Golden Creek Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Golden Creek Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF602May 29, 2021

  Based on observations, interview, record review, and review of the facility's policy, the facility failed to have safeguards in place to ensure residents' medications were not misappropriated for one of one sampled resident reviewed for misappropriation of property (Resident (R) 16). The facility employed the Assistant Director of Nursing (ADON) even after becoming aware that the ADON could not have access or administer any narcotic mediations per the Texas Peer Assistance Program for Nurses (TPAPN). The facility failed to ensure the nurse did not have access to R16's narcotic medications. […]

• Actual harm, isolatedF742Feb 9, 2022

  Based on, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (Resident #1) of one resident reviewed for behavioral health services. -The facility did not assess Resident #1 after a change in behavior in which Resident #1 refused to leave her room and stopped attending activities after she reported being traumatized by isolation in another room for COVID-19. […]

• Actual harm, isolatedF600May 29, 2021

  Based on interview, record reviews, review of the facility's investigations, and review of the facility's policy, the facility failed to ensure all residents were free from abuse for two of six sampled residents reviewed for abuse and neglect (Resident (R) 4 and R10). R4 sustained actual harm of a fractured rib after the resident was physically abused by R9. Additionally, R10 was victim to verbal and emotional abuse from a facility employee. Findings include: Review of the facility's policy titled, Abuse Prohibition Policy, revised 10/08/20 revealed .This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment .1. […]

• No harm, potential for more than minimal, widespreadF812Apr 11, 2024

  Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to dispose of expired milk located in the kitchen's reach in refrigerator. 2. The facility failed to label and date all food items located in the reach in refrigerator, walk in refrigerator, and dry storage room. 3. The facility failed to properly store all food items to prevent contamination or spoilage. 4. The facility failed to sanitize the blender and thermometer during food preparation and temperature checks. 5. The facility failed to maintain a clean microwave, toaster, fryer, and clean the oven drip pans. 6. […]

• No harm, potential for more than minimal, widespreadF812Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. A. The facility failed to ensure the floors in the walk-in freezer and walk-in refrigerator was free of ice and water. B. The facility failed to properly store and label food in the facility's walk- in refrigerator and walk-in freezer. C. The facility failed to ensure Dietary Aide I and Dietary Cook J properly sanitized hands between tasks. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: A. […]