Tuskegee Airmen Texas State Veterans Home

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 Residents (Resident #1) reviewed for essential equipment. The facility failed to ensure Resident #1's WanderGuard device (wander management bracelet) was functioning on all sensors of the four exit doors on the Delta pod. This failure could place residents at risk for elopement and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #3) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #3 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN. Resident #3 was ordered PRN Lorazepam (a benzodiazepine medication used primarily to treat anxiety disorders and sever agitation) on 06/03/26 without a stop date. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #109) reviewed for intravenous fluids. The facility failed to change and maintain the integrity of the dressing on Resident #109's Central Venous Catheter (an indwelling device inserted into a large, central vein that sends medicines and other treatments into a large vein in the middle of your chest) per professional standards. These failures could place residents at risk for infections and cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the clinical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 6 residents (Resident #109) records reviewed for treatment documentation. RN B inaccurately documented that Resident #109's Central Venous Catheter (an indwelling device inserted into a large, central vein that sends medicines and other treatments into a large vein in the middle of your chest) dressing was changed on 07/02/26 and 07/07/26 when it was not. These failures could affect the residents' medical record not being an accurate representation of the resident's medical condition or medical needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 2 residents (Resident #1) reviewed for ADL care .The facility failed to provide incontinence care to Residents #1 as needed. This failure could place residents at risk for loss of dignity, infections and a decreased quality of life.

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 and to prevent the development and transmission of communicable diseases and infection for 2 of 2 residents (Residents #1 and #2) reviewed for infection control.1. CNA B and CNA D failed to perform hand hygiene while providing incontinence care to Residents #1 and #2.2. RN C failed to perform hand hygiene and change her gloves when she performed a skin assessment on Resident #2. These failures could place residents at risk for worsening conditions and cross-contamination.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accident and hazards. The facility failed to ensure Resident #1 received adequate supervision to prevent the resident from eloping from the facility through an ancillary door on the service hallway on 03/21/26 at approximately 3:30 PM. An Immediate Jeopardy (IJ) situation was identified on 03/31/26. While the IJ was removed on 04/01/26 the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate effectiveness of their corrective systems. This failure could place residents at risk of serious injury, harm or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 6 residents (Resident #1) reviewed for medical records. The facility failed to ensure Resident #1's medical record included documentation reflecting the resident had received showers/baths in February and March of 2026. The failure placed residents at risk of not having continuity of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to immediately report allegations that involved injuries of unknown source to HHSC for 1 of 4 residents (Resident #1) reviewed for reportable incidents of abuse and neglect. The facility failed to report an injury of unknown origin to HHSC when Resident #1's sustained a bruise of unknown origin to his right eye area on 02/05/2026. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on interviews and reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's CPAP treatments were coded in his MDS dated [DATE]. This failure could result in Resident missing essential treatment treatments and interventions for care.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 residents (Resident #1) reviewed for care plans. Resident #1's, care plan dated 02/03/2026 did not address his CPAP treatment for obstructive sleep apnea. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that at resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 4 residents (Resident #1) reviewed for physician orders. The facility failed to ensure there were physician orders for Resident #1's use of a CPAP machine, which is non-invasive ventilation machine that involved the administration of air usually through the nose by an external device at a predetermined level of pressure, that was provided by the nursing staff daily. This failure placed residents at risk of not receiving adequate respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to remove previously applied Rivastigmine Patches for Resident #1 as ordered by the physician. This failure could place residents at risk for medication duplication, adverse drug reactions, and potential side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 had the right to be free from abuse on 11/27/25, while on the memory care unit, Resident #1 punched Resident #2 in the face causing him to fall against the wall and then to the ground resulting in facial bleeding and a fractured hip. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 11/27/25 and ended on 12/02/25 the facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm and/or severe injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #2) reviewed for supervision. The facility failed to provide adequate supervision to prevent a physical altercation when Resident #1, who was sitting at the dining room table eating and talking with LVN A, got up from the table. LVN A asked him where he was going and to have a seat, Resident #1 stated, I will be right back with you. He then walked up to Resident #2 and punched him in the face causing Resident #2 to fall against the wall and then to the ground, which resulted in Resident #2 sustaining facial bleeding and a fractured hip on 11/27/25. The noncompliance was identified as a past non-compliance. [...]