Goldthwaite Health & Rehab Center

Inspectors wroteBased on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to dispose of 3 expired cereal containers located on the dry goods storage shelves.2. The facility failed to dispose of 1 expired chocolate topping located in the kitchen's walk-in refrigerator.3. The facility failed to dispose of used cooking oil.4. The facility failed to label and date all food items located in the designated resident refrigerator located in the dining room. 5. The facility failed to ensure dietary staff followed policy and procedure for hand hygiene.6. The facility failed to ensure staff followed policy and procedure for hand hygiene prior to serving food to residents. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide reasonable accommodations to meet the needs and preferences for 4 residents (Residents # 20, # 24, #28 and # 120) of 14 residents reviewed for accommodations. The facility failed to ensure that Residents # 20, # 24, #28 #47 and #120 had the call light button device in reach. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for 2 (hall 2 and hall 3) of 2 resident shared restrooms and 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 8 resident rooms reviewed for cleanliness and homelike environments.1. The facility failed to promote a clean, homelike environment in hall 2's resident shared restroom , which had overflowing trash, dirty light switches, and a wet towel in the corner.2. The facility failed to promote a clean, homelike environment in hall 3's resident shared restroom , which had a filthy call light string, corroded caulking and limestone tiles, broken/missing grout in the shower, and the vent fan was covered in dust. 3. [...]

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 help to prevent the development and transmission of communicable diseases and infections for 4 out of 5 residents (Resident #20, Resident #40, Resident #48, Resident #42) reviewed for infection control. MA H failed to disinfect the blood pressure cuff between residents (Resident #20, Resident #40, Resident #48, Resident #42) while performing medication administration. The failure placed residents at risk for cross contamination and the development of infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from Toilet and bathing facilities for 2 (hall 2 and hall 3)of 2 shared resident restrooms reviewed for call lights.1. The facility failed to ensure the hall 2 resident shared restroom call light was accessible from the floor. 2. The facility failed to ensure the hall 3 resident shared restroom call light string was accessible from the shower and was in good repair. These failures could place residents at risk of not being able to call for staff assistance from the floor or shower in the restroom, or in their room, in order to meet their care needs or at risk for injury, pain, hospitalizations.

Inspectors wroteBased on observations, interviews and record review the facility failed to establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 1 residents reviewed for pharmacy services. (Resident #44)The facility failed to account for controlled substances for Resident #44. This failure could put residents at risk for not having medications administered as ordered by physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. (i)Documentation in the resident's medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). (ii)The documentation required by paragraph (c)(2)(i) of this section must be made by- (A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; [...]

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 one of one kitchen reviewed for food storage and sanitation, in that: 1. The facility failed to ensure food in the walk-in refrigerator freezer were labeled and dated. 2. The facility failed to ensure food on the shelf was covered, labeled, and dated. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on interview, and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #43) of six residents reviewed for PASRR evaluation and screening. The facility failed to refer Resident # 43 to the appropriate state designated MH/ID authority for evaluation. Resident #43 was diagnosed with a mental illness prior to admission. This failure could place residents at risk of risk of not being assessed by the local MH/ID authority and not receiving mental health services to address and prevent decline.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounted for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for one (Resident #43) of six residents reviewed for quality of care. The facility failed to ensure Resident #43's potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 5 of 9 residents (Residents #1, #2, #3, #4, and #5) reviewed for abuse. 1. The facility failed to prevent COTA D from sexually abusing Resident #1 when COTA D had intercourse with the resident in the resident's room after the resident was on the therapist's caseload. 2. The facility failed to protect Resident #2 when COTA D removed the resident's pants for therapy treatment. 3. The facility failed to prevent COTA D from touching Resident #4 and Resident #5's buttocks while rubbing their back during their therapy session. 4. The facility failed to prevent COTA D from touching Resident #3's buttock and genitalia while rubbing her back during her therapy session. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures to prevent mistreatment, abuse, neglect, and exploitation of a resident, and misappropriatoions of residents property for 4 of 9 residents (Residents #1, #2, #3, #4, and #5) reviewed for abuse. 1. The facility failed to follow their plocies and procedures to investigate and report to state office when they received allegations that COTA D was having a relationship Relationship with COTA D. COTA D had intercourse with Resident #1 in the resident's room after the resident was on the therapist's caseload. 2. The facility failed to protect Resident #2 when CNA A witnessed COTA D was in the resident's room and she was not wearing pants for her therapy treatment. CNA B was also informed by the resident that COTA D removed her pants when providing therapy. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental, and psychological well-being of each resident in that: The facility failed to ensure that residents were free from abuse for 5 (Residents #1, 2, 3, 4, 5)) of 9 residents reviewed for abuse. The facility failed to follow their policy and procedure for investigating allegations of abuse. The Administrator was first alerted that COTA D and Resident #1 were having a relationship beyond resident and therapist on 10/ 2024 but failed to further investigate and report the allegation. The facility failed to implement interventions to ensure Resident #1 was safe after receiving an allegation that COTA D was having a relationship beyond therapist and resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated. 2. The facility failed to ensure general cleanliness was maintained in the kitchen. 3. The facility failed to ensure hairnets were worn. 4. The facility failed to ensure staff did not use hands when serving food. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 8 (Resident #3, #9, #16, #21, #22, #23, #33, and #49) of 18 residents reviewed for advanced directives. The facility failed to ensure Residents #3, #16, #21, #22, #23, and #33 DNR's were not missing information in the Physician Statement Section. The facility failed to ensure Resident #9's DNR was not missing information in the Witness Section. The facility failed to ensure Resident #49's DNR was not missing information in the Physicians Statement Section and a different DNR in her printed record that was missing information in the Physicians Statement Section. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans were developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment which included both the comprehensive and quarterly review assessments for 7 of 18 residents (Residents #1, #3, #23, #31, #33, #35 and #38) reviewed for comprehensive care plans. The facility failed to update the comprehensive person-centered care plans to address the needs of Residents #1, #3, #23, #31, #33, #35 and #38 within 7 days after MDS assessments were completed. This deficient practice could place residents at risk of delayed treatment, care, and services that could result in residents not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record reviews and interviews, the facility failed to assess residents timely using the quarterly review instrument specified by the State, no later than 14 days from the ARD date for 1 of 18 residents (Resident #38) reviewed for MDS assessments. Resident #38's quarterly MDS was not completed fourteen days after the ARD date of 1/5/24. This failure can result in inadequate care and care plans not updated correctly.

Inspectors wroteBased on interview and record review the facility failed to ensure new residents were not admitted with mental disorders, unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission for 1 of 18 residents (Resident #44) reviewed for PASRR assessments . The facility failed to ensure Resident #44 had a PASRR Level 1 screening prior to admission. This failure could place residents at risk of not obtaining services related to mental illness, intellectual or development disabilities, or developmental disabilities.

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 to help prevent the development and transmission of communicable diseases and infections for 2 (CNA D and CNA E) of 5 staff observed for resident care. -CNA D did not wash her hands or place supplies properly while performing incontinent care. -CNA E did not wash her hands while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.