Golden Estates Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options is he or she preferred for 1 (Resident #6) of 7 residents reviewed for resident rights. The facility failed to notify Resident #6's responsible party on 09/16/2025, prior to Resident #6 being administered an anti-anxiety medication, Alprazolam. This failure could affect residents and/or responsible parties by placing them at risk for not getting consent for medications and unknown side effects.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the MDS assessment accurately reflected the resident's status for 1 of 7 (Resident #1) whose MDS assessments were reviewed in that:1. Resident #1 had a diagnosis of Schizophrenia that was not coded on the MDS assessment. 2. Resident #1 had orders for a lidocaine patch and antibiotic that was not coded on the MDS assessment. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 7 residents (Resident #6) reviewed for accuracy of medical records. Resident #6 had an order from hospice upon admission on [DATE] to notify Resident #6's responsible party prior to administration of Alprazolam .5mg prn. The instructions to notify the responsible party were not included in Resident #6's Alprazolam order. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nursing staffing formation that included the facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nurse aides and resident census in a prominent place readily accessible to residents, staff, and visitors for (11/19/2025 and 11/20/2025) in that:The facility failed to post the daily staffing posting information on 11/19/2025 and 11/20/2025. This failure could place residents and visitors at risk of not being able to review the facility's daily staffing hours.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, 2 of 3 medication carts (station 1 and station 2) observed, in that: The medication aide cart for station 2 contained 4 loose medication pills. The medication aide cart for station 1 contained 1 loose medication pill. These deficient practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 facility beauty shop, in that: The facility beauty shop contained potentially unsafe items and was unlocked. This deficient practice could result in residents, staff, and/or the public encountering potentially unsafe items.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #2) whose assessments were reviewed. he facility failed to accurately document Resident #2's dental status on the resident's admission assessment dated [DATE]. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to ensure a container of shredded cheese and a case of breakfast sausage were properly sealed in the reach-in cooler. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Residents #1) reviewed for accidents hazards and supervision: The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility near the access road near the expressway on Saturday, 5/10/25. The facility did not have a plan in place for monitoring the front door to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. An IJ was identified on 5/28/25. The IJ template was provided to the facility on 5/28/25 at 5:04 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 18 residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's physician and representative when the resident was missing on 5/10/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement baseline care plans that included the instructions needed to provide effective and person-centered care within 48 hours of admission for 1 of 1 resident (Resident #1) reviewed for baseline care plans: The facility failed to complete Resident #1's baseline care plan within 48 hours. This deficient practice could affect residents who receive care at the facility and could result in missed or inadequate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 nurse medication carts (Unit 1 medication cart)reviewed for storage of drugs and biologicals. The facility failed to ensure the Unit 1 medication cart was locked and secured when Medication Aide U left a medication cart unlocked and unsecured on 5/29/2025. This failure could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment, for 30 of 75 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29 and #30) and 11 additional residents with rooms on the 200/100 hallways (all residents of 300 affected), 3 of 3 halls (halls 300, 200 and 100) and affected residents who utilized the facilities hallways, and main living area reviewed in that: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 24 hours after the allegation was made to the State Survey Agency for neglect for 1 of 1 facility, in that; The facility did not report to the State Survey Agency (HHSC) an incident in which the facilities heater system was not operation on the 300-hallway and was in need of repair since 1/22/2025 and when Resident #24 complained of lack of heat on the 200-hallway and a repair could not be immediately completed leaving the facility without heat when the local temperatures dropped to 21 degrees. This failure could place residents at risk for neglect and could lead to a diminished quality of life and harm.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #17) of 2 residents reviewed for accidents. The facility failed to ensure Resident #17 had two staff in attendance during a mechanical lift transfer when the resident was left hoisted in the sling and connected to the lift on her bed without any staff in the room. This failure could place the resident at risk of falls and place them at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 17 residents (Resident #63) reviewed for physician notification of changes. The facility failed to consult with Resident #63's physician and provide all necessary details to the DON when Resident #63 had a significant change in condition on [DATE], that included pain, vomiting, diarrhea, and low oxygenation and subsequently died. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:28 PM. [...]

Inspectors wroteBased on observation, interview and record review LVN A failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 17 residents (Resident #63) reviewed for Full Code status. The facility failed to ensure emergency protocol was followed and failed to ensure Resident #63, who had a Full Code order in place, was provided continuous and uninterrupted CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice on [DATE] when LVN A stopped CPR once and continued after obtaining an AED, and Resident #63 subsequently died. An Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were fed by enteral means, received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for 1 of 7 residents (Resident #63) reviewed for enteral feedings. 1. The facility failed to ensure all the necessary components of an order for enteral feeding were included for Resident #63 when Resident #63 was admitted to the facility on [DATE]; the order did not include formula type, total volume, time of administration, or contraindications. 2. The facility failed to recognize and respond appropriately when Resident #63 had a significant change in condition on 4/28/2024, that included pain, decreased oxygenation, multiple emesis, and fecal incontinence and subsequently died. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to ensure [NAME] Z wore a beard restraint for his beard. 2. The facility failed to ensure foods in the refrigerators were t were dated with a prepared date and discard dates. 3. The facility failed to ensure [NAME] AA took temperatures for proteins that had the consistency of soft and bite sized and minced and moist, until after survey intervention. 4. The facility failed to ensure the CDM took temperatures of the milk until after survey intervention. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 4 of 8 residents (Residents #29, #36, #50, and #35) reviewed for care plan revisions, in that: 1. The facility failed to ensure Resident #29's care plan had updated fall interventions after 2 major falls with injury. 2. The facility failed to document how Resident #36 was supposed to be transferred by staff. 3. The facility failed to update care plan to include Resident #50 and Resident #35 were appropriate for 1 person transfers instead of just a 2 person Hoyer transfer. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who had not used psychotropic drugs were are not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #39) reviewed for unnecessary medications. The facility failed to ensure Resident #39 was taking a psychotropic medication (Citalopram Hydrobromide (an antidepressant)), to treat a specific diagnosed condition. This deficient practice could place residents at risk for receiving medications that were not necessary for their care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 6 medication carts (the 300-hallway Nurses Medication Cart) reviewed for medication storage. The facility failed to ensure the 300-hallway Nurses Medication Cart was locked when it was left unattended in the common area in front of the 300-hallway nurses' station. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 24 residents (Resident #52) reviewed for dietary needs. The facility failed to ensure Resident #52 received a vegetable side for the 07/23/24 lunch meal. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received food and drink prepared in a form designed to meet individual needs for 1 of 2 lunch meals reviewed for nutrition services. The facility failed to ensure the lunch meal served on 07/25/24 had the appropriate consistency for the minced and moist textured diet. This failure could place residents at risk of not being served the correct diet texture, which could leave residents at risk for poor intake, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable disease and infection for two of 16 residents (Resident #46 and Resident #38) reviewed for infection control. 1.) The facility failed to ensure CNA S washed or sanitized her hands when donning clean gloves 3 times while providing incontinent care to Resident #46 on 7/26/2024. 2.) The facility failed to ensure RN O washed or sanitized her hands, until intervention by the VP RN, when donning clean gloves during medication administration for Resident #38 on 7/27/2024. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview, observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 6 resident (Resident #1, Resident #2, Resident #3) reviewed for care plans. The facility failed to ensure Resident #1, Resident #2 and Resident #3's comprehensive care plans were person centered and included fall preventions interventions that had been implemented prior to investigation beginning, such as appropriate footwear, non-slip socks, and bed in low position. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure portable space heating devices that heated above 212 degrees were prohibited for 29 of 229 resident rooms inspected for fire safety according to NFPA 101, 19.7.8. in that: There were 29 occupied resident rooms which had portable space heaters in use in 100 and 200 Hall. This failure could affect the health of safety of resident's dependent on electrical appliance safety, in the event of electrical fire, exposing resident to smoke inhalation and other fire related injuries.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 12 out of 16 residents (Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #107, #257, and Resident #258) reviewed for diabetic care in that; 1. The facility failed to administer injectable insulin for Residents #2, #3, #7, #11, #12, #16, #21, #23, #34, #257, and Resident #258, sporadically from 04/14/2023 to 05/13/2023, due to an update in the electronic medication system. 2. The facility failed to identify and assess for harm, report to the PCP, report to the Residents and/or their Representatives all residents who did not receive their insulin due to the systemic update in the electronic medication administration record. 3. [...]

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a grievance process ensuring the maintenance of complete and accurate evidence demonstrating responses and results of all grievances for a period of no less than 3 years from the issuance of the grievance decision, that include date the grievance was received, a summary statement of the grievance, steps taken to investigate the grievance, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken, and the date the written decision was issued for 1 of 1 resident reviewed for residents rights, in that, The Grievance Log and associated binder were incomplete, missing Complaint/Grievance Report dated 5/15/2023 regarding an allegation of missed dosing of insulin [a medication necessary to control blood [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect were reported not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #258) of 15 residents reviewed for abuse. An allegation of neglect was not reported to the State Survey Agency within 24 hours of being made by Resident #258. This failure could place the residents at risk of abuse and neglect allegations being uninvestigated.

Inspectors wroteBased on interview and record review the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, in that: There were no monthly medication reviews documented for the months of March 2023 and April 2023. This deficient practice could place residents at risk from harm related to unnecessary medications or dosages, could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 1 of 6 residents (Resident #7) reviewed for medication administration, in that: The facility failed to administer medications as prescribed for Resident #7. This failure could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status.