Inspection Reports for Birchwood of Spring Branch (formerly Arden Wood)
TX, 77055
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
114% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Dec 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program compliance, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) signage and PPE usage.
Findings
The facility failed to maintain proper EBP signage outside resident rooms requiring PPE, which could lead to staff not following appropriate precautions and increase the risk of infection transmission. Observations and interviews confirmed missing signage and inconsistent placement of PPE equipment outside rooms for three residents reviewed for infection control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide and implement an infection prevention and control program, specifically missing EBP signage outside resident rooms needed for PPE. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for infection control: 3
Date of inspection: Dec 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Infection Preventionist | Named in relation to replacing missing EBP signs and conducting in-service training |
| LVN M | Licensed Vocational Nurse | Interviewed regarding PPE procedures and signage |
| LVN E | Licensed Vocational Nurse | Interviewed regarding PPE procedures and signage |
| CNA Y | Certified Nursing Assistant | Interviewed regarding PPE procedures and signage |
| ADMN | Administrator | Interviewed regarding facility procedures for EBP and isolation |
| CNA J | Certified Nursing Assistant | Interviewed regarding PPE usage and signage |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 28, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program and to submit a Nursing Facility Specialized Services (NFSS) request by the required deadline for a resident.
Findings
The facility failed to submit a NFSS request for a specialized pressure-reducing support surface mattress for Resident #119 by the deadline of 12/04/2024, due to issues with the resident's social security numbers and inability to obtain a medical equipment supplier quote on time. The resident was discharged before the mattress was ordered and the NFSS was submitted. The facility did not provide a written PASRR process policy.
Complaint Details
The complaint investigation found that the facility did not submit the NFSS request on time due to social security number issues and delays in obtaining supplier quotes. The resident was discharged before the mattress was ordered. The facility lacked a written PASRR process policy. The DOR was aware of the 20 business day submission requirement but was unable to meet it.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to coordinate an assessment with the PASRR program to avoid duplicative testing and effort for Resident #119. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to submit a NFSS request for Resident #119's specialized mattress by the deadline. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deadline for NFSS submission: Dec 4, 2024
Date of PASRR Physical Evaluation: Sep 27, 2024
Date of IDT meeting: Nov 6, 2024
Business days to submit NFSS: 20
Inspection Report
Routine
Deficiencies: 5
Mar 28, 2025
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations, focusing on medication management, physician supervision, pharmaceutical services, drug storage, and food safety in the facility.
Findings
The facility was found deficient in multiple areas including failure to ensure appropriate physician orders for blood sugar monitoring, missed medication administration, inaccurate controlled drug records, improper storage of drugs with torn seals, and contamination risk in the kitchen's ice machine due to personal drink items.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, specifically missing upper blood sugar parameters in physician orders for Resident #98. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain a doctor's order to admit a resident and ensure medical supervision, including lack of blood sugar reporting parameters for Resident #98. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services including missed administration of Lorazepam to Resident #6 and inaccurate controlled drug records. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store all drugs and biologicals in locked compartments with intact seals; torn seals on narcotic pill cards and use of tape to cover torn seals. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, distribute, and serve food in accordance with professional standards; ice machine contained personal bottled water risking contamination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood sugar readings: 330
Blood sugar readings: 98
Missed medication dose: 1
Lorazepam tablets remaining: 33
Lorazepam tablets in secured unit cart: 7
Lorazepam tablets in front hall cart: 23
Tramadol tablets in front hall cart: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Signed out Lorazepam but did not administer it; acknowledged medication error |
| ADON #2 | Assistant Director of Nursing | Provided statements about blood sugar reporting and nursing responsibilities |
| LVN C | Licensed Vocational Nurse | Discussed blood sugar parameters and reporting responsibilities |
| LVN A | Licensed Vocational Nurse | Discussed blood sugar parameters and missed reporting high blood sugar |
| DON | Director of Nursing | Provided statements on medication administration, blood sugar monitoring, and narcotic counts |
| Dietitian | Dietitian | Discussed blood sugar monitoring and dietary changes |
| DM | Dietary Manager | Observed ice machine contamination and described corrective actions |
| Corporate DM | Corporate Dietary Manager | Conducted in-service on ice machine contamination and food safety |
| ADM | Administrator | Provided expectations on storage protocols and food safety |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 19, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident neglect and failure to protect residents from abuse and ensure proper supervision in a memory care unit.
Findings
The facility failed to ensure residents were free from neglect and failed to supervise residents, resulting in an unwitnessed resident-to-resident altercation causing injury. The facility also failed to develop and implement comprehensive, person-centered care plans for residents with behavioral and psychosocial needs, and failed to revise care plans timely. Immediate Jeopardy was identified but later removed after the facility implemented a Plan of Removal including increased supervision, staff training, and care plan updates.
Complaint Details
The complaint investigation was substantiated with findings of neglect and failure to supervise residents, resulting in injury to residents #2 and #3. Immediate Jeopardy was identified on 02/14/24 and removed on 02/17/24 after corrective actions were implemented.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect residents from neglect and abuse, resulting in an unwitnessed resident-to-resident altercation causing injury. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to develop and implement a comprehensive person-centered care plan for residents with behavioral and psychosocial needs. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to review and revise the person-centered care planning for a resident to include behavioral triggers and aggression. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents with potential to wander: 13
Residents on memory care unit: 30
Staffing ratios: 3
Staffing ratios: 2
Staffing ratios: 1
Care plans reviewed: 33
Staff educated on care plans: 14
Staff educated on accessing care plans: 57
Staff educated on supervision: 80
Walkie talkies purchased: 12
Resident #2 BIMS score: 3
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a safe, functional, sanitary, and comfortable environment, specifically related to staff access to memory care residents and timely incontinence care.
Findings
The facility failed to ensure staff had timely access to memory care residents when their bedroom door was wedged with the bathroom door, creating an immediate jeopardy situation. Additionally, the facility failed to provide timely and proper incontinence care to residents, resulting in risks for infections, skin breakdown, and decreased quality of life. The facility implemented a Plan of Removal to address door handle issues and staff training on emergency access and incontinence care.
Complaint Details
The complaint investigation was triggered by an incident on 01/30/24 where staff were unable to access two memory care residents for approximately 50 minutes due to their bedroom door being wedged with the bathroom door. Immediate Jeopardy was identified and later removed on 02/01/24. Additional complaints involved failure to provide timely and proper incontinence care to residents #3 and #4, leading to risks of infection and skin breakdown.
Severity Breakdown
Immediate jeopardy: 1
Minimal harm or potential for actual harm: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide a safe, functional, sanitary, and comfortable environment due to bedroom door wedging with bathroom door preventing staff access to residents. | Immediate jeopardy |
| Failure to provide timely incontinence care to residents, resulting in soiled linens and risk of infection. | Minimal harm or potential for actual harm |
| Failure to provide appropriate care for residents incontinent of bowel/bladder, including proper catheter care and prevention of urinary tract infections. | Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program, including improper infection control precautions during incontinence care. | Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Door handles replaced: 23
Signatures on in-service training: 128
BIMS score: 0
BIMS score: 2
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Involved in attempts to open wedged bedroom door and described emergency procedures | |
| Nurse A | Attempted to open wedged bedroom door and coordinated with maintenance | |
| Nurse B | Attempted to open wedged bedroom door | |
| Floor Tech | Used metal tool to open wedged bedroom door | |
| Maintenance Director | Inspected and repaired door hinges and coordinated door handle replacements | |
| CNA G | Provided incontinence care to Resident #3 with noted deficiencies | |
| CNA H | Provided incontinence care to Resident #4 with noted deficiencies | |
| DON | Director of Nursing | Provided expectations for proper incontinence care and infection control |
| Administrator | Notified of Immediate Jeopardy and involved in corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 6
Dec 23, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding neglect, infection control, respiratory care, and pest control at the facility.
Findings
The facility failed to protect residents from neglect, failed to provide appropriate respiratory care for a resident with a tracheostomy, failed to implement an effective infection prevention and control program including managing a scabies outbreak, failed to ensure staff competencies in respiratory care, and failed to maintain effective pest control. These failures resulted in multiple residents contracting scabies, respiratory distress in a resident with tracheostomy, and presence of pests such as cockroaches and gnats in the facility.
Complaint Details
The complaint investigation revealed multiple issues including neglect, infection control failures, respiratory care deficiencies, and pest control problems. Immediate jeopardy was identified related to respiratory care and infection control.
Severity Breakdown
Immediate jeopardy: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to protect residents from neglect including failure to retain qualified infection preventionist, failure to track infections timely, failure to treat and isolate residents with scabies, and failure to maintain sterile procedures for tracheostomy suctioning. | Immediate jeopardy |
| Failed to provide safe and appropriate respiratory care for Resident #49 including failure to maintain oxygen mask placement, failure to suction secretions timely, and failure to maintain sterile technique during suctioning. | Immediate jeopardy |
| Failed to ensure licensed nurses possess competencies and skills necessary to provide nursing services safely, specifically LVN R's failure to identify respiratory distress and maintain sterile technique during suctioning. | Immediate jeopardy |
| Failed to establish and maintain an infection prevention and control program including failure to retain qualified infection preventionist, failure to implement environmental controls to prevent scabies outbreak, and failure to ensure staff compliance with infection control procedures. | Immediate jeopardy |
| Failed to ensure a qualified infection preventionist had completed specialized training in infection prevention and control, resulting in failure to implement an effective infection control program. | Immediate jeopardy |
| Failed to maintain effective pest control program resulting in presence of live cockroaches and gnats in the kitchen, hallways, and resident rooms. | — |
Report Facts
Residents affected by neglect and infection control failures: 13
Staff affected by infection control failures: 4
Residents with tracheostomy reviewed: 2
Residents with scabies: 13
Dates of infection tracking completed retrospectively: 3
Dates of pest control service: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN R | Licensed Vocational Nurse | Failed to maintain sterile technique and failed to provide appropriate respiratory care for Resident #49 |
| ADON B | Assistant Director of Nursing | Provided interview regarding respiratory care and facility response |
| RN D | Registered Nurse | Provided interview regarding respiratory distress and nursing responsibilities |
| RT B | Respiratory Therapist | Provided interview regarding respiratory distress signs and training |
| MA A | Medical Assistant | Interviewed regarding Resident #107's dermatology treatment |
| Treatment Nurse | Interviewed regarding residents with scabies and observations | |
| Hospital Nurse | Interviewed regarding Resident #107's hospital admission and scabies diagnosis | |
| CNA EE | Certified Nursing Assistant | Interviewed regarding Resident #49's condition and signs of distress |
| Maintenance Director | Interviewed regarding pest control issues and contract | |
| COO | Chief Officer of Operations | Interviewed regarding pest control and facility policies |
| CNO | Chief Nursing Officer | Interviewed regarding pest control and resident rights |
Inspection Report
Complaint Investigation
Deficiencies: 8
Dec 23, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding neglect, infection control, respiratory care, pharmaceutical services, and pest control at the facility.
Findings
The facility failed to protect residents from neglect, failed to provide appropriate respiratory care for a resident with a tracheostomy, failed to ensure pharmaceutical services met residents' needs, failed to maintain an effective infection prevention and control program including managing a scabies outbreak, failed to ensure staff competencies, and failed to maintain effective pest control. These failures resulted in multiple residents contracting scabies, respiratory distress for a resident, expired medications in use, and pest infestations in the facility.
Complaint Details
The complaint investigation revealed substantiated findings of neglect, infection control failures, respiratory care deficiencies, pharmaceutical service issues, and pest control problems placing residents at risk of harm.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 5
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to protect residents from neglect including failure to retain qualified infection preventionist, track infections timely, treat and isolate residents with scabies, and maintain infection control surveillance. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide safe and appropriate respiratory care for a resident with tracheostomy including failure to maintain oxygen mask placement, suction secretions timely, and maintain sterile technique. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure licensed nurses possess competencies and skills necessary to provide safe nursing services, specifically respiratory care. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide pharmaceutical services to meet residents' needs including expired injectable antidiabetic medication in use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were labeled properly, stored securely, and accessible only to authorized personnel, including inappropriately labeled protein supplements in medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an effective infection prevention and control program including failure to prevent and control a scabies outbreak affecting multiple residents and staff. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to designate a qualified infection preventionist with required training resulting in ineffective infection control program and scabies outbreak. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to maintain effective pest control program resulting in presence of live cockroaches and gnats in kitchen, hallways, and resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected by neglect and infection control failures: 13
Staff affected by infection control failures: 4
Residents with tracheostomy requiring respiratory care: 2
Residents with scabies: 13
Residents with scabies diagnosis date: 12
Expired injectable medication discard date: 30
Pest control service frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN R | Licensed Vocational Nurse | Failed to provide appropriate respiratory care to Resident #49 including failure to maintain oxygen mask placement and sterile technique during suctioning. |
| DON | Director of Nursing | Failed to complete required Infection Preventionist training and timely infection tracking and trending. |
| MA A | Treatment Nurse | Observed Resident #107 with scabies rash and stated rash on Resident #39 and Resident #107 appeared the same. |
| Hospital Treatment Nurse | Observed Resident #107 with crusted scabies at hospital and was not notified of scabies diagnosis on admission. | |
| CNA S | Licensed Nurse | Responsible for medication cart with expired injectable medication. |
| Kitchen Manager | Reported multiple gnats in kitchen and pest control visits monthly. | |
| Maintenance Director | Reported ongoing pest issues with cockroaches and gnats and new pest control company started August 2023. | |
| DON | Director of Nursing | Stated nursing carts should be checked daily for expired medications and proper labeling. |
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the care and treatment of residents, specifically focusing on the appropriate use and management of feeding tubes.
Findings
The facility failed to ensure that Resident #77's head of bed was elevated at the required minimum angle during enteral feeding, placing the resident at risk for aspiration and other complications. Observations and interviews confirmed the head of bed was flat during feeding, contrary to physician orders and facility policy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #77's head was elevated at a minimum of 30 degrees during enteral feeding via gastrostomy tube. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Feeding pump rate: 55
Date of observation: Oct 26, 2022
Physician order date: Sep 23, 2022
Care plan initiation date: Oct 17, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Unit Manager | Observed and reported Resident #77's head of bed was flat during feeding |
| DON | Director of Nursing | Confirmed head of bed was not in proper position and elevated it |
| Administrator | Acknowledged the issue and described corrective actions including staff discipline and in-service training |
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