Alfredo Gonzalez Texas State Veterans Home

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 3 residents (Resident #1) reviewed for urinary catheters. The facility failed to ensure Resident #1's indwelling catheter was appropriately placed while lying in bed. This failure could place residents at risk for a decline in their health status.

Inspectors wroteBased on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (500 hall cart) of 5 medication carts reviewed for storage. The facility failed to ensure LVN D locked his medication cart on 07/09/26 when he walked away to care for a resident. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 3 (Resident #1) residents reviewed for infection control. The facility failed to ensure CNA A wore proper PPE while feeding Resident #1 in bed on 07/08/26. This failure could place residents at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected oral care issues. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2) reviewed for reporting alleged allegations of abuse. The facility did not report to HHSC within two hours, when Resident #1 hit Resident #2's hand with an empty water bottle on 03/13/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to put interventions in place to protect Resident #2 from abuse after a reported resident to resident physical altercation with Resident #1 on 02/07/26. On 02/08/26 a 2nd altercation between Resident #1 and Resident #2 occurred which resulted in Resident #2 being found on the floor with bilateral skin tears to arms and right knee and stated Resident #1 had pulled him down to the floor on 02/08/26. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of physical harm, mental anguish and, emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to protect Resident #2 from abuse after a reported resident to resident physical altercation with Resident #1 on 02/07/26. On 02/08/26 a 2nd altercation between Resident #1 and Resident #2 occurred which resulted in Resident #2 being found on the floor with bilateral skin tears to arms and right knee and stated Resident #1 had pulled him down to the floor on 02/08/26. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 1. The facility failed to follow their skin and wound prevention and management policy and did not have a licensed nurse complete and document a skin assessment at least weekly for Resident #3. This failure could put residents at risk of having skin breakdowns that could go unidentified and untreated.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 1 (Resident #1) of 3 residents reviewed for unnecessary medications. 1. The facility failed to have an adequate indication for the use of the medication Seroquel (an antipsychotic) for Resident #1 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the alleged violation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 3 residents (Residents #1 and #2) reviewed for reporting alleged allegation of abuse. The facility did not report to HHSC within 2 hours, when Resident #2 was found on the floor with bilateral skin tears to arms and stated Resident #1 had pulled him down to the floor on 02/08/26. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for 1 (Resident #42) of 42 residents reviewed for call lights. The facility failed to ensure Resident #42 had the call light within reach while in bed in their room. This failure could place residents at risk of being unable to obtain assistance when needed and in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #96) reviewed for comprehensive care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #96's contact precautions. These failures could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner.

Inspectors wroteBased on interviews and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 8 residents (Resident #96) reviewed for resident records. The facility failed to ensure a physician order was written for isolation precautions for Resident #96 on 12/23/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. Findings Included: Record review of Resident #96's face sheet dated 01/05/2026 reflected the resident was an 83 -year-old male admitted to the facility on [DATE] with an original admission date of 06/10/2021. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 5 medication carts (400 Hall medication cart) reviewed for storage of drugs. The facility failed to ensure that there were no expired medications inside the 400-hall medication nurse cart for Resident #152 on 01/06/2026. This failure could place the residents at risk of not receiving the medication's full therapeutic benefits and possible side effects.

Inspectors wroteBased 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 8 (Resident #96) residents reviewed for infection control, in that: The facility failed to ensure that Resident #96 had a Contact precaution sign on the door or PPE. This failure could place residents at risk for healthcare associated cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 (Resident # 105) of 6 residents reviewed for resident call system. The facility failed to ensure Resident #105 had a call light that was functional. Resident #105's call light did not turn on when the button was pressed. This failure could place residents at risk for a delay in assistance and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, 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 3 residents (Resident #2) reviewed for infection control practices, in that: The facility failed to ensure CNA A performed proper hand hygiene and proper incontinent care for Resident #2. This deficient practice could place residents at-risk for infection due to improper hand sanitizing and incontinent care practices.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and 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 5 Residents (Resident #1) that were reviewed for infection control and transmission-based precautions policies and practices, in that: LVN I failed to don (put on) the appropriate PPE before she entered Resident #1's room and provided medication on 03/10/25 at 7:27 PM. CNA M failed to don the appropriate PPE before she entered Resident #1's room to provide care on 05/11/25 at 08:02 PM. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases.

Inspectors wroteBased on observation, record review, and interview, the facility failed to establish and 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 5 Residents (Resident #1) that were reviewed for infection control and transmission-based precautions policies and practices, in that: LVN A failed to don (put on) the appropriate PPE before she entered Resident #1's room and provided care to Resident #1's PEG tube on 02/04/25 at 3:15 PM, on 02/06/25 at 7:47 PM, and on 02/18/25 at 7:25 PM and 10:13 PM. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 5 rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to ensure the facility was sanitary when the facility did not effectively clean room [ROOM NUMBER]'s shower as there was a white dirty towel with brown colorations. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records, in that: The facility failed to accurately document as the staff continued to log temperatures on the MAR for Resident #1's personal refrigerator from [DATE]-[DATE], although the refrigerator was taken home on [DATE] by Resident #1's family. This failure could affect residents whose records are maintained by the facility and could place them at risk for errors in care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to establish and 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 2 of 5 Residents (Resident #3 and Resident #5) that were reviewed for infection control and transmission-based precautions policies and practices. 1. LVN A failed to don the appropriate PPE before he entered Resident #5's room and provided care to Resident #5's PEG tube. 2. LVN B failed to don the appropriate PPE before he entered Resident #3's room and provided care to Resident #3's midline. These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases.

Inspectors wroteBased on observation, interviews, and record review the facility failed to have physician orders for the resident's immediate care at time of admission for 2 of 5 residents (Resident #4 and #5) reviewed for physician admission orders. 1. The facility failed to have physician orders in place for Resident #4's enhanced barrier precautions. 2. The facility failed to have physician orders in place for Resident #5's enhanced barrier precautions. This deficient practice could place residents with indwelling devices at risk of developing infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their policy regarding storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption of the food and beverages for 1 of 2 Residents (Resident #3) reviewed for personal food storage. The facility did not have completed documentation of temperature checks for Resident #3's personal refrigerator for the month of October. This failure could place residents with personal refrigerators at risk of food borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #49) reviewed for respiratory care. The facility failed to ensure Resident #49 received oxygen at the prescribed rate. This failure could place residents at risk for respiratory distress.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for 2 (10/2/24 and 10/3/24) of 4 days reviewed for nurse staffing information. The facility failed to ensure the daily staffing information was posted in a prominent location on 10/2/24 and 10/3/24. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for four Residents (Resident #76, Resident #93 ) of eight residents whose records were reviewed for elopement and supervision. 1. The facility failed to ensure Resident #76, and Resident #93 received adequate supervision. Resident #76 eloped from the facility memory unit on 10/22/2022 & 12/19/22. Resident #93 eloped on 1/30/23. The non-compliance was identified as Past Non Compliance. The Immediate Jeopardy (IJ) began on 12/18/22 and ended on 2/13/23. The facility corrected the non-compliance before the survey began. These failures could place the residents with exit seeking behaviors at risk for injury or death and could place residents at risk for smoking-related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, for one Resident (Resident #114) of thirteen residents reviewed for dignity issues. The facility failed to pull down the privacy cover for foley catheter drainage bag, leaving the urine in the bag visually exposed. The facility failed to knock on Resident #114's door before entering his room. This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for two (Resident #54, Resident # 114) of eight residents reviewed for accommodation of needs: 1. Resident #54's restroom inside door was not equipped with an accessible door handle from the inside. 2. Resident #114's call light was placed out of reach and lying on the floor. This failure could place residents who require assistance with their activities of daily living and use of call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #1 to address his smoking needs. This failure could affect residents in the facility by placing them at risk of not being provided with necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and medical devices used in the facility were labeled in accordance with professional standards, including expiration dates for 2 of 2 medication rooms reviewed for expired medications in that: -24 Acetaminophen suppositories were expired -A 100 ml bag of intravenous fluid was expired This failure could place residents at risk of being administered medications that were ineffective.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and 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 3 residents (Resident #114, Resident #66, and Resident # 100) of 25 residents observed in that: CNA A did not perform hand hygiene after picking call light up off the floor and placing it next to Resident #114. CNA C and CNA D did not perform hand hygiene between glove changes while providing Resident #66 and Resident #100 with incontinent care. These failures could place residents at risk for infections and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their established smoking policy regarding smoking safety for 2 of 6 residents reviewed for safe smoking. (Resident #1 Resident #30) 1. Resident #1 had a package of cigarettes in his shirt pocket and a lighter. 2. Resident #30 was smoking unsupervised. These failures could place the residents with exit seeking behaviors at risk for injury or death and could place residents at risk for smoking-related injuries.