Ussery Roan Texas State Veterans Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or obtain pharmaceutical services to meet the needs of its residents for 3 out of 4 medication carts (Hall 400, Hall 500, and Hall 600 Medication Carts) reviewed. The facility failed to complete mandatory daily quality control (QC) checks on glucometers to ensure accurate diagnostic readings for 3 out of 4 medication carts (Hall 400, Hall 500, and Hall 600 Medication Carts) from December 1st, 2025 to July 27th, 2026 on night shift. This failure could place residents at risk for severe medication errors, inappropriate dosing, and serious injury or hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure current daily Menus were posted for residents in 1 of 1 kitchen/dining area (locked unit). The facility failed to update the posted daily menus for 4 consecutive days for residents who resided on the locked unit. This failure could place residents at risk of not knowing the meals scheduled to be served and contributing to confusion and frustration when the posted menu did not match the food provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure freezer, refrigerator, and pantry items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident 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 1 (Resident #52) of 25 residents reviewed for resident rights. Urine was observed in Resident #52's catheter bag during the noon meal in the dining room on 7/28/26 because no privacy bag was provided to cover his catheter bag. This failure could place residents at risk of feeling uncomfortable and disrespected, leading to isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow residents privacy of communications sent to the facility by a postal service for 2 of 25 residents reviewed for resident rights (Resident #35 and Resident #108). The facility failed to allow Resident #35 and Resident #108 to receive unopened mail at the facility. This failure could place residents at risk of decreased quality of life, hinder autonomy, and increase symptoms of depression. Findings Included:Resident #35Record review of Resident #35's face sheet, dated 07/28/2026, revealed a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 25 residents (Resident #4) reviewed for accuracy of assessments. The facility failed to accurately code Resident #4's MDS assessment by incorrectly identifying the resident as receiving dialysis while being a resident in the facility. This failure could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 1 resident (Resident #13) reviewed for significant weight loss. The facility failed to ensure that dietary interventions were accurately provided according to the resident's meal ticket preferences, failed to accurately reconcile meal consumption data with active medical records, and failed to report systemic supplement refusals to the Physician and Registered Dietitian (RD) for Resident #13. This failure could place residents at risk for severe malnutrition, skin breakdown, and physiological decline.

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 out of 1 resident (Resident #52) observed. The facility failed to ensure that proper personal protective equipment (PPE) was worn during indwelling urinary catheter care by Certified Nursing Assistant (CNA) providing care to Resident #52. This failure could place residents at risk for cross-contamination, colonization of MDROs, and severe urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure [NAME] F and [NAME] G 's hands were washed and gloves were changed during preparation of food. 2. The facility failed to ensure [NAME] E wore beard covers while in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

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 to help prevent the development and transmission of communication diseases and infections for 9 of 32 residents (Resident #22, #35, #11, #70, #51, #25, #58, #107, and Resident #9) reviewed for infection control. -CNA A failed to use proper hand hygiene techniques in between assisting Resident #22, #35, #11, #70, and Resident #51 with cutting up their food. -CNA B failed to use proper hand hygiene techniques when assisting Resident #107 to eat after assisting Resident #9 with the cutting up of his meal. -CNA C failed to use proper hand hygiene techniques when assisting Resident #25 to eat after assisting Resident #9 to sit up in his wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had a right to a dignified existence and to treat each resident with respect and dignity for 1 (Resident #63) of 24 residents reviewed for resident's rights. The facility failed to keep Resident #63's catheter bag covered with a privacy bag. This failure could lead to residents at risk of experiencing feelings of shame and/or embarrassment as well as having their right to privacy violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for 1 of 24 residents (Resident #117) reviewed for environment. -Resident #117 had his evening meal tray left in his room until the next AM. This failure could place residents 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 ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 24 residents reviewed for accuracy of assessments. Resident #1 had an active order for oxygen at 3 lpm via NC to maintain Oxygen sats above 90% dated 03/14/2025 and his MDS with a completion date of 05/08/2025 did not indicate he received oxygen while a resident. This failure could place residents at risk of not having their needs identified and therefore not receiving necessary care. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #1) of 24 residents reviewed for respiratory care. Resident #1 had orders for oxygen at 3 liters per minute and was observed to have an empty oxygen tank for an hour while in the dining area. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of 1 out of 6 residents (Residents #97) who was observed for medication administration. -RN D administered medication to Resident #97 via nebulizer and left Resident #97 unattended. This failure can affect residents that receive medications resulting in adverse reactions to medication, deterioration in their health, exacerbation of their disease process, and/or hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed, in accordance with State and Federal laws, 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 (Resident #20) of 24 residents reviewed for medication storage. The facility failed to ensure Resident #20 did not have access to 650 mg acetaminophen capsules. This failure could place residents at risk of injury due to ingesting non-prescribed medications. Findings Included: [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the residents environment remained free from accidents as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 did not elope from the facility. The noncompliance was identiified as Past Non-Compliance. The Immediate Jeopardy began on 3/7/25 and ended on 4/3/25. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents at risk a serious injury or serious harm and placed residents at risk of heat or cold exposure, dehydration and/or other medical complications, or being struck by a motor vehicle.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care to residents in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 11 residents (Resident #1) reviewed for quality of care. CNA L failed to ensure Resident #1 had catheter care on 08/20/2024 resulting in Resident #1's suprapubic catheter leak to go undetected, resulting in Resident #1 being left in a saturated brief and in a bed with urine satured bed linens. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 08/20/2024 and ended on 08/21/2024 The facility corrected the noncompliance before the investigation began. This deficient practice could result in residents not receiving the necessary care to maintain optimum health and place them at risk of skin breakdown.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure drugs were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication rooms. -The facility failed to store Hydrocodone-Acet 325mg properly by putting them with non-controlled discontinued medication in Medication room [ROOM NUMBER] and then later putting the medication in an ADON's office. This failure could result in a drug diversion placing residents at risk of not getting their medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure general sanitary conditions in the kitchen were maintained during preparation and serving of food. 2. The facility failed to ensure hairnets and beard covers were worn. 3. The facility failed to ensure the food items were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to ensure residents were free from abuse, for 6 of 7 residents (Resident #'s 61, 73, 86, 90, 104 and 112) reviewed for abuse. This failure could place these residents at risk of continued abuse on the locked unit of the facility. The failure was identified as past noncompliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance.

Inspectors wroteBased on Interview and Record Review the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment for 1 of 23 residents (Resident #110) reviewed for accurate assessments. This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 23 residents (Resident #79) reviewed for accuracy of MDS assessments. -The facility did not correctly identify anticoagulation therapy for Resident #79 on his MDS assessment. This failure to ensure accurate assessments could affect all residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 3 of 20 residents (Resident #13, Resident # 37, anonymous resident) reviewed for self-determination. A. The facility failed to ensure Resident #13 was allowed to have cereal when he expressed, he would like cereal after breakfast. B. The facility failed to ensure Resident #37 was allowed to choose the type of foods he preferred when he expressed, he would like bacon at breakfast like all the other residents were served. C. In a confidential interview one resident stated he asked for toast and was told no by the DM. [...]

Inspectors wroteBased on Interview and Record Review the facility failed to review and revise the resident's care plan after each assessment for 1 of 23 residents (Resident #110) reviewed for care plan accuracy. This failure could place residents at risk of not receiving the care needed to maintain their highest, most practicable, physical, social, and psychosocial level of well-being. Findings Included: On 3/4/24 at 9:02AM an interview was attempted with Resident #110 but could not be completed due to resident's level of cognitive decline. Record review on 3/4/24 at 2:19PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease with Late Onset; Major Depressive Disorder, Recurrent Severe, without Psychotic Features; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 (Hall 800 medication cart and Hall 500 medication cart) of 4 Medication Carts. There was 1 medication bottle with no expiration date and 3 loose pills in the Hall 800 Medication Cart. There were 2.5 loose pills were in the Hall 500 Medication Cart. The facility's failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the menus met the nutritional needs of the residents in accordance with established national guidelines, and failed to ensure menus were followed, and failed to ensure menus reflected input received by residents /groups for 3 of 3 days of menus reviewed. The facility failed to: A. Follow the menu from the Menu Management Corporation as written. B. Ensure lunch items served on 03/04/24 and 03/6/24 reflect what was on the DM's menu. C. Ensure all residents recieved Bread/Rolls for the 3/4/24 lunch meal. D. Condiments were available for residents' meals. These failures affected all residents that received meals from the facility kitchen and put them at risk for malnutrition, dissatisfaction of meals and 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 to help prevent the development and transmission of communication diseases and infections. -MH failed to use proper hand hygiene techniques when preparing a beverage for himself in the dining area. -CNA L failed to use proper hand hygiene techniques when assisting 2 unidentified residents to eat during lunch meal service. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.

Inspectors wroteBased on interview, and record review, the facility failed to provide provide routine and emergency drugs and biologicals to its residents, or obtain them for 1 of 1 residents (Resident #1) reviewed for medications as evidenced by: The facility failed to transcribe physician orders correctly when Resident #1 returned from the hospital with discharge orders. This failure could place residents at risk of not receiving care and treatment to address their medical condition.