Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding nutritional needs, food safety, and sanitation standards at Golden Years Nursing and Rehabilitation Center.
Findings
The facility failed to ensure menus met residents' nutritional needs, were prepared in advance, and were properly posted and accessible. Additionally, the facility did not follow professional standards for food safety, including discarding expired foods, sanitizing food processors between uses, labeling and dating food items, and properly storing serving utensils and dishes.
Deficiencies (2)
Menus did not meet nutritional needs, were not prepared in advance, not properly posted, and residents lacked access to individual menus.
Failed to procure, store, prepare, distribute, and serve food in accordance with professional standards, including expired foods not discarded, food processor not sanitized between uses, food items not labeled and dated, and dirty serving utensils and dishes stored improperly.
Report Facts
Deficiencies cited: 2
Date of observation: Aug 5, 2025
Date of interviews: Aug 7, 2025
Food storage duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CK A | Cook | Named in findings related to failure to sanitize food processor between food items |
| CK B | Cook | Named in findings related to food labeling, sanitation, and storage practices |
| DM | Dietary Manager | Provided information on menu posting and food safety practices |
| ADM | Assistant Director of Nursing | Provided statements on menu accessibility and food safety expectations |
| DA | Dietary Aide | Provided information on food dating and disposal practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding incomplete and inaccurate medical record documentation for Resident #1, specifically related to nursing progress notes, assessments, and transfer documentation during a hospital transfer.
Complaint Details
The complaint investigation found that documentation was incomplete and inaccurate for Resident #1, with no assessments or progress notes on 10/28/24, no physician order for transfer, and missing transfer documentation. Staff interviews revealed acknowledgment of documentation failures and the potential for delayed care.
Findings
The facility failed to ensure complete and accurate documentation in Resident #1's medical record, including missing nursing progress notes, assessments, and physician orders related to the resident's transfer to an acute care hospital. Interviews with staff confirmed documentation lapses and acknowledged the risk of delayed or inadequate care due to poor communication.
Deficiencies (1)
Failure to document nursing progress notes, assessments, or transfer documents when Resident #1 was transferred to the acute care hospital.
Report Facts
Residents reviewed for clinical records: 4
BIMS score: 9
Date of admission MDS assessment: Oct 4, 2024
Date of missing assessments and progress notes: Oct 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Wrote progress note about ambulance transport; admitted to not completing required documentation. |
| LVN B | Licensed Vocational Nurse | Contacted surgeon about wounds; acknowledged expected documentation but uncertain if completed. |
| DON | Director of Nursing | Provided statements about wound status, documentation expectations, and risks of incomplete records. |
| ADM | Administrator | Stated expectations for accurate and timely documentation and noted risks of delayed care. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as a full recertification survey to assess compliance with federal and state regulations for the nursing home.
Findings
The facility failed to post the results of the most recent survey for residents to view, violating residents' rights. Additionally, the facility failed to provide ordered wound treatment to a resident, placing her at risk of worsening infection and complications.
Deficiencies (2)
Failed to ensure residents' right to examine the results of the most recent survey and plan of correction by not posting survey results in a public area.
Failed to provide ordered wound treatment to Resident #33, resulting in risk of worsening infection, sepsis, and amputation.
Report Facts
Residents interviewed: 11
Residents reviewed for quality of care: 16
Resident #33 BIMS score: 15
Date of survey completion: Jul 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in wound treatment deficiency for failing to perform ordered treatment |
| LVN B | Licensed Vocational Nurse | Provided wound treatment to Resident #33 after deficiency identified |
| DON | Director of Nursing | Identified wound treatment failure and initiated staff in-service |
| ADM | Administrator | Responsible for ensuring survey results availability and provided policy information |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 3, 2024
Visit Reason
The inspection was conducted due to complaints regarding misappropriation of resident property and failure to prevent elopement of residents at the facility.
Complaint Details
The complaint investigation confirmed drug diversion of Resident #2's medication and an elopement incident involving Resident #1. The Immediate Jeopardy related to the elopement began on 5/21/2024 and ended on 5/22/2024. The facility corrected both issues prior to the survey. Staff were drug tested with negative results, and the facility implemented increased security measures including locking the front door 24/7 and conducting elopement drills.
Findings
The facility failed to prevent the misappropriation of Resident #2's medication and failed to prevent Resident #1 from eloping on 05/21/2024. Both issues were identified as past non-compliance and were corrected before the survey began. The medication diversion was confirmed after investigation, and the elopement incident led to immediate changes in facility security and supervision.
Deficiencies (2)
Failed to ensure the right to be free from misappropriation of resident property for Resident #2, specifically diversion of Ativan medication.
Failed to ensure the resident environment remained free of accident hazards and provide adequate supervision to prevent accidents, resulting in Resident #1 eloping from the facility.
Report Facts
Medication tablets: 60
BIMS score: 3
Wandering/elopement risk score: 7
Staff signatures: 50
Employees interviewed: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Signed for medication delivery, counseled for not following controlled substance policy, interviewed regarding missing medication |
| LVN B | Licensed Vocational Nurse | Inserviced on accepting controlled substances and interviewed about medication acceptance process |
| DON | Director of Nursing | Interviewed regarding elopement incident, medication diversion investigation, and facility corrective actions |
| CNA B | Certified Nursing Assistant | Interviewed about elopement policy and response procedures |
| Maintenance Director | Maintenance Director | Reported on code pink elopement drills and alarm system adjustments |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
The inspection was conducted as an annual survey of Golden Years Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 6, 2023
Visit Reason
The inspection was conducted as an annual survey of Golden Years Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected are unknown.
Inspection Report
Routine
Deficiencies: 5
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, catheter care, medication administration, medication storage, and therapeutic diets.
Findings
The facility was found deficient in developing and implementing comprehensive person-centered care plans, securing catheters properly, maintaining medication error rates below 5%, storing medications according to professional standards, and providing therapeutic diets as prescribed. These deficiencies posed risks to resident dignity, safety, and health outcomes.
Deficiencies (5)
Failed to develop and implement a comprehensive person-centered care plan including resident preferences for wearing a hospital gown instead of personal clothing.
Failed to ensure Resident #11's catheter was secured with a catheter secure device, risking traumatic removal and infections.
Medication error rate was 20%, exceeding the 5% threshold, with multiple medications not administered to three residents by one LVN.
Failed to ensure proper medication storage including dating multi-use eye drops, removing expired medications, and maintaining clean and sanitary medication storage areas.
Failed to provide Resident #15 with the prescribed consistent carbohydrate therapeutic diet, serving extra carbohydrate portions instead.
Report Facts
Medication error rate: 20
Residents reviewed for care plans: 15
Residents affected by care plan deficiency: 1
Residents reviewed for catheter care: 1
Residents affected by catheter care deficiency: 1
Residents affected by medication errors: 3
Medication carts reviewed: 4
Medication rooms reviewed: 2
Residents reviewed for therapeutic diet: 8
Residents affected by therapeutic diet deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in medication error finding and catheter care deficiency |
| DON | Director of Nursing | Interviewed regarding care plan, catheter care, medication errors, and medication storage deficiencies |
| CNA J | Certified Nursing Assistant | Interviewed regarding Resident #2's preference for hospital gown |
| MDS Nurse | Interviewed regarding updating Resident #2's care plan | |
| RNC | Registered Nurse Consultant | Interviewed regarding medication error and retraining LVN A |
| DM | Dietary Manager | Interviewed regarding therapeutic diet for Resident #15 |
| RD | Registered Dietitian | Interviewed regarding therapeutic diet for Resident #15 |
Report
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