Lamun-Lusk-Sanchez Texas State Veterans Home

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure all residents were treated with respect and dignity for 1 of 3 residents (Resident #27) reviewed for dignity. The facility failed on 08/06/2025 to ensure Treatment Nurse provided privacy during wound care for Resident #27. This failure placed all residents at risk of psychosocial harm due to a diminished quality of life.

Inspectors wroteThe facility failed on 8/7/2025 to ensure 15 of 31 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 15 of 31 confidential residents. The facility failed on 8/7/2025 to ensure 15 of 31 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on personal resident refrigerators for 2 of 32 personal resident refrigerators reviewed for food safety (Resident #12 and #134) The facility failed on 08/07/2025 when the refrigerators located in Resident #12 and Resident #134's rooms were not being monitored for internal temperature and expiration/used by dates. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 1 of 2 residents (Resident #69) and 2 of 4 staff (CNA A and CNA B) reviewed for infection control. The facility failed on 08/06/2025 when CNA A and CNA B failed to follow policy and procedure for handwashing and glove changes while providing incontinent care for Resident #69. This failure could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. 1) Dietary/Facility staff (Dietary Aide A, B, C and CNA D) failed to use good hygienic practices during dietary duties (handwashing). 2) Dietary/Facility staff (Dietary A, B and CNA D) failed to use good hygienic practices during dietary duties (Properly wearing hair net). These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and at an appetizing temperature for the lunch meal observed on 02/26/2025. Resident's #1, #2, #3, and #4 complained the food was served cold. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, or preferences for 3 of 12 residents (Resident #1, #2, #6) reviewed for meal preferences. 1. The facility failed to ensure there was no cheese or Resident #1's sandwich, a documented allergy, resulting in Resident #1 having anaphylaxis symptoms and receiving an epi-pen (epinephrine, a medication that can help decrease a body's allergic reaction) on 12/15/2024. 2. The facility gave Resident #2, Resident #6's meal tray, and Resident #2 consumed the incorrect tray on 12/17/2024. 3. The facility gave Resident #6, Resident #2's meal tray, and Resident #6 consumed the incorrect tray on 12/17/2024. An Immediate Jeopardy (IJ) was identified on 12/18/24 at 9:22 AM. The IJ template was provided to the facility on [DATE] at 9:22 AM. [...]

Inspectors wroteResident #5 Advance Directives 07/11/24 11:23 AM observed DNR with no date by the physician signature and no date by the resident name. Resident #16 Advance Directives 07/10/24 02:15 PM signature for person signing on behalf of resident did not provide a signature and no date next to the witnesses. Resident #54 Advance Directives 07/10/24 04:18 PM observed Resident # 54 with no date next to name on DNR. Resident #120 Advance Directives 07/11/24 12:09 PM observed no date by physician signature and no date by the witness signature. Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 5 of 32 residents (Residents #5, #54, #84, #120, and #124) reviewed for advanced directives. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (07/10/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

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 4 of 31 residents (Resident #30, Resident #16, Resident #84, Resident #54) and 5 of 5 staff (CNA A, CMA A, LVN B, MA A, Laundry staff member A) reviewed for infection control. 1. CMA A failed to wash her hands or use hand sanitizer prior to medication preparation or medication administration to Resident #30 during observation of medication pass. 2. LVN B failed to wash her hands or use hand sanitizer prior to medication preparation or medication administration to Resident #16 during observation of medication pass. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 laundry room in that: 1. The facility failed to maintain clean lint traps in all 3 dryers in the laundry room by failing to clean the lint traps per policy. These failures could place residents at risk for receiving cold meals/coffee and at risk for fire emergencies.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 of 32 residents; The facility failed to address complaints for 2 of 10 confidential resident's that were interviewed and voiced concerns related to missing personal laundry These problems could result in residents having a lack of personal clothing to wear and low self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of thirty-two residents (Resident #109) reviewed for quality of care. The facility failed to follow physician ordered skin treatments for edema to Resident #109's legs on 07/10/24. These failures could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. Record review of Resident #109's undated face sheet reflected Resident #109 was an [AGE] year-old male whose admission date to the facility was on 1/18/24. Resident #109 had the following diagnoses: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents receiving psychotropic medications had an approved diagnosis and PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, for 1 of 32 residents (Resident #133). Resident #133 continued to have a PRN order for Doxepin 10mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions, decreased quality of life and dependence on unnecessary psychotropic medications.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure 1 of 1 resident (Resident #106) reviewed for medication administration were free of significant medication errors. 1. The facility failed to administer eye drops (Brimonidine Tartrate Ophthalmic Solution 0.2%) according to physician orders for Resident #106.

Inspectors wroteBased on observation and interview that 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, and the expiration date when applicable and the facility failed to ensure, in accordance with State and Federal laws. 1. The facility failed to ensure that medication storage was free from expired medications; five expired medications were located in the medication room on hall These failures could place residents at risk of receiving prescribed medications after their expiration date and drug diversions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintained medical records on each resident that were complete and accurately documented for one (Resident #109) of thirty-two residents reviewed. The facility failed to ensure the LNAR was accurately documented for physician ordered skin treatments that were not provided. This failure could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. Record review of Resident #109's undated face sheet reflected Resident #109 was an [AGE] year-old male whose admission date to the facility was on 1/18/24. Resident #109 had the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1), reviewed for abuse. The facility failed to ensure a safe environment free from abuse when Activities worker A called Resident #1 a Llorona (Spanish for crybaby or weeping woman) in the dining room. This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 3 of 29 residents (Residents #98, #101, and #213) reviewed for care plans as follows: *Resident #98 did not have a care plan for urinary and nutritional needs. *Resident #101 was classified as a DNR status and did not have a care plan for DNR status. *Resident #213 did not have a care plan for visual and urinary needs. These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 29 residents (Residents #9 and #101) reviewed for advanced directives. Residents #9 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. Residents #101 was listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on record review and interview, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 6 residents (Residents #7, 59, 36, 62, and 96) reviewed for PASRR screening, in that: Resident #7 did not have an accurate PASRR Level 1 assessment when he had a diagnosis of major depressive disorder. Residents #59 and #62 did not have accurate PASRR Level 1 assessment when they had a diagnosis of post-traumatic stress disorder (PTSD) and Major Depressive Disorder. Residents #36, #62, and #96 did not have accurate PASRR Level 1 assessment when they had a diagnosis of post-traumatic stress disorder (PTSD). These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 29 residents (Resident #9) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #9 continued to have a PRN order for Lorazepam concentrate 2mg/ml after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions.