Greenville Gardens

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of receipt of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, residents' safety, and drug diversion.

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 of 6 residents (Resident #20 and Resident #11) reviewed for infection control. 1. The facility failed to ensure staff wore PPE when entering Resident #20's room on 08/12/25 and 08/13/25 who was on contact isolation for Extended-spectrum beta-lactamase also known as ESBL (a group of bacteria that are resistant to many commonly used antibiotics. 2. The facility failed to ensure LVN F used proper hand hygiene when preforming blood sugar checks and given insulin for Resident #11 on 08/12/25. These failures could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for the memory care unit. The facility did not maintain an effective pest control program to ensure the memory care unit was free of gnats and other flying insects. This could place residents at risk for an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 22 residents reviewed for resident rights. (Resident #44) The facility failed to ensure Resident #44's bathroom light was functioning properly and not flashing on and off rapidly. This failure could place residents at risk for diminished quality of life in an environment that is not homelike.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 6 residents (Resident #30) reviewed for care plans. The facility failed to ensure a care plan was developed for Resident #30's medication of Clonazepam used to produce a calming effect on the brain and nerves, which helps to reduce anxiety, prevent seizures, and promote relaxation. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #74) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #74's foley catheter was secured on 08/11/25. This failure could place residents at risk for urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 2 of 22 residents (Residents #75 and #39) reviewed for nutrition. 1. The facility did not ensure Resident #75 was given chopped meats for lunch on 08/11/25 as ordered by the physician. 2. The facility did not ensure Resident #39 was given chopped meats for lunch on 08/11/25. This failure could place residents at risk for choking, poor intake, weight loss, and unmet nutritional needs. Findings Included: 1. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 22 residents (Residents #25 and #62) reviewed for medications at their bedside. 1. The facility did not ensure Resident #25's hydrocortisone cream (topical ointment used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) was not left on her dresser. 2. The facility did not ensure Resident #62's omeprazole (used to treat excess stomach acid) was not left on her bedside table. These failures could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 22 residents (Resident #40) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #40's preference for dislike of tomatoes products and green peas on 07/21/25, 08/07/25, and 08/10/25. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #50) reviewed for hospice services. The facility failed to obtain Resident #50's most current hospice certification, plan of care, nurse visit notes, interdisciplinary meetings, and medication profile. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse. The facility failed to protect Resident #2 from Resident #1, when Resident #1 pulled Resident #2's hair, which resulted in Resident #2's fall, and Resident #2 having to go to the ER for evaluation on 04/30/2024. The facility failed to protect Resident #3 from Resident #1, when Resident #1 hit Resident #3 on the chest on 05/10/2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse. The facility failed to implement their policy on reporting abuse when Resident #1 pulled Resident #2's hair which caused Resident #2 to fall and be sent to the ER for evaluation on 04/30/2024. The facility failed to implement their policy on reporting abuse when Resident #1 hit Resident #3 on the chest on 05/10/2024. The facility failed to implement their abuse policy to prevent Resident #1 from pulling Resident #2's hair on 4/30/2024, and hitting Resident #3 on the chest on 5/10/2024 These failures could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 5 residents (Resident #2, and Resident #3) reviewed for abuse and neglect reporting. The facility failed to report to HHSC when Resident #1 pulled Resident #2's hair which caused Resident #2 to fall and be sent to the ER for evaluation on 04/30/2024. The facility failed to report to HHSC when Resident #1 hit Resident #3 on the chest on 05/10/2024. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged for 1 of 3 residents (Resident #1) reviewed for discharge requirements. The facility failed to allow Resident #1 to return to the facility after being sent to the behavioral hospital for treatment. This failure could place residents at risk for inappropriate discharge from the facility and cause psychological harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident on the secured unit met the criteria for the unit and was not provided with the access codes or other information for independent egress for 5 of 18 residents (Resident #'s 35, 23, 38, 18, and 47) reviewed for seclusion. The facility failed to ensure Resident #35 met the facility's criteria to reside on the secured unit based on her elopement risk assessment dated [DATE] indicating no risk. The facility failed to ensure Resident #23 met the facility's criteria to reside on the secured unit based on her elopement risk assessment dated [DATE] indicating she was not a risk to elope. The facility failed to ensure Resident #38 met the facility's criteria to reside on the secured unit based on his elopement assessments on 1/10/2024 indicating he was a moderate risk to elope. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs (without adequate behavior or side effect monitoring) for 3 of 8 (Resident # 54, Resident # 64, and Resident # 3) residents who were reviewed for psychotropic medication. 1. The facility failed to ensure Resident #54 had behavior monitoring (monitor activities and mood) for his prescribed Venlafaxine (an antidepressant used to treat major depression) for the months of May and June 2024. 2. The facility failed to ensure Resident #64 had behavior monitoring (monitor activities and mood) and side effects (unwanted undesirable effects that are possibly related to a drug) for his prescribed Lexapro (an antidepressant used to treat depression) for the months of May and June 2024. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate monitoring of cigarettes to prevent accidents or hazards for 1 of 3 residents reviewed (Resident #54) and the facility failed to ensure 1 of 1 unit environment remained free of accident hazards for 1 of 18 residents (Resident #38) reviewed for accidents and hazards. 1. The facility did not ensure Resident # 54 did not have his cigarettes which were left out on his bedside table. 2. The facility failed to ensure Resident #38's personal disposable razor was disposed of or stored properly after use to prevent accidents. These failures could place residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rates were not 5 percent or greater. There were 3 errors out of the 58 opportunities, resulting in a 5.17 percent medication error rate involving 2 out of 5 residents reviewed for medication errors. (Residents #6 and #35) 1. The facility failed to ensure Resident #6's MiraLAX (laxative) was administered as ordered on 06/04/24. 2. The facility failed to ensure Resident #35's fluticasone (nasal spray that treats allergy symptoms) and guaifenesin (medication used to relieve chest congestion) were administered as ordered on 06/04/24. These failures could place residents at risk of not receiving the therapeutic outcomes and possible negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 nurse medication carts and 2 of 23 residents reviewed in sample (Residents #69 and #43). 1. The facility failed to ensure Resident #69 did not have prescribed medication Prostat AWC oral liquid (medication used to aid in wound healing) left at bedside on 06/04/24. 2. LVN D failed to ensure the 400 hall nurse medication cart was locked when it was left unattended on 06/04/24 when she went to wash her hands. 3. The facility failed to ensure LVN D properly secured Resident #43's insulin pen inside the nurse's medication cart on 06/04/24. These failures could place residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure 3 muffin tins were free from carbon build-up, rust, and food particles on 6/03/24. This failure could place residents at risk of foodborne illness, and food contamination.

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 1 of 4 residents (Resident #43) reviewed for infection control. The facility failed to ensure LVN D performed hand hygiene during Resident #43's insulin administration on 06/04/24 . This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, 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 centralized staff work area, for 1 of 23 residents (Resident #69) reviewed for physical environment. The facility failed to ensure Resident #69 had a working call light in the room on 06/04/2024. This failure could place residents at risk of not being able to get assistance when needed.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 8 resident rooms (Resident #8 and Resident #234) reviewed for clean and sanitary environment. The facility failed to ensure Resident #8 and Resident #234's rooms did not have gnats. This failure could put all residents at risk of not having a clean, sanitary, and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's safety while smoking. Resident #1 was allowed to sit on a public roadway in a space used by cars to parallel park where he could have been injured in a vehicle and pedestrian accident. An IJ was identified on 4/09/2024 at 3:45 PM. The IJ template was provided to the facility on 4/09/2024 at 4:49 PM. While the IJ was removed on 4/10/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 2 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure MA R administered Resident#1's oxycodone 10 milligrams timely as scheduled on 3/10/2024 at 7:30 a.m. and 11:30 a.m. The facility failed to ensure MA R administered Resident #1's Lasix 40 milligrams timely as scheduled on 3/102024 at 8:00 a.m. The facility failed to ensure MA R administered Resident #1's Gabapentin 300 milligrams timely as scheduled on 3/102024 at 8:00 a.m. The facility failed to ensure MA R administered Resident #1's Aldactone 100 milligrams timely as scheduled on 3/102024 at 8:00 a.m. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 19 residents reviewed for resident rights. (Resident #36, Resident #56, and Resident #58) 1. The facility failed to ensure Resident #56's pants were well-fitted and did not fall to expose her brief. 2. The facility failed to ensure MA G treated Resident #36 with dignity and respect by referring to her as a feeder. 3. The facility failed to ensure CNA L fed Resident #58 while sitting down. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to coordinate assessments with the PASARR program to the maximum extent practicable to avoid duplicative testing and effort for 3 of 19 residents (Resident #8, Resident #23, and Resident #44) reviewed for PASARR. The facility failed to coordinate IDT meetings to discuss specialized services with the Local Mental Health Authorities/Local Behavioral Health Authorities for Resident #8 and Resident #44. The facility failed to ensure the correct PASARR Screening was submitted to the local authority for Resident #23 who had MI diagnosis upon admission. These failures could place residents with positive PASARR at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 secured unit and 3 of 19 residents reviewed for activities on the secured unit. (Resident's #53, #55, #62) The facility failed to ensure activity care plans and quarterly activity assessments were completed for Resident's #53, #55, and #62. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 9 errors out of 36 opportunities, resulting in a 25 percent medication error rate for 2 of 7 residents reviewed for medication error. (Resident #6, Resident #24) The facility failed to ensure the following: 1. Resident #24 received clonazepam (antianxiety) at the prescribed time. 2. Resident #24 did not receive vitamin C after the prescribed 10 days. 3. Resident #24 received sucralfate (used to prevent ulcers in the intestines) at the prescribed time and on an empty stomach. 4. Resident #24 received ondansetron (used for nausea) at the prescribed time. 5. Resident #24 received 5 mg dose of Trintellix (antidepressant). 6. Resident #6 received Bactrim DS (antibiotic) at the prescribed time. 7. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 7 residents reviewed for medication pass. (Resident #6) The facility failed to ensure MA F held Resident #6's losartan, metoprolol, and amlodipine (blood pressure medications) when her blood pressure was below the parameters ordered by the doctor. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards and were stored in a locked compartment and only accessible by authorized personnel for 1 of 19 residents (Resident #61) reviewed for medication storage and 2 of 4 medication carts (Hall 3 & secure unit) reviewed for drugs and biologicals. 1. The facility did not keep medication being administered under the direct observation of the person administering medications. Resident #61 had 1 bottle of Chlorhexidine Gluconate Solution (mouthwash) on his bedside table. 2. The facility failed to ensure multi-dose bottles of over-the-counter medications on the hall 3 and secured unit medication carts were dated when opened. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 19 residents (Resident #8, Resident #18, and Resident #26) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was not hot and did not taste or look good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o expired food items were discarded. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 3 of 19 residents (Resident #11, Resident #53, Resident #62) reviewed for accuracy of medical records. 1. The facility failed to ensure Resident #62's responsible party signed the antipsychotic consent form after giving consent to administer the medication. 2. The facility failed to ensure Resident #53's responsible party signed the antipsychotic consent form after given consent to administer the medication. 3. The facility did not ensure Resident #11's OOH-DNR was dated by the physician. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient space to accommodate dining and activities for 1 of 2 dining rooms observed. (Secured unit) The facility did not provide a dining room on the secured unit that accommodated all residents who wanted to eat in the dining room without causing resident crowding. This failure could place the residents at risk for injury, discomfort, and decreased quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life and privacy and confidentiality of the medical records for 2 of 19 residents reviewed for resident rights. (Resident #27 and Resident #42) 1. The facility failed to ensure LVN O closed the EMAR of Resident #42 before entering her room to provide a blood glucose check and administer insulin. 2. The facility failed to ensure CNA U and CNA V provided privacy to Resident #27 while providing incontinent care. This failure could place residents at risk for a violation of resident's rights, diminished quality of life, and loss of dignity or self-worth.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 secured unit observed for homelike environment. The facility served 12 out of 12 residents in the dining room, on the secured unit, on a serving tray. The facility posted signs on the secured unit doors that stated, Elopement and Wandering in Seniors. These failures could result in resident having poor self-esteem and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure an accurate MDS was completed for 2 of 19 residents (Residents #48 and #73) reviewed for MDS assessment accuracy. 1. The facility failed to accurately document smoking for Resident #48 on the MDS assessment. 2. The facility failed to accurately document discharge status for Resident #73 on the MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 19 residents (Resident #4 and Resident #23) reviewed for care plans. The facility failed to develop and implement the comprehensive care plan from the triggered CAAs from the comprehensive MDS assessment for Resident #4 and Resident #23. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 19 residents reviewed for activities of daily living. (Resident #13 and Resident #60) 1. The facility failed to ensure Resident #60 was toileted and provided with a clean brief. 2. The facility failed to provide facial hair removal/shaving for dependent female Resident #13. This failure could place residents who were dependent on staff to perform personal hygiene at risk or embarrassment, decreased self-esteem, or decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 4 residents (Resident #38) reviewed for respiratory care and services. The facility failed to administer oxygen between 2-3 liters per minute via nasal cannula as prescribed by the physician for Resident #38 This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #52) reviewed for dialysis. The facility failed to ensure nursing staff was checking Resident #52's shunt (vascular access used for hemodialysis) to left upper arm for bruit (sound heard through a stethoscope when held over the shunt) and thrill (vibration or buzz felt when fingers are laid on top of the shunt). This failure could place residents who receive dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service department for 2 of 9 dietary staff (Dietary Aide C and Dietary Aide D). The facility failed to ensure that dietary staff (Dietary Aide C and Dietary Aide D) serving in the kitchen maintained a current Food Handler Certificate. This failure could place residents at risk of not having their nutritional needs met and place them at risk for foodborne illnesses.

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 of 2 staff (CNA U and CNA V) reviewed for infection control. The facility failed to ensure CNA U and CNA V performed hand hygiene between glove changes while providing incontinent care. This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 smoking area. The facility failed to ensure cigarette butts were disposed of appropriately. This failure could place the residents at risk for injury.