Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 3
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care standards related to catheter care, medication regimen review, infection prevention, and control practices at The Army Residence Community Health Care Center.
Findings
The facility failed to ensure appropriate catheter care to prevent urinary tract infections for one resident, failed to ensure the attending physician addressed pharmacist recommendations for psychotropic medication dose reduction for one resident, and failed to maintain proper infection prevention and control practices including PPE use during care.
Deficiencies (3)
Failure to provide appropriate care for residents with indwelling foley catheters to prevent urinary tract infections and restore continence.
Failure to ensure attending physician documented review and action on pharmacist's recommendation for gradual dose reduction of psychotropic medication.
Failure to maintain an infection prevention and control program including failure to use PPE during perineal and incontinent care with an indwelling foley catheter.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Consultant Pharmacist review date: Apr 29, 2025
Medication dose: 20
Training dates: Feb 19, 2025
Training dates: Feb 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNA A | Performed perineal and incontinent care; involved in catheter care incident | |
| RNA B | Performed perineal and incontinent care; involved in catheter care incident | |
| LVN C | Attempted to reconnect catheter drainage bag; involved in catheter care incident | |
| DON | Director of Nursing | Provided statements on staff training and infection risks |
| RN F | Responsible for reviewing Consultant Pharmacist reviews and contacting MD | |
| MD D | Physician | Prescribing physician for Resident #18; did not document response to pharmacist recommendation |
| NP E | Nurse Practitioner | Signed in lieu of Resident #18's MD on Consultant Pharmacist review |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and pharmaceutical services, specifically focusing on the adequacy of care plans for infections and the administration of antibiotics to residents.
Findings
The facility failed to ensure comprehensive care plans were developed and implemented for residents with infections and antibiotic treatments, affecting 3 residents. Additionally, the facility failed to provide pharmaceutical services that assured accurate administration of medications, resulting in a missed antibiotic dose for one resident.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, including timely updates for infections and antibiotic treatments for 3 residents (#5, #6, #7).
Failure to provide pharmaceutical services ensuring accurate administration of drugs, resulting in a missed antibiotic dose for Resident #5.
Report Facts
Residents reviewed for care plans: 4
Residents affected by care plan deficiency: 3
Residents reviewed for pharmacy services: 7
Missed antibiotic dose: 1
Antibiotic treatment duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Charge Nurse | Named in medication error finding related to missed antibiotic dose for Resident #5 |
| LVN D | Licensed Vocational Nurse | Responsible for reviewing lab results and notifying physician; involved in medication order and correction for Resident #5 |
| LVN E | Licensed Vocational Nurse | Documented UA result and initial antibiotic order for Resident #5 |
| MDS Coordinator | Responsible for care planning infections and antibiotics; interviewed regarding care plan deficiencies | |
| DON | Director of Nursing | Responsible for care planning oversight and notified about missed antibiotic dose; interviewed regarding care plan and medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to timely report suspected abuse and neglect, failure to provide necessary personal hygiene care, and food service safety violations at The Army Residence Community Health Care Center.
Complaint Details
The complaint investigation revealed multiple failures in reporting an allegation of verbal abuse involving RN F and Resident #25, with CNA D, RN E, and HR not reporting the incident promptly. The investigation included interviews with involved staff and review of records. Additionally, the investigation found failures in providing scheduled hygiene care and food service safety violations.
Findings
The facility failed to timely report an allegation of verbal abuse involving staff and a resident, failed to provide a resident with scheduled bed baths for five days, and failed to maintain proper food service safety standards including lack of thermometer in freezer, improper handling and drying of sheet pans, staff not wearing beard restraints, uncovered food on stove, and uncovered trash cans.
Deficiencies (3)
Failure to timely report suspected abuse involving Resident #25; CNA D did not report witnessed verbal abuse immediately, resulting in delayed notification to the administrator.
Failure to provide necessary personal hygiene care; Resident #25 did not receive bed baths for five days as scheduled, resulting in poor hygiene.
Failure to store, prepare, distribute and serve food in accordance with professional standards; issues included no thermometer in satellite kitchen freezer, wet sheet pans stacked and handled without handwashing, staff without beard restraints, uncovered pot on stove, and trash cans without lids.
Report Facts
Residents reviewed for abuse: 8
Days without bed bath: 5
Kitchens inspected: 2
Trash barrels without lids: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Witnessed verbal abuse and failed to report it immediately | |
| RN E | Registered Nurse | Did not report the allegation of abuse to the administrator |
| RN F | Registered Nurse | Alleged to have verbally abused Resident #25 |
| LVN C | Licensed Vocational Nurse | Did not sign to confirm Resident #25 received bed baths on certain days |
| DSD | Dietary Service Director | Observed not wearing beard restraint properly in kitchen |
| DA G | Dietary Aide | Handled wet sheet pans without handwashing and dried them with cloth towel |
| Chef H | Chef | Reported trash barrels should have lids to avoid attracting pests |
| DS K | Dietary Supervisor | Did not notice dietary worker without beard restraint and planned to reinforce policy |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 26, 2024
Visit Reason
The inspection was conducted to investigate complaints related to failure to timely report suspected abuse and neglect, failure to provide necessary care for activities of daily living, and food service safety violations at The Army Residence Community Health Care Center.
Complaint Details
The complaint investigation revealed substantiated failures in timely reporting of verbal abuse involving Resident #25, inadequate personal hygiene care for Resident #25, and multiple food safety violations in the facility kitchens.
Findings
The facility failed to timely report an alleged verbal abuse incident involving Resident #25, failed to provide bed baths for Resident #25 for five consecutive days, and failed to maintain proper food service safety standards in both satellite and main kitchens, including lack of thermometer in freezer, improper handling of wet sheet pans, failure to wear beard restraints, uncovered food on stove, and uncovered trash cans.
Deficiencies (3)
Failure to timely report suspected abuse involving Resident #25; CNA D did not report verbal abuse incident immediately, resulting in delayed notification to the administrator.
Failure to provide necessary care for activities of daily living; Resident #25 did not receive bed baths for five days, resulting in poor hygiene.
Failure to store, prepare, distribute, and serve food in accordance with professional standards; issues included no thermometer in freezer, wet sheet pans stacked and handled improperly, staff without beard restraints, uncovered pot on stove, and trash cans without lids.
Report Facts
Residents reviewed for abuse: 8
Days without bed bath: 5
Number of kitchens reviewed: 2
Number of trash barrels without lids: 5
Number of dietary staff without beard restraints: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Failed to immediately report witnessed verbal abuse involving Resident #25. | |
| RN E | Registered Nurse | Did not report the allegation of abuse to the administrator as required. |
| RN F | Registered Nurse | Alleged to have verbally abused Resident #25 by telling him to quit crying like a baby. |
| LVN C | Licensed Vocational Nurse | Did not sign to confirm Resident #25 had received a bed bath and was unaware of missed baths. |
| Chef H | Chef | Reported that all trash barrels should have lids to avoid attracting insects and rodents. |
| DSD | Dietary Service Director | Observed wearing a surgical mask that did not cover facial hair; confirmed food safety violations. |
| DA G | Dietary Aide | Handled wet sheet pans without washing hands before and after; dried pans with cloth towel. |
| DS K | Dietary Supervisor | Did not notice dietary worker without beard restraint; stated she would reinforce hair restraint use. |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care, medication administration, infection control, hospice services, food safety, and reporting of abuse or misappropriation of property.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to organize independent resident councils, invalid advance directives, breaches of confidentiality, failure to report missing resident property, improper incontinent care technique, medication administration errors with a 32% error rate, failure to coordinate hospice care documentation, food safety violations including improper temperature checks and hand hygiene, and lapses in infection prevention practices.
Deficiencies (10)
CNA E referred to Resident #22's brief as a diaper, failing to maintain dignity.
Facility failed to organize and allow residents to participate in independent resident council meetings.
Resident #9's Do Not Resuscitate order was invalid due to missing physician's printed name and license number.
Facility failed to maintain confidentiality of residents' medical records by leaving a binder with sensitive information in a public dining area.
Facility failed to report missing resident property (earrings) to the State Survey Agency within required timeframe.
CNA E did not use proper front-to-back wiping technique during incontinent care for Resident #22.
Medication error rate was 32% with errors including incorrect dosage, missed medication, partial dose, and failure to observe administration.
Facility failed to collaborate and maintain hospice documentation for residents receiving hospice services.
Food temperatures were not checked or recorded properly before serving; staff failed to wash hands before handling ice.
Infection control lapses included staff using gloves dropped on the floor, touching medication with bare hands, and improper hand drying technique.
Report Facts
Medication administration opportunities observed: 28
Medication errors: 9
Medication error rate: 32
Residents reviewed for medication administration: 5
Staff reviewed for medication administration: 3
Residents affected by confidentiality breach: 7
Residents affected by dignity deficiency: 1
Residents affected by resident council deficiency: 3
Residents affected by advance directive deficiency: 1
Residents affected by incontinent care deficiency: 1
Residents affected by hospice documentation deficiency: 2
Residents affected by infection control deficiency: 3
Value of missing earrings: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Named in dignity and incontinent care findings | |
| MA B | Medication Aide | Named in medication administration error and infection control findings |
| MA C | Medication Aide | Named in medication administration error findings |
| LVN A | Licensed Vocational Nurse | Named in medication administration error and infection control findings |
| CNA D | Named in infection control and incontinent care findings | |
| ADON | Assistant Director of Nursing | Interviewed regarding resident council, medication, and hospice documentation |
| DON | Director of Nursing | Interviewed regarding incontinent care, medication administration, and infection control |
| Social Worker | Named in missing property and hospice documentation findings | |
| Administrator | Interviewed regarding missing property, hospice documentation, and medication administration | |
| Dietary Manager | Interviewed regarding food safety and temperature checks | |
| Dietician | Interviewed regarding food safety and hand hygiene | |
| Activity Director H | Interviewed regarding resident council meetings |
Inspection Report
Deficiencies: 0
Date: Feb 16, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for The Army Residence Community Health Care Center, summarizing the findings of a survey completed on 02/16/2023.
Findings
No health deficiencies were found during the survey.
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