The Villa at Texarkana

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 6 residents (Resident #1) reviewed for infection control practices. The facility failed to ensure CNA A performed hand hygiene and changed her gloves during Resident #1's incontinent care on 06/29/26. 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 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 memory care unit consisting of 14 residents reviewed for activities. The facility failed to provide meaningful activities for dementia residents on the memory care unit. 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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for kitchen sanitation. The facility did not ensure:1. The flour scoop was kept out of the storage container on 03/09/2026, 03/10/2026, and 03/11/2026.2. The deep fryer and stove were free of caked on grease. These failures could place residents at risk for cross contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 1 of 22 residents (Resident #47) reviewed for comprehensive MDS assessment timing. The facility failed to complete Resident #47's annual comprehensive MDS assessment within 366 days of the previous comprehensive MDS assessment. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on interview and record review the facility failed to complete the quarterly MDS assessment not less frequently than every 3 months for 1 of 16 (Resident #62) residents reviewed for MDS completion. The facility failed to complete the quarterly MDS assessment for Resident #62, within 92 calendar days of the previous annual assessment dated [DATE]. These failures could place residents at risk of not receiving services to provide quality care.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 16 residents reviewed for MDS accuracy. (Resident #8) The facility failed to accurately code Resident #8's psychotropic medication use. This failure could place residents at risk of receiving unneeded care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free from accident hazards for 1 of 20 residents (Resident #84) reviewed for accident hazards. The facility failed to keep prohibited items, chemical insecticide (targeting roaches), out of Resident #84's room. This failure could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 18 residents (Resident #63, Resident #53) reviewed for resident rights. The facility failed to protect and value Resident # 63's rights when the facility failed to allow Resident #63 call the police to report a potential crime. The facility failed to protect and promote the rights of Resident #53 by not knocking on the door prior to entering the resident's room. This failure could place residents at risk for decreased quality of life, increased anxiety, decreased privacy, and increased stress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 23 residents reviewed for environment. (Resident #57 and Resident #72) 1. The facility failed to repair an electrical outlet in the room of Resident #57 a timely manner. 2. The facility failed to provide a functioning bed light pull string for Resident #72. These failures placed residents at risk of injury of, living in an uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident assessments accurately reflected the resident's status for 1 (Resident #20) of 12 residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #20's MDS quarterly assessment accurately reflected the resident had 5 injections of insulin and had no UTI (urinary tract infection). This failure put residents at risk for not receiving care and services needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 14 residents (Resident #66, Resident #72) reviewed for adequate supervision. The facility failed to ensure that Resident #66 and Resident #72 did not have cigarette lighters in their room and in their personal possession. This failure could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 23 residents (Resident #30) reviewed for bedrails . 1. The facility failed to ensure informed consent for the use of Resident #30's bed rails were obtained prior to installation. 2. The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #30's bed rails. These failures could place residents at risk of entrapment or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 2 of 5 residents (Resident #8 and Resident #18) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #8 had an appropriate rationale for declining a GDR for her Zyprexa medication (an antipsychotic medication used to treat bipolar disorder). 2. The facility failed to ensure Resident #18 had an appropriate diagnosis for her prescribed Trileptal (it can treat epileptic seizures). This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #75). The facility failed to ensure the refrigerator for Resident #75 did not contain expired bologna and milk. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the hand hygiene procedures were followed by staff involved in direct resident contact for 1 of 5 residents (Resident #59) reviewed for infection control. The facility failed to ensure Staffing Coordinator M performed appropriate hand washing after incontinent care was performed for Resident #59. This failure could result an increase the infections, cross contamination and decrease quality of life. Record review of face sheet date 12/10/2024 indicated Resident #59 was a [AGE] year old male initially admitted to the facility on [DATE] with a diagnoses which included unspecified dementia (a general term for dementia that doesn't have a specific diagnosis), anoxic brain damage (cerebral hypoxia occurs when the brain doesn't receive enough oxygen) and a personal history of urinary tract infections. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure all food items were labeled and dated. The facility failed to ensure a clean ice machine. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 2 of 4 shower rooms reviewed for environment. (Shower # 1 and Shower # 4) The facility failed to clean and repair tiles in the facility shower room [ROOM NUMBER] and 4. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 21 residents (Residents #37, #78), reviewed for care plans. The facility failed to revise and update Resident #37's comprehensive care plan with new enteral feeding orders. The facility failed to revise and update Resident #78's comprehensive care plan for hospice services. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 21 residents reviewed for ADLs. (Resident #3 and Resident #72) The facility failed to remove facial hair from female Resident #3. The facility failed to shave facial hair for male Resident #72. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 2 residents (Resident #24 and #55) reviewed for respiratory care and services. The facility failed to ensure Resident #24's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #55. This failure could place residents at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 21 residents reviewed for pharmacy services. (Resident # 73) The facility failed to provide adequate supervision for Resident #73 during medication administration. This failure could place residents at risk for inaccurate drug administration.

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 21 reviewed. (Resident #73) The facility failed to securely store over the counter medications for Resident #73. This failure could place residents at risk for adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 1 resident reviewed for accidents and supervision. (Resident #2) The facility failed to provide appropriate supervision for Resident #2 to prevent falls with and without injury. This failure places residents at risk for serious injury related to falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1of 1 memory care unit reviewed for infection control and 6 of 24 residents observed during hydration pass. (Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) The facility failed to ensure the ice scoop for the memory care unit was sanitarily stored while not in use. The facility failed to ensure CNA A did not use a contaminated ice scoop to fill the memory care unit residents' cups with ice. The facility failed to ensure HA C did not cross-contaminate each resident's cup while using an ice scoop to fill Resident #6, 7, 8, 9, 10, and 11's cups during hydration pass. [...]

Inspectors wroteBased on interview and record review, the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 28 residents (Resident #3) reviewed for grievances. The facility failed to make prompt efforts to resolve a Grievance/concern report when Resident #3's Representative #1 reported being concerned that another family member may be giving Resident #3 medication, because she noticed Resident #3's speech being different after the other family member visited. This deficient practice of not making prompt efforts to resolve grievances could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure each resident was free from abuse and neglect for 1 (Resident # 1) of 8 residents reviewed for abuse and neglect. The facility failed to ensure Resident #1, was free from verbal abuse when he was cursed at by CNA E during care. This failure could place residents at risk of serious harm from possible abuse and neglect.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse to the state survey agency for 1 of 28 residents (Resident #3) reviewed for abuse, neglect, exploitation, and misappropriation of resident property. The facility failed to report an allegation of abuse within 2 hours after Resident #3's Representative #1 filed a Grievance/concern report on 8/01/23 about being concerned that another family member may have been giving Resident #3 medications because Resident #3's speech was slurred after the other family member visited. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 10 residents reviewed for care plans. (Resident #5, and Resident #4) 1. The facility failed to develop a comprehensive person-centered care plan including interventions for falls for Resident #5. 2. The facility failed to develop a comprehensive person-centered care plan including interventions for pain and opioid use for Resident #4 These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 2 of 12 residents reviewed for ADLs (Residents # 2 and Resident # 6) 1. The facility did not provide incontinent care for Resident #2 for 6-8 hours for 2 days 2. The facility did not provide scheduled showers for Resident #6. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1. [...]