Richard a. Anderson (state of Texas Veterans Land

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure a resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider ordered a therapeutic diet for 1 of 24 residents (Resident #4) reviewed for nutrition status. The facility failed to provide Resident #4 with a fortified meal plan as ordered by his physician between 7/22/25 and 9/11/25. This failure could affect all residents on therapeutic diets by placing them at increased risk for significant weight loss and malnutrition.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 24 residents (Resident #3) reviewed for assessments, in that: Resident #3's quarterly MDS assessment dated [DATE] inaccurately indicated he did not receive insulin injections during the lookback period of 7 days. This failure could place residents at risk of not having accurate assessments to receive care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 18%, based on 5 errors out of 27 opportunities, which involved 1 of 4 residents (Resident #1) and 1 of 3 staff (MA A) observed during medication administration reviewed for medication error, in that: -MA A administered the incorrect dose of Chlor-Con (potassium chloride) to Resident #1. -MA A failed to administer 4 additional medications/supplements prior to surveyor intervention. -MA A had documented she administered the 4 medications/supplements. -The resident did not receive the medications/supplements until after surveyor intervention. These failures placed the resident at risk for inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 2 (Resident #1 and Resident #2) of 7 residents reviewed for accidents hazards/supervision in that: -Resident #1 who resided in the Memory Care Unit was let out of the facility by CNA A on 2/16/24 at 6:45 pm and located by the Resident Representative around 8:30 pm on the corner of a major high traffic street corridor approximately ½ mile away. -The facility failed to prevent Resident #2 in Memory Care Unit from ingesting shampoo on 5/17/24 which resulted in emergency treatment services at the local hospital. An Immediate Jeopardy was identified on 06/21/24 at 3:49 pm. The Immediate Jeopardy was removed on 06/23/24 at 12:54 pm; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately or no later than 24 hours after the allegation was made for 2 of 7 residents (CR#1 and Resident #2) reviewed for reporting in that: -The facility failed to report to the State agency CR #1's fall incident with serious injury (a left distal clavicle fracture) resulting in hospitalization on 3/5/24. -The facility failed to report to the State agency Resident #2's incident of ingesting a non-food item and was transported via emergency services for hospital treatment. These failures could affect all residents and could result in undetected neglect and emotional distress leading to serious harm/injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder and had a catheter upon admission, received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #29 and #50) of 3 residents reviewed for incontinent care. -The facility failed to ensure Resident #29's foley bag and tubing was not placed on the floor. -The facility failed to ensure CNA C followed appropriate infection control procedures during foley care for Resident #29. -The facility failed to ensure Resident #50's foley bag was positioned below the bladder. These failures could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 28 opportunities, which involved 1 (Residents #29) of 5 residents reviewed for medication errors. -RN A failed to administer three medications scheduled for 8:00 a.m. during Resident #29's medication administration through a g-tube. This failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication rooms (Medication Rooms) 1 out of 2 nursing medication carts (nurse medication cart for POA A), and residents reviewed for medication storage. - The facility failed to ensure nurse cart did not have discontinued, opened undated and opened medication not stored in its original packet. - The facility failed to ensure the Medication Rooms (POD D and POD C) did not contain expired medication, and unlabeled medication not stored in he delivery packet - The facility failed to ensure RN A did not leave medications in a medication cup on top of the unlocked medication cart and unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 Staff (CNA S, RN A, Dietary Aide O, and Laundry Aide H) reviewed for infection control. - The facility failed to ensure CNA S followed proper hand hygiene during hydration. - The facility failed to ensure RN A followed proper hand hygiene and infection control procedure during g- tube medication administration for Resident #29. - The facility failed to ensure RN A followed proper hand hygiene and infection control procedure during ACCU CHECK for Resident #58, Resident #75, and Resident #92. - The facility failed to ensure Dietary Aide O did not wear gloves in the hallway. [...]

Inspectors wroteBased on interview, and record review the facility failed refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for two (Residents #15 and #32) of six residents reviewed for PASRR. The facility failed to ensure an accurate additional PASRR Level I screening was completed for Residents #15 and #32. This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #13) of 3 residents reviewed for respiratory care. - The facility failed to provide Resident #13 appropriate nasal cannula for oxygen administration to prevent the prongs from hurting the resident's nostrils. - The facility failed to prevent Resident #13 from adjusting the oxygen setting on the concentrator. These failures placed residents who received oxygen therapy at risk of respiratory complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 2 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation and interview, the facility failed to ensure the call system was accessible to the resident at each resident's bedside for one (Resident #15) of twenty-two residents reviewed for call lights. -The facility failed to ensure the call light system in Resident #15's room was in a position which was accessible. This failure could place residents at risk of being unable to obtain assistance in the event of an emergency.