Spicewood Cottages Willows

The facility failed to ensure that one of three sampled medication aides had completed the required 10-hour medication aide training within 60 days of employment. While the staff member had completed 5-hour training and clinical skills validation, there was no documentation verifying the completion of the 10-hour course.

The facility failed to protect three out of five sampled residents from harm related to Resident #2, who had a known history of aggressive and possessive behaviors. Evidence showed that staff failed to prevent physical assaults, including hitting, slapping, and punching, and failed to take adequate action to move the aggressor despite multiple reports of bullying and physical injury.

The facility failed to protect residents from harm related to a resident with known aggressive behaviors. Specifically, staff failed to prevent Resident #2 from hitting, bullying, and physically intimidating other residents, including causing bruising and attempting to lock residents in bathrooms.

The facility failed to ensure at least one staff member was on duty at all times during the third shift to provide personal care and supervision. Interviews and record reviews revealed that staff members frequently had to float between four different buildings, leaving certain buildings completely unstaffed during the night. Documentation of time clock punches confirmed instances where staffing levels dropped below the required coverage for the facility.

The facility failed to ensure at least one staff member was on duty at all times during the third shift to provide supervision and personal care. Interviews with residents revealed that the medication aide frequently had to float between four different buildings, leaving the building without staff presence during certain periods. Additionally, the December 2023 staffing schedule failed to specify which staff members were assigned to each individual facility.

The facility failed to ensure at least one staff member was on duty at all times during the evening shift to provide supervision to residents. Interviews with residents revealed instances where staff left the building to assist at other facilities, leaving residents unsupervised and unable to receive assistance when calling for help. Specifically, one resident reported being left in a puddle of urine for approximately one hour after a fall because no staff were present in the building.

The facility failed to ensure that at least one staff member was on duty at all times during the evening shift to provide necessary supervision to the residents. This failure represents a continuation of a previous Type B violation that was not abated.

The facility failed to maintain adequate staffing coverage as required by the census. The facility must ensure that when the administrator is not on duty, there is at least one staff member on duty for all shifts, and the facility must address instances where there is not enough coverage in each building.

The facility failed to ensure that one of three sampled staff members had documentation of successful completion of the required 80-hour personal care training and competency evaluation program. Specifically, a PCA hired on 04/26/21 had not completed the training despite being provided with the necessary links and multiple opportunities to do so.