Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenville Gardens during CMS and state inspections, most recent first.
The facility did not maintain a detailed record of receipt or perform periodic reconciliation for controlled medications awaiting destruction. Controlled drugs were stored in a locked cabinet, but the process relied on verification at the time of receipt and destruction, without ongoing documentation or reconciliation as required by policy. This resulted in incomplete records and a lack of accountability for controlled substances.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not maintain an effective pest control program, resulting in persistent gnats and flying insects in the memory care unit. Multiple residents were observed swatting at gnats, and staff confirmed the ongoing presence of pests despite the use of traps and chemicals. The issue was acknowledged by both the Maintenance Director and the Administrator, and pest control treatment was only documented after the problem was observed by surveyors.
A resident's bathroom light was observed flashing rapidly for several days, causing discomfort. The malfunction was not reported in the maintenance log as required, and the Maintenance Director was unaware of the issue until he noticed it himself. Facility policy requires a safe, comfortable, and homelike environment, including proper lighting, but this was not maintained.
A resident with severe cognitive impairment and multiple mental health diagnoses was prescribed Clonazepam for anxiety, but the facility failed to include this medication in the resident's care plan. Despite staff discussions of resident changes in daily meetings, the care plan was not updated to reflect the new medication, contrary to facility policy.
A resident with a suprapubic catheter was found to have an unsecured Foley catheter, despite care plans and facility policy requiring securement with a leg strap. Nursing staff and the DON confirmed that catheters should be checked and secured every shift, but were unable to account for the lapse during the survey.
A resident did not receive enough food and fluids to maintain their health, as identified by surveyors through observations and records showing unmet nutritional and hydration needs.
Drugs and biologicals were not labeled according to accepted professional principles, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with intact cognition and specific food dislikes repeatedly received meals containing tomato products and green peas, despite these preferences being documented and communicated to dietary staff. The resident reported feeling ignored, and both the Dietary Manager and Administrator acknowledged that such preferences should be honored, as confirmed by facility policy.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
A resident with a history of aggressive behavior attacked two other residents, causing physical harm and emotional distress. Despite having a care plan to manage his behavior, the facility failed to prevent these incidents, resulting in a deficiency in care standards.
The facility failed to implement its abuse prevention policy when a resident with schizoaffective disorder and dementia physically assaulted two other residents. Despite the incidents being witnessed and reported to the doctor and family, the facility did not report them to the appropriate authorities, citing the aggressor's dementia as a reason for non-willful actions. This failure to report placed residents at risk of unreported abuse and decreased quality of life.
The facility failed to report incidents of resident-to-resident abuse within the required timeframe. A resident with schizoaffective disorder and dementia physically assaulted two other residents, causing one to fall and be sent to the ER. Despite being witnessed by staff, these incidents were not reported to HHSC, as required by the facility's policy. The DON believed the actions were not willful due to the resident's dementia diagnosis, leading to non-compliance with abuse reporting requirements.
A resident with schizoaffective disorder and dementia was sent to a behavioral hospital due to aggressive behavior. Despite stabilization, the facility did not allow the resident to return, citing safety concerns. The decision was made by corporate, and the family was not informed until they inquired. The facility failed to provide necessary documentation and communication as per their discharge policy.
The facility failed to ensure residents on the secured unit met the criteria for placement, as several residents were placed there despite assessments indicating no or moderate elopement risk. Documentation and assessments were inconsistent with residents' needs, and staff interviews revealed a lack of clarity regarding the necessity of secured unit placement.
A facility failed to monitor the effects of psychotropic medications for three residents, leading to inadequate behavior and side effect documentation. Despite pharmacy recommendations, the facility did not implement necessary monitoring for residents on medications like Venlafaxine, Lexapro, and Duloxetine, affecting their therapeutic outcomes.
A facility failed to monitor smoking materials and dispose of razors properly, creating safety hazards. A resident was found with cigarettes on his bedside table, against policy, while another resident with dementia had a razor on a window ledge. Staff interviews revealed lapses in policy enforcement, posing risks of fire and injury.
A facility reported a medication error rate of 5.17%, involving two residents. One resident did not receive MiraLAX as ordered, while another received incorrect dosages of fluticasone and guaifenesin. The errors were attributed to a medication aide's haste and improper documentation. Interviews with facility leadership confirmed expectations for accurate medication administration and documentation.
The facility failed to secure medications properly, leaving a resident's medication at the bedside and an unlocked medication cart unattended. A medication aide was distracted, leaving a resident's wound healing medication unsecured, while an LVN left an insulin pen on an unlocked cart. These actions violated facility policies and could risk resident safety.
The facility failed to maintain professional food service safety standards, as three muffin tins with carbon build-up, rust, and food particles were used in the kitchen. The Dietary staff and Manager acknowledged the potential for food contamination, and the Administrator confirmed that such equipment should not be used due to the risk of causing stomach issues for residents.
A facility failed to maintain an effective infection control program when an LVN did not perform hand hygiene between glove changes during insulin administration to a resident with multiple health conditions, including diabetes. This lapse was acknowledged by the LVN and confirmed as an infection control issue by the ADON and DON, highlighting a breach in the facility's hand hygiene policy.
A resident with multiple health conditions, including dementia and schizophrenia, was found to have a non-functional call light in their room, which could have delayed assistance. The issue was confirmed by staff and later fixed by the Maintenance Director. The facility's policy required immediate reporting and replacement of defective call lights, but this was not adhered to, resulting in the deficiency.
The facility failed to maintain an effective pest control program, leading to the presence of gnats in two resident rooms. A female resident with cognitive impairment and a male resident with a pelvic fracture both experienced issues with gnats. Despite regular cleaning, the housekeeper was not instructed to perform additional checks, and the pest control technician was unaware of the gnat problem in the rooms. Staff interviews revealed a lack of communication and reporting, highlighting the need for better coordination to maintain a clean environment.
A male resident with a history of mobility issues and falls was found smoking on a public roadway, highlighting gaps in supervision. Despite needing assistance with transfers and having a care plan for safe smoking practices, the resident smoked outside designated areas without proper oversight. Facility staff, including the DON and Administrator, were unaware of his location until informed by surveyors. The resident's revoked smoking privileges and lack of effective communication and monitoring contributed to the deficiency.
A resident did not receive their scheduled medications timely, leading to a significant delay in administration. The medication aide called in sick for her first shift, and the nursing staff on duty did not administer the medications, resulting in the resident receiving them several hours late.
Failure to Maintain Accurate Receipt and Reconciliation of Controlled Drugs Awaiting Disposal
Penalty
Summary
The facility failed to establish and maintain a detailed system for the receipt and reconciliation of all controlled drugs, specifically for medications awaiting disposal. During an observation, several controlled medications, including Hydrocodone/APAP, Alprazolam, Diazepam, and Lorazepam, were found stored in a locked cabinet awaiting destruction. The Director of Nursing (DON) reported that when controlled medications were brought to her, she verified the count with a nurse and both signed the narcotic sheet before placing the medication in the locked box. However, the DON did not reconcile these medications prior to their destruction with the pharmacy consultant, and there was no record of receipt for controlled medications awaiting disposition to allow for accurate and periodic reconciliation. Record review showed that the last medication destruction was completed several weeks prior, and the facility's policy required two licensed nurses to document and witness the removal of discontinued or expired narcotics from active inventory, with proper storage and a signed destruction log. Despite these policies, the process described by the DON and Administrator did not include logging the receipt of controlled medications awaiting destruction, and reconciliation was only performed at the time of destruction. This lack of documentation and periodic reconciliation could result in incomplete records and an inability to accurately account for all controlled substances in the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Pest Control in Memory Care Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in the memory care unit, resulting in the presence of gnats and other flying insects. Multiple observations documented gnats in residents' rooms, including in a water cup at a bedside and flying around residents as they ate or watched TV. Staff interviews confirmed that gnats were a persistent issue, with one CNA stating that traps were set but gnats were always present, and that the insects were bothersome to residents. The Maintenance Director acknowledged awareness of the problem and described the use of wall-mounted bug lights and drain chemicals, but admitted that gnats could be a health risk and that the issue persisted. The Administrator stated that the facility should be reasonably pest free for resident comfort and recognized the unsanitary conditions created by gnats in water cups or on food. Review of the pest control log indicated that treatment for gnats in the memory care unit only occurred after survey observations began. The facility's pest control policy required ongoing efforts to keep the building free of pests, with staff responsible for reporting signs of infestation. However, the observations and interviews demonstrated that the pest control measures in place were insufficient to prevent or eliminate the presence of gnats in the memory care unit.
Failure to Maintain Safe and Comfortable Resident Environment Due to Malfunctioning Bathroom Light
Penalty
Summary
A deficiency was identified when a resident's bathroom light was observed to be flashing rapidly over multiple days. The resident expressed that the flashing light was bothersome, although he could not specify how long it had been occurring. The issue was not reported in the facility's maintenance log, and the Maintenance Director confirmed that he was unaware of the malfunction until he noticed the flashing lights himself. Staff are required to report such issues in the maintenance logbook, but this was not done in this instance. Further review of the facility's policy indicated that the environment should be safe, clean, comfortable, and homelike, with lighting that is comfortable and suitable for residents' needs. The Administrator acknowledged that a flashing light could create an uncomfortable environment and stated that it is the Maintenance Director's responsibility to ensure lighting issues are addressed. The failure to report and promptly address the malfunctioning bathroom light resulted in the resident experiencing a non-homelike and uncomfortable environment.
Failure to Develop Comprehensive Care Plan for Antianxiety Medication
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan to address all of a resident's identified needs, specifically omitting a care plan for the administration of Clonazepam, an antianxiety medication. The resident in question was an elderly female with diagnoses including anxiety, depression, and dementia, and had a severely impaired cognitive status as indicated by a BIMS score of 03. She required maximum assistance with activities of daily living and was receiving Clonazepam both in the morning and at bedtime for anxiety, as documented in her physician orders. However, a review of her comprehensive care plan did not show any mention of Clonazepam or related interventions. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed a lack of clarity regarding responsibility for updating care plans, particularly for acute changes such as new medication orders. Although staff reported discussing resident changes during daily morning meetings, the care plan for this resident was not updated to reflect the use of Clonazepam. The facility's own policy required care plans to be revised as needed based on changes in resident condition, but this was not followed in this instance.
Failure to Secure Foley Catheter for Resident with Indwelling Catheter
Penalty
Summary
A deficiency was identified when a male resident with a history of benign prostatic hyperplasia and obstructive uropathy, who required a suprapubic catheter, was observed to have his Foley catheter unsecured during a survey. The resident was dependent on staff for toileting and had an order in place for staff to check the securement of his catheter every shift. During the survey, both the Assistant Directors of Nursing (ADONs) and the charge nurse were unable to explain why the catheter was not secured, and the catheter strap was not found in the resident's clothing. The facility's care plan and policy required the catheter to be anchored with a leg strap to prevent trauma and infection, but this was not followed at the time of observation. Interviews with nursing staff and the Director of Nursing (DON) confirmed that catheters were supposed to be checked and secured every shift, and that failure to do so could result in trauma or infection. The DON and Administrator both stated that monitoring catheter securement was their responsibility, but neither had noticed issues prior to the survey. The facility's policy specifically outlined the need to anchor catheters to prevent complications, yet this protocol was not adhered to for this resident.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals within the facility.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to accommodate a resident's documented food preferences and dislikes, specifically regarding tomato products and green peas. Despite the resident's dietary card indicating these dislikes, the resident received meals containing these items on multiple occasions, including buttered peas, mixed vegetables with green peas, and spaghetti with tomato meat sauce. The resident, who had intact cognition and was independent with eating, reported to staff that she did not like these foods, yet continued to receive them. The resident expressed that her preferences were not being considered, and photographic evidence was provided to support her claims. Interviews with the Dietary Manager confirmed awareness of the resident's dislikes and an expectation that alternatives should be provided when these items were on the menu. However, the Dietary Manager was not aware of the most recent incident and stated that the cook was responsible for ensuring appropriate substitutions. The Administrator also confirmed that food preferences and dislikes were expected to be followed, with oversight by the Dietary Manager through spot checks. Review of facility policy indicated a requirement to accommodate individual resident needs and preferences.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to physical harm and emotional distress. Resident #1, a male with schizoaffective disorder and dementia, exhibited aggressive behavior towards other residents. On two separate occasions, Resident #1 physically attacked Resident #2 and Resident #3. Resident #2, a female with severe cognitive impairment, was pulled by the hair by Resident #1, causing her to fall and require an emergency room evaluation for a hand contusion. Resident #3, a male with similar cognitive impairments, was hit on the chest by Resident #1, although he did not sustain any injuries. The facility's records indicate that Resident #1 had a history of aggressive behavior, as noted in his care plan, which included interventions to protect others. Despite this, the facility did not effectively prevent Resident #1 from harming other residents. The incidents were witnessed by staff, and the facility's policy on violence between residents required such altercations to be promptly reported and addressed. However, the facility's response was inadequate, as evidenced by the repeated incidents involving Resident #1. Interviews with staff and the Director of Nursing (DON) revealed that the incidents were reported to the doctor and family members, but there was a lack of consensus on whether Resident #1's actions constituted abuse due to his dementia diagnosis. The facility's policy on abuse prevention emphasizes zero tolerance for abuse and the protection of residents from harm by others, including fellow residents. The failure to adhere to these policies and adequately protect residents from abuse resulted in a deficiency in the facility's care standards.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, as evidenced by incidents involving two residents. The facility's policy, titled 'Abuse Prevention and Prohibition Program,' mandates that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property be reported immediately, but no later than two hours after forming the suspicion. However, the facility did not adhere to this policy when Resident #1 pulled Resident #2's hair, causing her to fall and be sent to the ER for evaluation, and when Resident #1 hit Resident #3 on the chest. These incidents were not reported to the state survey agency, adult protective services, law enforcement, or the Ombudsman as required. Resident #1, a male with schizoaffective disorder and dementia, exhibited aggressive behavior, including running down the hallway with fists up, being combative, and attacking staff and residents. His care plan included interventions to protect the rights and safety of others, such as approaching him calmly and removing him from situations as needed. Despite these measures, Resident #1 was involved in two separate incidents where he physically assaulted other residents. The facility's failure to report these incidents as abuse, as per their policy, placed residents at risk of unreported abuse and a decreased quality of life. Resident #2, a female with severe cognitive impairment, was standing in the hallway when Resident #1 pulled her hair, causing her to fall. She was sent to the ER for evaluation, where she was diagnosed with a hand contusion. Resident #3, a male with severe cognitive impairment, was sitting in the dining room when Resident #1 hit him on the chest. Both incidents were witnessed by staff, and the doctor and family were notified, but the facility did not report them to the appropriate authorities, citing that Resident #1's actions were not willful due to his dementia diagnosis. This decision was contrary to the facility's policy, which requires reporting all incidents of abuse, regardless of the perpetrator's intent.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframe for two residents. Specifically, the facility did not report to the Health and Human Services Commission (HHSC) when one resident pulled another resident's hair, causing her to fall and be sent to the emergency room for evaluation. Additionally, the facility did not report when the same resident hit another resident on the chest. These incidents were not reported immediately, as required, which could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Resident #1, a male with schizoaffective disorder and dementia, exhibited aggressive behavior, including verbal outbursts and physical aggression towards staff and other residents. His care plan included interventions to protect the rights and safety of others, such as speaking to him calmly and removing him from situations as needed. Despite these measures, Resident #1 was involved in two incidents where he physically assaulted other residents. The facility's records indicate that these incidents were witnessed by staff, and the doctor, family, and Director of Nursing (DON) were notified, but the incidents were not reported to HHSC. The Director of Nursing stated that the incidents were not reported to HHSC because they were witnessed and because Resident #1 had a diagnosis of dementia, which they believed meant his actions could not be considered willful. The facility's policy on abuse prevention and prohibition requires that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, or other incidents be reported immediately, but this was not adhered to in these cases. The failure to report these incidents as required by the facility's policy and regulatory guidelines constitutes a deficiency in the facility's compliance with abuse reporting requirements.
Improper Discharge and Failure to Readmit Resident
Penalty
Summary
The facility failed to ensure that a resident was not transferred or discharged without adequate reason and proper documentation. A resident, who had been admitted with diagnoses including schizoaffective disorder and dementia, was sent to a behavioral hospital for treatment due to aggressive behaviors. Despite the discharge being anticipated as temporary with a return expected, the facility did not allow the resident to return after stabilization and completion of treatment at the behavioral hospital. This decision was made by the facility's corporate office, citing the resident's aggressive behavior as the reason for not readmitting him. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge and potential return. The social worker indicated that the resident was supposed to return to the facility, but the decision not to allow his return was made by the administration and corporate office. The Director of Nursing (DON) mentioned that the facility reviews residents' records before readmission to ensure their needs can be met, but there was no attempt from the behavioral hospital to send the resident back. The resident's family was under the impression that he would return to the facility, and they were not informed of any changes to this plan until they inquired about his return. The facility's policy on transfer and discharge requires documentation and a physician's written statement if a resident is discharged due to endangering the safety or health of others. However, there was no evidence provided that such documentation was completed. The facility also failed to communicate effectively with the resident's family regarding the discharge process and the decision not to allow the resident's return, leading to confusion and distress for the family, who were unable to care for the resident long-term.
Inappropriate Placement of Residents on Secured Unit
Penalty
Summary
The facility failed to ensure that residents on the secured unit met the criteria for residing there, as evidenced by the lack of access codes or information for independent egress for five residents. Specifically, the facility did not appropriately assess the elopement risk for these residents, leading to their unnecessary placement in a secured environment. For instance, Resident #35 was placed on the secured unit despite an elopement risk assessment indicating no risk, and similar issues were noted for Residents #23, #38, #18, and #47, who were either not at risk or only at moderate risk of elopement. The report highlights that the facility's documentation and assessments were inconsistent with the residents' actual needs and behaviors. For example, Resident #35's care plan and medication records did not reflect any behaviors indicative of elopement risk, yet she was placed on the secured unit. Similarly, Resident #23, who had severe cognitive impairment and required substantial assistance, showed no documented elopement attempts or wandering behaviors, yet was also placed on the secured unit without proper justification. Interviews with staff, including the DON and CNA, revealed a lack of clarity and documentation regarding the residents' need to be on the secured unit. The DON admitted to being unsure why certain residents remained on the secured unit despite their elopement risk scores indicating otherwise. The facility's policy allowed for administrative discretion in keeping residents on the secured unit, but this discretion was not supported by adequate documentation or assessment, leading to inappropriate placements.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Resident #54, a cognitively intact male with depression, anxiety, insomnia, and high blood pressure, was prescribed Venlafaxine. However, there was no behavior monitoring documented for May and June 2024, despite a medication dose change and pharmacy recommendations to add behavior monitoring. Resident #64, a male with depressive disorders, anxiety, and dementia, had a BIMS score indicating moderately impaired cognition and required total assistance for all ADLs. He was prescribed Lexapro, but there was no behavior or side effect monitoring documented for May and June 2024. The pharmacy had recommended adding behavior monitoring, but the facility did not implement this. Resident #3, a female with depression, dementia, and diabetes, had severely impaired cognition and required total assistance for all ADLs. She was prescribed Duloxetine, but there was no behavior monitoring documented for May and June 2024. Despite pharmacy recommendations to add behavior monitoring, the facility failed to do so. Interviews with facility staff revealed that there was a lack of proper procedures to ensure behavior and side effect monitoring for residents on psychotropic medications.
Inadequate Monitoring of Smoking Materials and Razor Disposal
Penalty
Summary
The facility failed to ensure adequate monitoring of smoking materials for a resident, leading to a potential fire hazard. The resident, who was cognitively intact and required minimal supervision while smoking, was observed with cigarettes on his bedside table, contrary to the facility's policy that smoking materials should be kept at the nurses' station. Interviews with staff revealed a lack of awareness and enforcement of this policy, with the resident admitting to keeping his cigarettes and lighter due to the inconvenience of retrieving them from the nurses' station. Additionally, the facility did not properly manage the disposal of a personal razor for another resident, who had severe cognitive impairment due to dementia. The resident was observed with a disposable razor on the window ledge next to his recliner, which posed a safety risk as other residents who wandered could potentially access it. Staff interviews indicated that razors should be disposed of in a sharps container immediately after use, but this procedure was not followed, leading to a potential injury hazard. The facility's policies on smoking and sharps disposal were not adhered to, resulting in unsafe conditions for residents. The staff, including the DON and Administrator, acknowledged the lapses in policy enforcement and the associated risks, highlighting a need for improved supervision and adherence to safety protocols to prevent accidents and hazards.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with a reported rate of 5.17 percent. This deficiency involved two residents, one of whom did not receive MiraLAX as ordered. The resident, who had a history of type 2 diabetes, peripheral vascular disease, atrial fibrillation, and hypertension, was observed not receiving the prescribed MiraLAX on a specific date. The medication aide responsible for administering the medication admitted to marking the medication as given, despite the resident's refusal, due to being in a hurry. Another resident, with diagnoses including dysphagia, dementia, essential hypertension, and chronic kidney disease, did not receive the correct dosage of fluticasone and guaifenesin as ordered. The medication aide administered only one spray of fluticasone instead of two and failed to provide the guaifenesin tablet due to its unavailability. The aide acknowledged the error and the lack of proper documentation, attributing it to being rushed and nervous during the medication pass. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed the expectation that medications should be administered as ordered. They emphasized the importance of documenting refusals and unavailability of medications accurately. The facility's policy on medication administration was reviewed, highlighting the requirement for licensed nurses to know specific details about the medications they administer and to document any deviations appropriately.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, and that only authorized personnel had access to the keys. This deficiency was observed in one of the three nurse medication carts and involved two residents. Specifically, Resident #69 had his prescribed medication, Prostat AWC oral liquid, left at his bedside, which was against the facility's policy. The medication aide responsible for administering the medication was distracted and did not ensure that Resident #69 took his medication, leaving it unattended at the bedside. Additionally, LVN D failed to secure the 400-hall nurse medication cart when it was left unattended. During the administration of insulin to Resident #43, LVN D left the medication cart unlocked and placed the insulin pen on top of the cart while she went to wash her hands. This action left the medications unsecured and accessible to anyone passing by, which was against the facility's policy that required medication carts to be locked when not attended by authorized personnel. The facility's policies clearly stated that medications should not be left at the bedside and that medication carts should be locked when unattended. The Director of Nursing and the Administrator both acknowledged the failures and emphasized the importance of securing medications to prevent unauthorized access. These lapses in protocol could potentially place residents at risk of injury or medication errors.
Deficiency in Kitchen Equipment Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, three muffin tins were found to have carbon build-up, rust, and food particles, which were not cleaned properly. The Dietary staff acknowledged using these muffin tins and admitted they were not clean, which could potentially lead to food contamination and illness among residents. The Dietary Manager initially believed that the carbon build-up and rust would not affect the food since they were on the outside of the tins. However, upon demonstration that the build-up could be peeled off and food particles were present inside the tins, he conceded that this could lead to bacterial contamination and illness. The Administrator confirmed that such equipment should not be used as it could cause stomach issues for residents. The facility's policy on equipment operation and sanitation requires thorough washing and sanitizing between uses, which was not followed in this instance.
Infection Control Lapse During Insulin Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D during the administration of insulin to Resident #43. During the procedure, LVN D did not perform hand hygiene after removing gloves and before donning a new pair, which is a critical step in preventing cross-contamination and the spread of infections. This lapse in protocol occurred despite LVN D's acknowledgment of the importance of hand hygiene and her responsibility to ensure it was performed correctly. Resident #43, a male with a history of type 2 diabetes mellitus, metabolic encephalopathy, cerebral infarction, chronic kidney disease, and atrial fibrillation, was receiving insulin as part of his care plan. The failure to perform hand hygiene was observed during a medication administration session, and both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that this was an infection control issue. The facility's policy on hand hygiene clearly states that it is the primary means to prevent the spread of infections and must be performed after removing gloves.
Failure to Maintain Functional Call System for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, identified as Resident #69, which could have placed the resident at risk of not receiving timely assistance. On the date of the observation, the resident, who had a history of partial traumatic amputation, dementia, schizophrenia, diabetes mellitus, and weakness, was found to have a non-functional call light in his room. The resident, who required maximal assistance with daily activities such as toileting and transfers, reported having to wait a long time for assistance due to the malfunctioning call light. This was confirmed by both the surveyor and the MDS Nurse, who found that the call light did not activate when pressed. The Maintenance Director and the Administrator verified the malfunction and subsequently fixed the call light. The Maintenance Director stated that he was unaware of the issue until notified by the MDS Nurse and acknowledged that the malfunction should have been detected during morning rounds. The Director of Nursing (DON) expressed that the MDS Nurse was responsible for checking the call lights during rounds and should have reported any malfunctions. The facility's policy required that defective call lights be reported immediately and replaced, but this procedure was not followed, leading to the deficiency.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in two resident rooms. Resident #8, a female with atrial fibrillation, depression, and dementia, was observed with several gnats around her room on multiple occasions. Despite her cognitive impairment, she was aware of the gnats but did not understand their presence. The room was noted to have an odor, and the resident had a history of hoarding, which may have contributed to the issue. The housekeeper reported cleaning the room regularly but was not instructed to perform additional checks for cleanliness. Resident #234, a male with a pelvic fracture, depression, and high blood pressure, also experienced issues with gnats in his room. He reported the problem after becoming frustrated with the persistent presence of gnats. The pest control technician had sprayed common areas, the dining room, and the kitchen for flies and roaches but was not informed about the gnats in the resident rooms. The Maintenance Supervisor and other staff were unaware of the gnat issue until it was brought to their attention. Interviews with various staff members, including the DON, ADON, and the Administrator, revealed a lack of communication and reporting regarding the pest issue. The facility's pest control policy aimed to ensure a pest-free environment, but the oversight and reporting mechanisms were insufficient to address the gnat problem in the resident rooms. The deficiency highlighted the need for better coordination and communication among staff to maintain a clean and sanitary environment for residents.
Inadequate Supervision Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for Resident #1, a [AGE] year-old male with a history of difficulty walking, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and a history of falls. Despite being assessed as needing supervision or touching assistance with various activities, including sit to stand transfers and toilet transfers, Resident #1 was found sitting on a public roadway between parked cars while smoking. This lack of supervision put Resident #1 at risk of injury or harm, considering his medical conditions and the potential dangers of sitting in a space used by cars to parallel park. The facility's care plan for Resident #1 included goals for safe smoking practices, such as smoking in designated areas without injury. However, Resident #1 was observed smoking outside the facility without proper supervision or adherence to the designated smoking areas. Despite receiving warnings and notices for non-compliance with smoking rules, Resident #1 continued to smoke outside the facility, leading to the deficiency in supervision. The facility's policies regarding smoking by residents outlined clear consequences for non-compliance, including loss of smoking privileges, yet Resident #1's actions were not effectively managed to ensure his safety. Observations and interviews revealed gaps in communication and monitoring within the facility regarding Resident #1's whereabouts and activities. Staff members, including the Director of Nursing and Administrator, were unaware of Resident #1's location until prompted by surveyors. Resident #1 himself mentioned leaving the facility to smoke across the street due to his smoking privileges being revoked. The lack of proper documentation, supervision, and communication among staff members contributed to the deficiency in ensuring Resident #1's safety while engaging in smoking activities outside the designated areas.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who did not receive their medications timely as scheduled. On 3/10/2024, the resident's morning medications, including oxycodone, Lasix, Gabapentin, and Aldactone, were administered several hours late. The resident reported that his morning medications were given after lunch, and the Medication Administration Audit Report confirmed the late administration times. The resident's comprehensive care plan required timely administration of medications to manage conditions such as liver disease, high blood pressure, anxiety, and neuralgia, but these requirements were not met on the specified date. The issue arose because the medication aide (MA R) who was scheduled to administer the medications called in sick for her first shift on 3/10/2024. When she arrived for her second shift, she found that the medications had not been administered by the nursing staff on duty. The weekend RN was aware that MA R had called off her first shift but assumed that the nurse on duty had administered the medications. This assumption led to a significant delay in medication administration, which could have resulted in adverse reactions for the resident. Interviews with the weekend RN, the Director of Nursing (DON), the Medical Director, and the Administrator revealed that there was an expectation for medications to be administered timely and according to the physician's orders. The DON and the Medical Director emphasized the importance of administering medications at the correct times to ensure their effectiveness. The facility's Medication-Administration policy also stated that medications should be administered within one hour before or after the scheduled time, which was not adhered to in this case.
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Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcliff Health Center Of Greenville | 0.4 mi | ★★★★★ | 15 | 1 |
| Greenville Health & Rehabilitation Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Legend Healthcare And Rehabilitation - Greenville | 2 mi | ★★★★★ | 5 | 0 |
| Royse City Medical Lodge | 11.7 mi | ★★★★★ | 6 | 0 |
| Farmersville Health And Rehabilitation | 14.1 mi | ★★★★★ | 1 | 0 |
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