliness in the kitchen. However, these policies were not consistently followed, leading to the identified deficiencies.
Deficiencies in DNR Documentation for Residents
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advanced directive, specifically a Do Not Resuscitate (DNR) order, for eight residents reviewed. The deficiencies included missing information in the Physician Statement Section for several residents, such as the physician's license number or printed signature, and missing witness signatures for another resident. These omissions rendered the DNR orders incomplete and potentially invalid, which could lead to residents not receiving healthcare according to their wishes. The report details the medical conditions and cognitive impairments of the affected residents, highlighting their vulnerability. For instance, one resident with epilepsy, major depressive disorder, and schizophrenia was listed as a DNR, but the physician's license number was missing from the DNR form. Another resident with dementia and diabetes had a DNR form lacking witness signatures. These errors in documentation were consistent across multiple residents, indicating a systemic issue within the facility's process for handling advanced directives. Interviews with facility staff, including registered nurses and the Director of Nursing (DON), revealed a lack of awareness and training regarding the completion and validation of DNR forms. Staff members admitted to not verifying the completeness of the forms, and the DON acknowledged the issue but continued to consider the residents as DNR despite the invalid forms. This oversight in ensuring the accuracy of critical documentation could lead to significant consequences for residents' end-of-life care decisions.
Failure to Update Comprehensive Care Plans Timely
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed within seven days after the completion of comprehensive assessments and were reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for seven residents, who did not have their care plans updated in accordance with the required timeline following their Minimum Data Set (MDS) assessments. The lack of timely updates to the care plans could potentially place residents at risk of delayed treatment, care, and services, which might prevent them from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. For Resident #1, the care plans were completed significantly before the MDS assessments, with gaps of 23 to 26 days prior to the assessment dates. Similarly, Resident #3's care plans were completed well before the MDS assessments, with one care plan completed 49 days prior to the assessment. Resident #23's care plans were not aligned with the MDS assessment dates, with one care plan completed 21 days after the assessment. Resident #31 had care plans that were not updated following the MDS assessments, with the last care plan dated months before the assessments. The facility's Director of Nursing (DON) and MDS Coordinator were responsible for the care plans, but there was a lack of coordination and adherence to the facility's policy, which required care plans to be completed within seven days of the MDS assessments. Interviews with the MDS Coordinator and the DON revealed inconsistencies in the care plan process, with the DON stating that care plans were comprehensive and updated in real-time, yet the records showed otherwise. The facility's policy and the Resident Assessment Instrument guidelines were not followed, leading to the identified deficiency.
Failure to Timely Complete MDS Assessment
Penalty
Summary
The facility failed to complete a timely assessment for a resident using the quarterly review instrument specified by the State. Specifically, the quarterly Minimum Data Set (MDS) for a resident was not completed within the required 14 days from the Assessment Reference Date (ARD). The ARD for this resident was set on January 5, 2024, but the MDS was not completed until January 23, 2024, which is 18 days after the ARD. This delay in completing the MDS assessment can lead to inadequate care and care plans not being updated correctly. The resident involved was an elderly female with diagnoses including dementia, hypertension, syncope, and edema. The resident's clinical record indicated a Brief Interview for Mental Status (BIMS) score of 07, suggesting moderate cognitive impairment. During an interview, the MDS nurse acknowledged the delay and explained that the MDS assessments are scheduled using a calendar and should be completed every 92 days. The nurse also mentioned using the Resident Assessment Instrument (RAI) manual for guidance. The failure to complete the MDS on time resulted in the resident's care plan not being updated as required.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a new resident was not admitted with mental disorders unless the State mental health authority had determined, based on an independent physical and mental evaluation, that the admission was appropriate. Specifically, Resident #44 was admitted without a PASRR Level 1 screening being completed prior to admission. The resident, a female with diagnoses including Alzheimer's Disease, hypertension, and hyperlipidemia, was admitted to the facility, and her PASRR Level 1 screening was completed approximately 30 days after her admission. During an interview, the MDS Coordinator acknowledged that the PASRR assessment for Resident #44 was late and expressed uncertainty about how this oversight occurred. The MDS Coordinator mentioned that PASRR assessments are intended to identify any mental illness and determine if a resident qualifies for additional services. The Director of Nursing confirmed that there was no specific PASRR policy in place at the facility, as they followed the HHSC guidelines for PASRR assessments.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as observed during a survey. Two CNAs, identified as CNA D and CNA E, were observed performing incontinent care for a resident without adhering to proper hand hygiene protocols. Neither CNA washed their hands or used alcohol-based hand rub (ABHR) upon entering the resident's room or during the care process. Supplies such as wipes and a new brief were placed directly on the resident's mattress, which is against the facility's procedural guidelines. During the care, CNA D and CNA E did not change gloves between cleaning different areas of the resident's body, which is a critical step to prevent cross-contamination. After completing the care, both CNAs removed their gloves but did not perform hand hygiene before exiting the room. This lack of hand hygiene was confirmed by both CNAs during an interview, where they acknowledged the importance of handwashing and the potential for cross-contamination and infection if not performed correctly. The Director of Nursing (DON) confirmed the expectation for staff to perform hand hygiene consistently, especially during resident care. The competency assessments for both CNAs indicated they were deemed competent in hand hygiene and infection control practices, yet the observed actions contradicted these assessments. The facility's policy on perineal care, which includes specific steps for handwashing and glove changes, was not followed during the observed incident.
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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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Nursing homes near Goldthwaite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillview Nursing & Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| San Saba Nursing & Rehabilitation | 20.1 mi | ★★★★★ | 0 | 0 |
| Cross Country Healthcare Center | 27.9 mi | ★★★★★ | 1 | 0 |
| Pecan Bayou Nursing And Rehabilitation | 29.2 mi | ★★★★★ | 6 | 0 |
| Oak Ridge Manor | 29.2 mi | ★★★★★ | 5 | 0 |
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