Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Dec 18, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, baseline care planning, competent nursing services, medication error prevention, medical record maintenance, and infection control practices at St. Anthony's Care Center.
Findings
The facility was found deficient in ensuring residents' privacy rights, timely baseline care planning, competent nursing services including medication administration, accurate medical record keeping, and proper infection prevention and control practices. Specific issues included failure to knock before entering resident rooms, delayed baseline care plan creation, medication administration errors, incomplete vital sign documentation, and inadequate hand hygiene during care.
Deficiencies (5)
Failure to ensure residents had a right to personal privacy and confidentiality; CNAs failed to knock before entering resident rooms.
Failure to develop and implement a baseline care plan within 48 hours of admission for Resident #21, specifically addressing nutrition via enteral feeds.
Failure to ensure competent nursing services; medication administration error involving double dosing of hydrocodone/acetaminophen for Resident #21.
Failure to maintain complete and accurate medical records; missing weekly oxygen saturation documentation for Resident #28.
Failure to provide a safe and sanitary environment; staff failed to perform hand hygiene with glove changes during catheter care, wound care, and peri-care for multiple residents.
Report Facts
Residents reviewed: 10
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in medication administration error involving double dosing of hydrocodone/acetaminophen. |
| LVN A | Licensed Vocational Nurse | Named in medication administration error and subsequent reporting and monitoring. |
| CNA A | Failed to knock before entering resident rooms. | |
| CNA B | Failed to knock before entering resident rooms. | |
| CNA C | Failed to knock before entering resident rooms and improper catheter care without hand hygiene. | |
| LVN C | Licensed Vocational Nurse | Failed to perform hand hygiene during catheter care. |
| LVN F | Licensed Vocational Nurse | Failed to perform hand hygiene during suprapubic catheter care. |
| LVN D | Licensed Vocational Nurse | Failed to perform hand hygiene during wound care. |
| CNA D | Failed to perform hand hygiene during peri-care. | |
| DON | Director of Nursing | Provided interviews regarding privacy, baseline care plans, medication errors, infection control, and staff training. |
| ADM | Administrator | Provided interviews regarding privacy, baseline care plans, medication errors, infection control, and staff training. |
| ADON A | Assistant Director of Nursing | Provided interviews regarding baseline care plans, medication errors, and vital sign documentation. |
| ADON B | Assistant Director of Nursing | Provided interviews regarding baseline care plans, vital sign documentation, and infection control. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 12, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide appropriate pressure ulcer care and pharmaceutical services, specifically concerning one resident (Resident #1) who experienced pressure injuries and missed medication doses during a respite stay.
Complaint Details
The complaint investigation focused on Resident #1, who was admitted for a respite stay and was on hospice services. The facility failed to prevent pressure injuries and did not administer prescribed Parkinson's medication from 10/11/2024 to 10/13/2024, missing 5 doses. Family members reported skin breakdown and discomfort, and interviews with facility staff confirmed procedural gaps and errors in medication orders.
Findings
The facility failed to prevent pressure injuries for Resident #1 by not monitoring skin changes adequately and failed to administer prescribed Parkinson's medication, resulting in missed doses and increased symptoms. Interviews and record reviews confirmed these deficiencies, with actual harm noted and a few residents affected.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #1.
Failure to provide pharmaceutical services to meet the needs of Resident #1, including failure to administer prescribed Parkinson's medication resulting in missed doses.
Report Facts
Residents reviewed for pressure injuries: 6
Residents reviewed for pharmacy services: 6
Missed medication doses: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 7, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to carry out physician orders for a urinalysis (UA) for Resident #1, who was incontinent and suspected of having a urinary tract infection (UTI).
Complaint Details
The complaint investigation found that the facility did not collect the urine specimen for Resident #1's UA ordered on 4/15/2024 despite multiple reminders and hospice nurse involvement. The order was discontinued on 4/18/2024 due to non-collection. Staff interviews revealed unclear responsibility and lack of follow-through. The facility had no policy on specimen collection and failed to document attempts or communicate delays.
Findings
The facility failed to collect a urine specimen for UA as ordered by the physician and hospice nurse, resulting in a delay in diagnosis and treatment of a possible UTI for Resident #1. Interviews with staff and hospice personnel confirmed the order was not followed and there was no communication about the delay. The facility lacked a policy on specimen collection and documentation was missing.
Deficiencies (1)
Failure to carry out physician orders for a urinalysis for Resident #1 to diagnose a possible urinary tract infection.
Report Facts
Residents reviewed for quality of care: 5
BIMS score: 3
Date of physician order for UA: Apr 18, 2024
Date hospice nurse ordered UA: Apr 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Received the UA order on 4/15/2024 but did not attempt to collect the specimen and passed responsibility to night shift |
| ADON | Assistant Director of Nursing | Stated nurse receiving order is responsible for carrying it out and criticized LVN A for not attempting specimen collection |
| DON | Director of Nursing | Outlined expectations for specimen collection and documentation, noted lack of documentation for Resident #1 |
| Hospice Nurse Case Manager | Ordered UA on 4/15/2024 and reported no specimen collection or communication from facility | |
| FM | Family member of Resident #1 who reported symptoms and lack of specimen collection | |
| Hospice Physician | Expressed concern about non-collection of UA and importance of timely specimen collection | |
| The AD | Administrator | Stated expectation that physician orders be followed and communication occur if unable to comply |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, and pressure ulcer prevention at St. Anthony's Care Center.
Findings
The facility was found deficient in ensuring resident dignity by failing to conceal a catheter bag for Resident #53, failing to update care plans accurately for Resident #40, and failing to provide appropriate pressure ulcer care including timely repositioning for Residents #15 and #53. These deficiencies placed residents at risk for indignity, lack of proper care, and pressure ulcers.
Deficiencies (3)
Failed to ensure Resident #53's transparent plastic catheter bag was concealed in a dignity bag, risking indignity and diminished quality of life.
Failed to revise the care plan for Resident #40 to accurately reflect the absence of an indwelling catheter, risking improper care.
Failed to provide appropriate pressure ulcer care and reposition residents #15 and #53 every two hours to prevent skin breakdown and pressure ulcers.
Report Facts
Residents reviewed: 8
Repositioning frequency: 2
Care plan revision timeframe: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Interviewed regarding catheter bag concealment policy and practice |
| DON | Director of Nursing | Interviewed regarding catheter bag policy, care plan updates, and repositioning requirements |
| ADM | Administrator | Interviewed regarding catheter bag concealment and care plan update expectations |
| MDS LVN | Licensed Vocational Nurse | Interviewed regarding care plan update process and potential harm from outdated plans |
| MDS RN | Registered Nurse | Interviewed regarding care plan update process and potential harm from outdated plans |
| LAR #40 | Interviewed regarding Resident #40's catheter status | |
| LAR #15 | Interviewed regarding concerns about Resident #15's care and repositioning | |
| LAR #53 | Interviewed regarding concerns about Resident #53's repositioning and care | |
| CNA A | Certified Nursing Assistant | Interviewed and observed regarding repositioning duties and documentation |
| RN A | Registered Nurse | Interviewed regarding importance of repositioning and resident care |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 5, 2023
Visit Reason
The inspection was conducted as an annual survey of St. Anthony's Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable standards.
Inspection Report
Routine
Deficiencies: 2
Date: Sep 22, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of practice related to respiratory care and medication management in the facility.
Findings
The facility failed to provide appropriate respiratory care by not maintaining humidifier bottles with water for oxygen concentrators for two residents, placing them at risk of discomfort and skin breakdown. Additionally, the facility failed to ensure that expired or discontinued medications were removed from nurses' medication carts, risking medication errors.
Deficiencies (2)
Failure to provide safe and appropriate respiratory care by not maintaining humidifier bottles with water for oxygen concentrators for Residents #14 and #90.
Failure to ensure all drugs and biological medications were not past their expiration dates and/or discontinued on two nurses medication carts.
Report Facts
Residents reviewed for oxygen therapy: 5
Residents affected by respiratory care deficiency: 2
Nurses medication carts reviewed: 2
Expired medication found: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Charge Nurse | Named in relation to responsibility for oxygen tubing and humidifier bottle maintenance for Resident #14. |
| LVN C | Charge Nurse | Named in relation to responsibility for oxygen concentrator and tubing maintenance for Resident #90. |
| MDSN | Provided information about the importance of humidifier bottles for residents' comfort. | |
| DON | Director of Nursing | Discussed responsibilities and procedures related to oxygen therapy and humidifier bottle maintenance. |
| ADM | Administrator | Discussed accountability for oxygen concentrator maintenance and medication cart oversight. |
| LVN A | Nurse | Interviewed regarding responsibility for removing discontinued medications from medication carts. |
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