Golden Creek Healthcare and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and document a care plan conference following a quarterly or annual MDS for 3 of 5 residents (Resident #34, #35 and #51) reviewed for care plan conferences. The facility failed to document a care conference for Resident #34, Resident #35 and Resident #51. This failure could place residents at risk of not having their physical, mental and psychosocial needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly store, label, and date all food items located in the kitchen facility refrigerator, freezer and in the dry food pantry area on 06/29/2026, 06/30/2026 and 07/01/2026. 2. The facility failed to properly clean and sanitize food storage containers on 06/29/2026, 06/30/2026 and 07/01/2026. 3. The facility failed to discard dented soup can and expired instant potatoes from dry food area on 06/29/2026, 06/30/2026 and 07/01/2026. 4. The facility failed to ensure kitchen trashcan was covered with lid on 7/01/2026.5. The facility failed properly clean and sanitize food plate warmer dispenser on 7/01/2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one facilities reviewed for the pest control program. The facility failed to keep flies out of resident rooms, the facility kitchen, the facility dining room, and the facility common areas. This failure placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 8 residents (Resident #51) reviewed for infection control. CNA D failed to change her gloves or clean her hands when moving from a dirty to clean site while performing peri-care for Resident #51 on 07/01/2026 at 03:15 PM.This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that drugs were stored properly, and only authorized persons have access for 3 of 5 medication carts (MC #1, MC #2, and MC #3) reviewed for drug storage. The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors. The facility failed to ensure MC #2, was locked, medications secured, and not accessible to other staff, residents, or visitors. The facility failed to ensure MC #3, was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 resident (Resident #1) of 12 residents (Resident #1) reviewed for privacy and confidentiality. The facility failed to ensure Resident #1's privacy curtain was used and the door to his room was closed when CNA A was providing incontinent care. This failure could place residents at risk of feeling embarrassed and diminishing the resident's quality of life. Findings Included:Record review of Resident #1's face sheet, dated 04/28/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of ten residents reviewed for care plans. The facility failed to ensure a comprehensive care plan was developed for Residents #1 that addressed physician ordered orthopedic devices, behaviors involving orthopedic devices, and an ordered sitter during scheduled dialysis. This failure could place residents at risk for not attaining the highest practicable well-being possible. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for one of five residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1, on 08/06/25, was wearing her physical therapy ordered resting hand splint for left hand. This failure could place residents at risk of not maintaining the mobility necessary maintain the highest practicable well-being. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, that the facility maintained medical records on each resident that were accurately documented for one of five residents (Resident #1) reviewed for medical records. The facility failed to accurately document Resident #1's application of her orthopedic device and dialysis wound dressing removal. This failure could place residents at risk of not identifying or receiving care, for unassessed changes in conditions and improper documentation of treatments. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after events to the State Survey Agency for 1 (Resident #1) of 4 residents reviewed for injury of unknown origin. The facility failed to report to HHSC when Resident #1 was found with a head laceration of unknown origin requiring staples on [DATE]. This failure placed residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interviews, and record reviews, 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 sanitation. The facility failed to ensure DD A and [NAME] C were practicing food contamination prevention while preparing foods. The facility failed to ensure dietary employees were preventing cross-contamination of harmful substances to food by cloth towels. The facility failed to ensure the commercial ice machine was cleaned on a routine basis to prevent the development of slime or soil residues. The facility failed to ensure the ensure the commercial countertop water and ice dispenser machine was cleaned on a routine basis to prevent the development of slime or soil residues. [...]

Inspectors wroteBased 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. The facility failed to ensure dietary staff wore hairnets and beard guards while in the kitchen. 7. [...]

Inspectors wroteBased on interviews and record review the facility failed to have an assessment that accurately reflected the status for 1 of 3 Residents (Resident #92) reviewed for assessment accuracy in that: Resident #92's discharge MDS dated [DATE] reflected he was discharged to Short Term General Hospital (acute hospital) when he was discharged home. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 4 residents (Resident #53) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #53 to the appropriate, State-designated authority when she was diagnosed schizoaffective disorder. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASARR Level II Screening for 1 of 4 residents (Resident #36) reviewed for PASARR coordination, in that: A PASARR Level I was completed inaccurately for Resident #36 who had an active mental health diagnosis on admission. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a possible decline in mental health. Findings Included: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #4) reviewed for respiratory care. The facility failed to ensure Resident #4's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #4's oxygen treatment and tubing changes were documented on the respiratory MAR. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interviews, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals for 1 of 1 resident (Resident #38) reviewed for pharmacy services and procedures in that: The facility failed to ensure medication administered to a resident was taken and not left in the room. This failure could place residents at risk of not receiving their physician ordered medications resulting in a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safely for 1 of 1 kitchens reviewed for food storage and sanitation, in that: 1. The facility failed to ensure food and beverages in refrigerator unit #1 were covered, labeled, and dated. 2. The facility failed to ensure food in the dry food storage room were labeled and dated. These deficient practices could place residents at risk of foodborne illness.