Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Army Residence Community Health Care Center during CMS and state inspections, most recent first.
A resident with a Foley catheter experienced a disconnection of the catheter tubing during incontinent care when two nursing assistants failed to move the drainage bag before turning her, causing the tubing to stretch and come apart. A nurse then attempted to reconnect the same drainage bag and tubing, which had touched the bed and a gloved hand, instead of replacing it as required by protocol. The resident was dependent on staff for perineal hygiene and had a care plan specifying the need to maintain a closed catheter system to prevent infection.
A resident with severe cognitive impairment and multiple psychiatric diagnoses continued to receive a daily antidepressant without documented physician review of the consultant pharmacist's recommendation for a gradual dose reduction. The attending physician did not address or document a response to the recommendation, and the review was instead signed by a nurse practitioner not authorized to act on behalf of the physician.
Staff did not use required PPE, specifically gowns, while providing perineal and catheter care to a resident with an indwelling Foley catheter, despite clear care plans, physician orders, and available supplies. The involved staff acknowledged the lapse and attributed it to nervousness, and facility leadership confirmed that proper infection control procedures were not followed.
The facility failed to update care plans for three residents who were on antibiotics for infections. A resident with a urinary tract infection and two residents with upper respiratory infections did not have their care plans updated to reflect their conditions and treatments in a timely manner. Interviews with staff revealed discrepancies in responsibility for care plan updates, highlighting a lapse in adherence to facility policy requiring timely updates for significant changes in residents' conditions.
A resident with a UTI did not receive a scheduled dose of Levaquin due to miscommunication and errors in medication administration. The resident was prescribed the antibiotic following elevated lab results, but the dose on the morning of March 29 was missed. The error was discovered the next day, and the medication was reinstated. The facility's guidelines require nurses to ensure all medications are given as scheduled and to notify the physician and DON of any missed doses.
The facility failed to adhere to professional standards for food service safety, including the absence of a thermometer in the satellite kitchen freezer, improper handling of wet sheet pans, uncovered trash cans, and staff not wearing beard restraints. These deficiencies could lead to food contamination and affect all residents.
A facility failed to ensure immediate reporting of an alleged verbal abuse incident involving a resident with secondary Parkinsonism and Cognitive Communication Deficit. CNA D witnessed RN F verbally abusing the resident but delayed reporting the incident to the ADM, leading to an 8-day delay in the investigation.
A resident with secondary Parkinsonism and Cognitive Communication Deficit did not receive scheduled bed baths for five days due to staff's failure to document and communicate. The resident's hair was observed to be tangled and matted, indicating poor hygiene care.
Failure to Maintain Closed Foley Catheter System During Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with an indwelling Foley catheter did not receive appropriate care to maintain a closed catheter system and prevent infection. During perineal and incontinent care, two nursing assistants assisted the resident in turning without first moving the Foley drainage bag, which was still attached to the bed rail on the opposite side. This action caused the catheter tubing to stretch tightly and ultimately disconnect from the drainage bag, with the tubing falling onto the resident's bed and coming into contact with a gloved hand. Following the disconnection, a nurse attempted to reconnect the same drainage bag and tubing to the resident's indwelling Foley catheter, despite the tubing having touched the bed and a staff member's glove. The nurse was unaware of this contact until informed by the surveyor and stated that she would have replaced the bag and tubing had she known. The nurse and both nursing assistants confirmed they had been trained in catheter care but did not follow proper protocol in this instance. The resident involved was a cognitively intact female with a flaccid neuropathic bladder, muscle weakness, and mobility issues, who was dependent on staff for perineal hygiene. Her care plan specified maintaining a closed catheter system and minimizing manipulation of the tubing. The facility's guidance, referencing CDC and AHRQ recommendations, required replacement of catheters and urine collection bags if the system became disconnected, which was not initially followed in this event.
Failure to Document Physician Review of Pharmacist's Psychotropic Medication Recommendation
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that a drug regimen irregularity identified by the consultant pharmacist had been reviewed and addressed for a resident receiving psychotropic medication. Specifically, the consultant pharmacist recommended evaluating and considering a gradual dose reduction of Prozac, which the resident had been receiving daily. The recommendation was not reviewed or signed by the resident's attending physician, and there was no documentation in the resident's medical record indicating that the physician had considered or responded to the pharmacist's recommendation. Instead, the recommendation was signed by a nurse practitioner from a psychiatric consulting agency who was not the resident's attending physician or an authorized extender. The resident involved had severe cognitive impairment and multiple psychiatric diagnoses, including dementia, adjustment disorder with depressed mood, recurrent depressive disorders, and generalized anxiety disorder. The care plan indicated the need for the lowest therapeutic dose of psychotropic medications and required consultation with the pharmacist and physician regarding dose reduction. Interviews with facility staff confirmed that the process for ensuring physician review of pharmacist recommendations was not followed, and there was no documentation of any discussion or decision by the attending physician regarding the recommended gradual dose reduction.
Failure to Use PPE During Perineal and Catheter Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during perineal and incontinent care for a female resident with an indwelling Foley catheter. The resident, who was cognitively intact and dependent on staff for perineal hygiene, had a care plan and physician orders specifying the use of enhanced barrier precautions (EBP), including gloves and gowns, during high-contact care activities. Despite clear signage and the availability of PPE supplies in the resident's room, two restorative nursing assistants (RNAs) and a licensed vocational nurse (LVN) performed perineal and catheter care without donning the required gowns, although they did wash their hands and use gloves. Interviews with the involved staff and nursing leadership confirmed that the staff had been trained on EBP and were aware of the requirement to use PPE during such care. The staff acknowledged their failure to use PPE, attributing it to nervousness during the observed care. The facility's EBP guidance, as provided by the DON, reiterated the necessity of PPE for residents with indwelling devices during high-contact care, regardless of multidrug-resistant organism status.
Failure to Update Care Plans for Residents on Antibiotics
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were updated to reflect the current medical conditions and treatments for three residents. Resident #5, a female with osteoporosis, atrial fibrillation, and chronic respiratory failure, was diagnosed with a urinary tract infection on March 28, 2024, and was prescribed an antibiotic. However, her care plan did not include this diagnosis or the antibiotic treatment. This oversight was confirmed during an interview with LVN D. Resident #6, a male with Parkinson's disease, type 2 diabetes, and dementia, was diagnosed with an upper respiratory infection on July 20, 2024, and was prescribed an antibiotic. His care plan was not updated to include this information until July 25, 2024, despite the treatment starting earlier. This was confirmed during an interview with LVN C, who acknowledged the delay in updating the care plan. Similarly, Resident #7, a female with multiple sclerosis, type 2 diabetes, and hyperlipidemia, was diagnosed with an upper respiratory infection on July 21, 2024, and was prescribed an antibiotic. Her care plan was also not updated until July 25, 2024. The MDS Coordinator and the DON had conflicting statements regarding responsibility for updating care plans, but both acknowledged the importance of timely updates to ensure accurate resident care. The facility's policy requires care plans to be updated with significant changes in a resident's condition, which was not adhered to in these cases.
Failure to Administer Prescribed Antibiotic Dose
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #5, as evidenced by the failure to administer a prescribed dose of Levaquin 500mg on March 29, 2024. Resident #5, a female with diagnoses including osteoporosis, atrial fibrillation, and chronic respiratory failure, was prescribed Levaquin for a urinary tract infection (UTI) following elevated white blood cell count and urinalysis results. The initial dose was administered on March 28, 2024, but the subsequent dose scheduled for the following morning was not given. The deficiency arose from a series of miscommunications and errors in medication administration. LVN C, responsible for administering the medication on March 29, 2024, did not give the dose, mistakenly believing the order would be changed to an evening administration. LVN D, who entered the initial order, noticed the discontinuation of the medication on March 30, 2024, and informed the Director of Nursing (DON), who then instructed to reinstate the medication. The physician confirmed that no order was given to discontinue the medication and emphasized the importance of consistent antibiotic administration. The facility's in-service guidelines, dated March 18, 2024, required licensed nurses to ensure all medications are administered as scheduled and to notify the physician and DON of any missed doses. Despite these guidelines, the failure to administer the medication as prescribed occurred, highlighting a lapse in following established procedures. The absence of a care plan for the UTI and antibiotic treatment further contributed to the oversight.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in both the satellite and main kitchens. The deficiencies included the absence of a thermometer in the satellite kitchen freezer, wet sheet pans being stacked without proper drying, and staff handling these pans with bare hands without washing them before or after. Additionally, multiple trash cans in the main kitchen did not have lids, which could attract insects and rodents. A pot of rue was left uncovered on the stove for about 15 minutes, and several staff members, including the Dietary Service Director (DSD), were observed without proper beard restraints, which could lead to hair contamination in the food. During the survey, it was observed that the DM and DA touched the inside surfaces of wet sheet pans with their bare hands and dried them with a cloth towel, which is against the facility's policy of air drying all dishes, pots, and pans. The DSD and other dietary staff were found not wearing beard restraints, and the DSD admitted to removing his beard restraint before re-entering the kitchen. The facility's policy requires all staff to wear hair and beard restraints to prevent hair from contaminating the food. The lack of proper sanitation practices and adherence to policies was confirmed through interviews with the DM, DA, and other kitchen staff. The facility's policies on uniform dress code and sanitation and infection prevention/control were not followed, leading to potential contamination risks. The DM acknowledged the absence of a thermometer in the freezer and the improper handling of wet sheet pans. The Dietician confirmed that all kitchen equipment was shared between the main and satellite kitchens, affecting all residents in the facility. The failure to adhere to these policies and standards could contribute to foodborne illnesses and the spread of diseases among residents.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by policy. Specifically, CNA D witnessed an act of verbal abuse by RN F towards Resident #25 but did not report it immediately to the Administrator (ADM) or the abuse coordinator. Instead, CNA D informed RN E the following day and left a message for the facility HR. The ADM did not learn about the incident until 8 days later, significantly delaying the investigation process. This delay in reporting was a violation of the facility's policy, which mandates immediate reporting of abuse allegations to the ADM and other officials, including the State Survey Agency. Resident #25, who has diagnoses including secondary Parkinsonism and Cognitive Communication Deficit, was verbally abused by RN F, who told the resident to quit crying like a baby. The incident occurred while Resident #25 was holding his catheter and yelled out in pain. CNA D reported feeling shocked and reluctant to report the incident immediately due to concerns about retaliation, as RN F was her immediate supervisor and RN E was related to RN F. Interviews with facility staff revealed multiple failures in reporting the abuse allegation, including delays by CNA D, RN E, and HR, which contributed to the ADM not being informed in a timely manner.
Failure to Provide Necessary Hygiene Care
Penalty
Summary
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. Specifically, Resident #25 did not receive a bed bath for five days, from 4/19/24 to 4/24/24. Resident #25, who has diagnoses including secondary Parkinsonism and Cognitive Communication Deficit, was dependent on staff for all activities of daily living, including bathing. Despite being scheduled for bed baths on Mondays, Wednesdays, and Fridays, the resident's shower sheet and nurse's notes did not document any bed baths or refusals on 4/22/24 and 4/24/24. Observations on 4/24/24 revealed that Resident #25's hair was tangled and matted, indicating a lack of proper hygiene care. Interviews with the caregiving staff revealed that the assigned CNA did not have time to bathe Resident #25 on the scheduled days due to other pressing duties and did not inform the charge nurse. The charge nurse, LVN C, was unaware that Resident #25 had not received his scheduled bed baths and admitted to not documenting the resident's refusals properly. The Assistant Director of Nursing (ADON) provided multiple policies about activities of daily living, but none addressed the specific care required for residents needing assistance with hygiene. This lack of documentation and communication among staff led to the deficiency in providing necessary hygiene care for Resident #25.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Crestway Nursing & Rehabilitation | 0.1 mi | ★★★★★ | 2 | 0 |
| Avir At Converse | 0.9 mi | ★★★★★ | 13 | 0 |
| Avir At Heritage | 2 mi | ★★★★★ | 3 | 0 |
| Advanced Rehabilitation & Healthcare Of Live Oak | 2.4 mi | ★★★★★ | 3 | 0 |
| Windcrest Nursing And Rehabilitation | 3 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.