F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
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.
Findings included:
Review of Resident #43's face sheet, dated 03/18/2025, reflected a [AGE] year-old male admitted to the
facility on [DATE].
Review of Resident #43's facility's Comprehensive Care Plan dated 11/10/2024 reflected diagnoses were,
Schizoaffective Disorder, Bipolar Type (a mental health condition of both schizophrenia and bipolar
disorder, that caused manic episodes, increased energy and feelings of sadness and hopelessness),
Anxiety Disorder (extreme fear or worry), Metabolic Encephalopathy (a change in how your brain works due
to an underlying condition), Depression (mood disorder that causes persistent feeling of sadness and loss
of interest) and Post Traumatic Stress Disorder (a mental health disorder causes by an extremely stressful
or terrifying event). Resident #43's care plan did not address his schizoaffective disorder and PTSD.
Review of Resident #43's MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition.
Section A1500 Pre-admission Screening and Resident Review (PASRR). The question Is the resident
currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual
disability or related condition? was coded as zero which indicated a response of no to the question.
Review of Resident #43's PLI dated 10/04/2025, completed by an acute care hospital reflected a diagnosis
of altered mental status and Section C - PASRR Screening C0100.Mental Illness is checked No and
C0200. Intellectual Disability is checked No.
Review of Point Click Care (electronic medical record), Miscellaneous Section reflected Resident #43 was
receiving psych services two times per month.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
676086
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an observation and interview on 3/18/2025 at 9:20 AM, Resident #43 had returned to the building
after an outside smoke break. The resident was walking down the hallway with his head down. Resident
#43 said he preferred not to speak to or answer surveyor questions. Resident #43 was pleasant and said
his intention was not to offend the surveyor.
During an interview on 3/19/2025 at 1:50 PM, the MDS Nurse stated prior to admission they reviewed the
PL1 to determine if the resident had a MH/ID diagnosis. She said if the resident had a negative PL1 and
had a MH/ID diagnosis they should have submitted a PLI. She said, I feel like we meet the needs of the
residents. The resident would not get the proper care if appropriate psych services were not provided.
Regarding Resident #43, she said his PLI was negative from the hospital, they did not initial a PLII, and the
facility provided psych services via a contracted provider.
During an interview on 3/19/2025 at 2:15 PM, the DON stated the facility reviewed previous health records
and the ADM has gone to meet the resident to determine if the resident was a good fit for the facility. He
stated the MDS nurse was responsible to complete and submit the PASRR evaluation. He said if a
resident's PL1 screening was negative, the facility provided in-house psychiatric services via a contracted
provider. Regarding Resident #43, she said his PLI was negative from the hospital, they did not initial a
PLII, and the facility provided psych services via a contracted provider. He said the [NAME] from hospitals
were most often negative and inaccurate. He said they met the needs of Resident #43 and placed the
resident on psych services.
During an interview on 3/19/2025 at 2:25 PM, the ADM stated the MDS nurse was responsible to complete
and submit the PASRR evaluation. He also said they provide psychiatric services through a contracted
provider.
The facility's PASRR policy was requested on 3/192025 at 2:30 PM, and the facility did not have a related
policy.
Review of the facility's policy admission Criteria revised March 2019 reflected the following:
9.
All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID)
or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR)
process.
a.
The facility conducts a Level I PASRR screen for all potential admissions, regardless of payer source, to
determine if the individual meets the criteria for a MD, ID, or RD.
b.
If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is
referred to the state PASARR representative for the Level II (evaluation and determination) screening
process.
(1)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
The admitting nurse notifies the social services department when a resident is identified as having a
possible (or evident) MD, ID, or RD.
Level of Harm - Minimal harm
or potential for actual harm
(2)
Residents Affected - Few
The social worker is responsible for making referrals to the appropriate state-designated authority.
c.
Upon completion of the Level II evaluation, the state PASARR representative determines if the individual
has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether
placement in the facility is appropriate.
d.
The state PASARR representative provides a copy of the report to the facility.
e.
The interdisciplinary team determines whether the facility is capable of meeting the needs and services of
the potential resident that are outlined in the evaluation.
f.
Once a decision is made, the state PASARR representative, the potential resident and his or her
representative are notified.
10.
The preadmission screening program requirements do not apply to residents who, after being admitted to
the facility, were transferred to a hospital.
11.
The state may choose not to apply the preadmission screening requirement if:
a.
the individual is admitted directly to the facility from a hospital where he or she received acute inpatient
care;
b.
the individual requires facility services for the condition for which he or she received care in the hospital;
and
c.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0645
the attending physician has certified (prior to admission) that the individual will need less than 30 days of
care at the facility.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
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.
Findings included:
Review of Resident #43's face sheet, dated 03/18/2025, reflected a [AGE] year-old male admitted to the
facility on [DATE].
Review of Resident #43's facility's Comprehensive Care Plan dated 11/10/2024, reflected diagnoses were
Schizoaffective Disorder, Bipolar Type (a mental health condition that affects how people think/behave and
causes manic episodes, increased energy and feelings of sadness and hopelessness), Anxiety Disorder
(extreme fear or worry), Metabolic Encephalopathy (a change in how the brain works due to an underlying
condition), Depression (mood disorder that causes persistent feeling of sadness and loss of interest) and
Post Traumatic Stress Disorder (a mental health disorder causes by an extremely stressful or terrifying
event). No goals and interventions were documented to address and/or mitigate the triggers for Resident
#43's documented PTSD diagnosis.
Review of Resident #43's MDS dated [DATE] reflected a BIMS score of 15, indicating intact cognition.
Section D - Mood,
reflected Resident #43 rarely felt isolated from others. Section E - Behaviors, reflected Resident #43 had no
hallucinations or delusions.
Review of Point Click Care (electronic medical record), Miscellaneous Section reflected Resident #43 was
receiving psych services two times per month.
During an observation and interview on 3/18/2025 at 9:20 AM, Resident #43 had returned to the building
after an outside smoke break. The resident was walking down the hallway with his head down. Resident
#43 said he preferred not to speak to or answer surveyor questions. Resident #43 was pleasant and said
his intention was not to offend the surveyor.
During an interview on 3/19/2025 at 1:50 PM, the MDS Nurse stated she and the DON were responsible to
complete care plans for residents. She said the nursing staff who cared for a resident diagnosed with PTSD
would have been aware if a resident needed a different type of care and staff reported no issues. She
stated she was unaware Resident #43's triggers were not care planned.
During an interview on 3/19/2025 at 2:15 PM, the DON stated he completed the initial comprehensive care
plans and the MDS Nurse completed the care plan updates. He said residents who had a PTSD diagnosis
were offered psych services through a contracted provider and they had made concessions for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Level of Harm - Minimal harm
or potential for actual harm
residents who needed more 1:1 care. He said a resident's triggers would have been identified through staff
interactions and then reported to him. He said, We have a few PTSD residents and have not had any
specific interventions for those residents. Additionally, he stated Resident #43 did not have behaviors
related to PTSD and that it should have been care planned. He said they met the needs of Resident #43
and placed the resident on psych services.
Residents Affected - Few
During an interview on 3/19/2025 at 2:25 PM, the ADM stated residents with a PTSD diagnosis were
offered psych services. When asked how the facility identified triggers for residents with a PTSD diagnosis,
he stated they have gone through trauma training. He said the DON was responsible to ensure care plans
were updated with goals and interventions. When he was asked to identify negative outcomes for residents
who did not receive the appropriate services, he said it was speculation and he could not answer that
question.
Review of the facility's policy titled Care Plans, Comprehensive Person Centered, revised in March 2022
reflected the following:
Policy Statement - A comprehensive, person-centered care plan that included measurable objectives and
timetables to meet the resident's physical, psychosocial and functional needs is developed and
implemented for each resident.
Policy Interpretation and Implementation
3. The care plan interventions are derived from a thorough analysis of the information gathered as part of
the comprehensive assessment.
7. The comprehensive, person-centered care plan:
a)
Includes measurable objectives and timeframes;
b)
Describes the services that are to be furnished to attain or maintain the resident's highest practicable
physical, mental, and
psychosocial well-being including:
(2) any specialized services to be provided as a result of PASRR recommendations; and
c)
Includes the resident's stated goals upon admission and desired outcomes;
d)
Builds on the resident's strength; and
e)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0699
Reflects currently recognized standards of practice for problem areas and conditions.
Level of Harm - Minimal harm
or potential for actual harm
8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:
a)
Residents Affected - Few
Provided by qualified persons;
b)
Culturally competent; and
c)
Trauma-informed
10. When possible, interventions address the underlying source(s) of the problem area(s), not just
symptoms or triggers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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.
Findings included:
Observation of the Kitchen on 03/17/2025 at 08:45 AM during initial tour of kitchen, the walk-in refrigerator
had a box of yogurt with an expiration date of 3/3/2025.
Observation of the Kitchen on 3/17/2025 at 9:10 AM while conducting the initial tour of the kitchen, a shelf
with apples and bananas revealed brown bananas, an open and expired pack of tortillas dated 2/20/2025; a
pack of strawberry gelatin in a zip lock bag that was dated 9/24/2024; and a pack of either lemon gelatin or
cake mix in an undated open bag.
Interview with the DM on 3/19/2025 at 09:50 AM, she stated if residents were served expired food, they
could get sick. The DM stated that it was her responsibility for daily to check for expired foods. DM stated
she was implementing a new policy of labeling opened food items with a printed label that indicates date
item is opened, expired, and a use by date. The DM stated her kitchen staff were trained on checking for
expired food and labeling/dating opened food items.
Interview with the DA on 3/19/2025 at 11:28 AM, she stated if residents were served expired food, they can
get sick. The DA stated they were to check for expired food daily. The DA stated she has been trained on
checking for expired food and labeling/dated opened food items. The DA stated per her training, she
learned to label open food in a sealed container with the date, a use by date, her initials, and the expiration
date. The DA stated that they were also not to use expired food.
Interview with the [NAME] on 3/19/2025 at 11:32 AM, she stated residents could get food poisoning or sick
if they received food that was expired. The [NAME] stated she checks food daily as she works. The [NAME]
stated she has been trained on checking for expired food and labeling/dated opened food items. The
[NAME] stated per her training, they were not to use expired food. When she opens food, it needs to be
labeled with the date opened, use by date and expiration date.
Observation of the refrigerator on 3/19/25 at 9:44 AM, refrigerated items that have been opened were
labeled with a printed label indicating open date, use by date, and expiration date. Opened sliced cheese
was wrapped in plastic wrap and labeled by handwritten open date 3-13-25 but it was missing the use by
date.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676086
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Goldthwaite Health & Rehab Center
1207 S Reynolds St
Goldthwaite, TX 76844
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Interview with the DON at 3/19/2025 at 2:15 PM he stated he stated if a resident received expired food, the
potential harm was they can become sick. The DON stated it was the dietary manager responsibility to
make sure expired food was discarded. The DON stated residents receiving expired food does not meet his
expectation.
Interview with the ADM at 3/19/2025 at 2:25 PM he stated if a resident had received expired food, the
potential harm was they can become sick. The ADM stated it was the dietary manager's responsibility to
make sure expired food was discarded. The ADM stated residents receiving expired food does not meet his
expectation.
Review on 3/19/2025 at 10:15 AM revealed Policy entitled Dietary Services Policy and Procedures Manual
including Food Safety and Storage Refrigerators, revealed The facility will ensure all food purchased shall
be wholesome and manufactured, processed, and prepared in the compliance with all State, Federal, and
local laws, and regulations. Food shall be managed in a safe manner. Food is to be tightly wrapped or
sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. Food
must be covered when stored, with a date label identifying what is in the container.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676086
If continuation sheet
Page 9 of 9