Spicewood Cottages Oaks

The facility failed to administer medications as ordered for one resident. Specifically, Gemtesa 75mg was not available for administration during an observation on June 4, 2025, and there was no documentation verifying the medication had been delivered to the facility.

The facility failed to administer medications as ordered for Resident #1. Specifically, the facility documented the administration of gemtesa and vitamin D2 on the eMAR, but an observation revealed the medications were not physically available on hand. This indicates that staff were documenting medication administration for drugs that had not been delivered by the pharmacy.

The facility failed to ensure at least one staff member was on duty at all times on the second and third shifts when the Administrator or Supervisor-in-Charge was not present. Staffing schedules were unidentifiable as they did not specify which staff worked in which of the three separate facilities. Interviews revealed periods where a resident was left without staff in the building because the assigned staff member had to assist at a sister facility.

The facility failed to ensure that at least one staff member was on duty at all times during the second and third shifts to provide personal care and supervision when the Administrator or Supervisor-in-Charge was not on duty. This finding represents a failure to abate a previous Type B violation.

The facility failed to ensure that 1 of 3 sampled staff members providing personal care had completed the required 80-hour personal care training and competency evaluation program. Documentation of successful completion for Staff C was not available in the personnel record.

The facility failed to maintain required staffing levels and oversight as specified for homes with certain capacities. The regulation requires an administrator or administrator-in-charge to be available or a specific staff member to be on duty to provide direct personal assistance and supervision.

The facility failed to ensure that one out of three sampled staff members had documentation of successful completion of the required 80-hour personal care training and competency evaluation program. Specifically, a Personal Care Aide hired in April 2021 had been working for approximately one year without completing the mandated training.

The facility failed to provide adequate supervision for a resident according to their assessed needs and care plan. This lack of supervision resulted in multiple falls with injuries, including a facial wound, and an incident where the resident was found attempting to elope from the facility.

The facility failed to provide adequate supervision for a resident with Alzheimer's disease, resulting in multiple falls with injuries and an elopement incident. Specifically, the resident was found halfway out of the facility door and had sustained several injuries, including a shoulder fracture and head lacerations, due to lack of appropriate monitoring.