Army Residence Community

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with an indwelling foley catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #16) reviewed for quality of care. Resident #16's foley catheter came apart from the drainage bag during incontinent care after being stretched and fell on the resident's bed. The nurse attempted to reconnect the same drainage bag and tubing to the indwelling foley catheter. These failures could result in pain, urinary tract infections, and urinary complications.

Inspectors wroteBased on interview and record review the facility failed to ensure the attending physician documented in the resident's medical record that the identified drug irregularity had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 1 Resident (Resident #18) whose psychotropic medications were reviewed. Resident #18's attending physician failed to address the pharmacist's recommendation to consider a gradual dose reduction. Resident #18 had been receiving Prozac (antidepressant) 20 mg everyday since 6/4/24. This deficient practice could contribute to Residents receiving a higher medication dose than necessary and result in adverse side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #16), reviewed for infection control. Resident #16 was provided perineal and incontinent care with an indwelling foley catheter without the use of PPE. This failure could result in pain and infection.

Inspectors wroteBased on interview and record review the facility failed to ensure that the comprehensive person-centered care plan described services that are furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 4 residents (#5, #6 and #7) reviewed for care plans in that: 1. Resident #5's care plan, undated, did not indicate that Resident #5 had an urinary tract infection, onset date 03/28/2024, and was on an antibiotic, initiated 05/28/2024. 2. Resident #6's care plan, undated, did not indicate that Resident #6 had an upper respiratory infection, onset date 07/20/2024, and was on an antibiotic, initiated 07/20/2024, prior to 07/25/2024. 3. Resident #7's care plan, undated, did not indicate that Resident #7 had an upper respiratory infection, onset date 07/21/2024, and was on an antibiotic, initiated 07/21/2024, prior to 07/25/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #5) of 7 residents reviewed for pharmacy services. Resident #5's March 2024 medication record reflected an order for Levaquin 500mg tab QD with a start date of 03/29/2024 9:00 a.m. and end date of 03/29/2024. The record reflected the medication was not administered on 03/29/2024. This deficient practice could affect residents who receive antibiotic mediations and could result in residents not receiving a therapeutic dose.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 2 of 2 kitchens Satelite Kitchen and Main Kitchen) reviewed for sanitation. 1. The freezer in the satellite kitchen did not have a thermometer inside of it. 2. Multiple sheet pans were stacked on a shelf underneath the microwave while wet. 3. The DM and DA put their hands on the surface of the sheet pans to check if wet. DA dried the wet sheet pans with a cloth towel and stacked the sheet pans back on the shelf under the microwave. 4. Three Dietary Staff in the main kitchen and one DW in the satellite kitchen did not have a beard restraint on while in the kitchen. The Dietary Service Director (DSD) had a mask on and it did not cover his facial hair along the jaw line. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 8 Residents (Resident #25) whose records were reviewed for abuse. CNA D failed to immediately report a witnessed act of verbal abuse to the ADM, the abuse coordinator on 2/28/24. Instead CNA D told RN E the following day and then left a message for the facility HR. As a result, the ADM did not learn about the witnessed abuse until 3/8/24, 8 days after the incident. These deficient practices could affect any resident and contribute to continued and avoidable resident abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 Residents (Resident #25) who whose records were reviewed for hygiene. Nursing staff failed to ensure Resident #25 received a bed bath for five days, from 4/19/24 to 4/24/24. This deficient practice could affect any resident who required assistance with showers/bed baths and could result in poor hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving, in that: 1. Food temperatures for the several meal items were not checked or recorded properly prior to the serving of residents. 2. An unknown staff member walked into the kitchen and failed to wash their hands before retrieving ice out of the ice machine. These failures could affect residents who reside at the facility and place them at risk of foodborne illness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents had a right to organize and participate in resident groups in the facility for 3 of 51 residents (Residents #9, #18, and #37) reviewed for resident groups, in that: The facility failed to organize and allow Residents #9, #18, and #37 to participate in monthly resident council groups. This failure could place residents who reside at the facility at risk of not being feeling comfortable voicing concerns.

Inspectors wroteBased on observations, interview, and record review the facility failed to maintain the residents right to confidentiality in his or her personal and medical records for 7 (Resident #19, #22, #26, #31, #36, #37, #48) of 7 residents in that: The facility failed to ensure a code status binder that included residents out-of-hospital do-not-resuscitate forms and face sheets were in a secure location. These failures could affect residents who reside at the facility and place them at risk of having personal and medical information accessible to the public.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 32% percent with 28 medications administration opportunities observed with 9 errors for 4 of 5 residents (Residents #19, #28, #44, and #49) and 3 of 3 staff (MA B, MA C and LVN A) reviewed for medication administration, in that: 1. Medication Aide B administered the incorrect dosage of a vitamin to Resident #44. 2. LVN A did not administered a medication to Resident #19. 3. LVN A did not administer the full dose of a medication to Resident #28. 4. Medication Aide C did not observe administration of 6 medications for Resident #49. These deficient practices could place residents at risk of not receiving therapeutic effects from their medications as intended by the prescribing physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 3 residents (Residents #5, #22, and #28) reviewed for infection control, in that: 1. MA B dropped a glove on the floor, put the glove on, and dispensed medications for Resident #5. 2. LVN A touched a medication with her hand while dispensing medication for Resident #28. 3. CNA D used the same paper towel to dry her hands, turn off the sink faucet, and dry her hands again prior to incontinent care for Resident #22. These deficient practices could place residents who receive medication or incontinent care at-risk for infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with dignity and respect in a manner and environment that enhances his and her quality of life for 1 of 13 residents (Resident #22) reviewed for, in that: CNA E referred to Resident #22's brief as a, diaper. This deficient practice could affect residents at the facility who receive assistance with incontinent care and could place them at-risk for diminished quality of life, loss of dignity and low self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 13 residents (Resident #9) reviewed for advanced directives, in that: Resident #9's OOHDNR order did not contain a printed physicians name, the physician's license number, and date which made the advance directive invalid. This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving misappropriation of resident property, are reported immediately, but not later than 24 hours after the allegation is made for 1 of 1 resident (Resident #23) reviewed for, reporting allegations of misappropriation of property, in that: The facility failed to report an incident to the State Survey Agency (HHSC), when Resident #23 reported a pair of earrings missing on 12/16/2022. This failure could place the residents at risk for unreported allegations of abuse, neglect, and injuries of unknown origin and misappropriation of resident property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bowel/bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #22) reviewed for incontinent care, in that: CNA E did not use proper technique when providing incontinent care for Resident #22. This deficient practice could place residents at risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 (Residents #30 and #17) reviewed for hospice services, in that: 1. The facility did not have Resident #30's hospice election form and the physician certification of terminal illness from the Resident's hospice provider. 2. The facility did not have Resident #17's hospice election form and the physician certification of terminal illness from the Resident's hospice provider. [...]