Frank M. Tejeda Texas State Veterans Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect right of residents to be free from verbal abuse, for 1 of 4 (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from verbal abuse, when CNA A. was verbally abusive on 5/5/2026. This failure could place residents at risk for abuse with psychological injury, intimidation and a decreased quality of life.

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 sources are reported immediately but not later than 2 hours (for an injury of unknown origin involving serious bodily injury) or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 2 of 10 Residents (Resident #1 and Resident #2) reviewed for abuse. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that alleged violations of abuse, neglect, and exploitation were thoroughly investigated, and the results of the investigation were reported to the State Survey Agency within five working days for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse, neglect, and exploitation. 1. The facility failed to have evidence of an investigation of alleged misappropriation of funds of Resident #1.2. The facility failed to have evidence of an investigation of alleged theft of property of Resident #2. These deficient practices could place residents at risk of harm by not having theft or misappropriation of resident property investigated.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent accidents for 2 of 38 residents (Resident #157, Resident #110) and 1 of 8 halls (300 hall) reviewed, in that: 1. The facility failed to ensure no hazardous products were left accessible to residents of 300 hall. 2. The facility failed to store a package of cigarettes found on Resident # 157's bed.3. The facility failed to secure a cigarette lighter found on Resident #110's bedside table. These deficient practices could place residents at-risk of avoidable accidents, decline in physical condition, and injury.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the status of the residents for 1of 24 residents (Residents #7) reviewed for resident assessments. The Facility failed to ensure Resident #7's CPAP (continuous positive airway pressure, is a medical device and therapy primarily used to treat obstructive sleep apnea, a condition where the airway collapses or becomes blocked during sleep, causing pauses in breathing and reduced oxygen levels. The device delivers a steady stream of pressurized air through a mask worn over the nose and/or mouth, keeping the airway open and allowing normal breathing throughout the night) was accurately reflected on his quarterly MDS assessment, dated 12/31/2025. This deficient practice could place residents at risk of missed or inaccurate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #50) reviewed for incontinent care and catheter care., in that: The facility failed to ensure that, while providing incontinent care for Resident #50, CNA D used a front to back motion to clean Resident #50. This failure could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wrote]Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 medication cart (400 Hall Medication Cart) of 6 medication carts reviewed. The facility failed to remove 2 male intermittent catheters with a use by date of 11/09/2025 from 400 Hall medication cart. This deficient practice could result in compromised sterility, safety, and efficacy of the device. Observation on 03/05/2026 at 11:24 a.m. of nurses' medication cart on 400 Hall revealed 2 male intermittent catheters with a use by hourglass symbol dated 11/09/2025. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication cart (300 Hall medication cart) of 6 medication carts reviewed. The facility failed to ensure an open multidose vial of Lidocaine Hydrochloride injection 1% (local anesthetic) was labeled when opened. This deficient practice could affect residents and result in cross contamination or decreased effectiveness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 1 of 4 residents' refrigerators (Resident #65) reviewed for personal food storage, in that: The personal refrigerator in Resident #65's room contained food items that were unlabeled and undated. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food.

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 disease and infection for 1 of 5 residents (Residents #8) reviewed for infection control, in that: 1. a The facility failed to ensure LVN F sanitized between their fingers while providing wound care for Resident #8. 1.b The facility failed to ensure LVN F changed gloves after cleaning the wound and before applying the treatment, while providing wound care for Resident #8. These failures deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 2 of 8 residents (Resident #2 and Resident #3) reviewed for abuse and neglect. The facility did not ensure it protected residents from abuse when Resident #1 threw lukewarm coffee, yelled, and cussed at Resident #2 and Resident #3 on 07/07/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 2 of 8 residents (Resident #2 and Resident #3) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident that occurred on 07/05/2025 in which Resident #1 threw lukewarm coffee, yelled, and cussed at Resident #2 and Resident #3. This incident has still not been reported in TULIP. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on observations, interviews, 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 3 of 5 residents (Residents #23, #90 and #135), reviewed for infection control. 1. The facility failed to implement contact precautions for Resident #23 after it was ordered by the physician. 2. The facility failed to ensure proper infection control practices during wound care for Resident #23, when LVN D did not change gloves or sanitize their hands after cleansing the resident's wound, and before picking up and placing a new dressing on the resident's wound. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 32 residents (Resident #50) whose assessments were reviewed: Resident #50's use of tobacco was not identified on the resident's annual MDS assessment with an ARD of 02/23/2024. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 32 residents (Resident #50) reviewed for care plans, in that: The facility failed to update Resident #50's comprehensive care plan to remove the focus area indicating the resident smoked tobacco. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #13) reviewed for incontinent care. The facility failed to ensure CNA A and CNA B thoroughly cleaned Resident #13 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions for 1 of 6 medication carts (Hall 500 Medication Aide carts) reviewed for medication labeling and storage. The facility failed to ensure a bottle of Ciprofloxacin 0.3% ophthalmological solution for Resident #135, which had been previously opened was labeled with an open date. This failure could place residents at risk of receiving expired medications.

Inspectors wroteBased on observation, interview and record review, the facility to ensure that the residents had the right to and that the facility promoted and facilitated resident self-determination through support of resident choice for 1 of 1 resident (Resident #61) whose care was reviewed, in that: Resident #61's preference was to have a shower on the shower bed instead of a bed bath but the resident did not receive showers because the shower bed was damaged. This deficient practice could place residents with the ability to make choices at risk of having their rights violated, diminished quality of life and unmet needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #124) of 8 residents reviewed for ADLs. The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #124. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a diminished quality of life.

Inspectors wroteBased on observations, 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 for 1 of 8 (Resident #56) residents in that: Resident #56's compression socks were not on as ordered. This could affect all residents with compression socks ordered and could result in swelling.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 6 medication carts (nurses medication cart for the 200 hall) reviewed for security, in that; The facility failed to ensure the narcotic box was separately locked inside the nurses medication cart for the 200 hall. This failure could place residents at risk of having access to unauthorized narcotic medications and/or lead to possible harm, drug overdose, or drug diversions.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #74) of 13 residents reviewed for resident records. The facility failed to ensure Resident #74's Medication Administration Record (MAR) reflected documentation of all administered doses of Morphine [an opioid medication to treat pain] in his Electronic Health Record (EHR). This failure could place all residents who receive medications at risk of having errors in care and treatment.