Tuskegee Airmen Texas State Veterans Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:Record review of Resident #1's quarterly MDS Assessment, dated 03/27/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Parkinsonism (any disorder manifesting symptoms of Parkinson's disease or any such symptom complex occurring secondarily to another disorder), chronic ischemic heart disease (heart damage caused by poor blood flow to the heart), respiratory failure (not enough oxygen travels from the lungs into the blood), anxiety disorder (excessive worry and feelings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:1. Record review of Resident #1's quarterly MDS Assessment, dated 3/27/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Parkinsonism (any disorder manifesting symptoms of Parkinson's disease or any such symptom complex occurring secondarily to another disorder), chronic ischemic heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included: Record review of Resident #1's admission MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male who was admitted on [DATE]. His diagnoses included Parkinsonism (any disorder manifesting symptoms of Parkinson's disease or any such symptom complex occurring secondarily to another disorder), chronic ischemic heart disease (heart damage caused by poor blood flow to the heart), chronic respiratory failure (not enough oxygen travels…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep), depression (mood disorder); and vertigo (a sensation that the environment is spinning in circles). Section C. cognitive patterns…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: During an observation and interview with Resident # 1 on 02/10/2026 at 1:10 PM his CPAP mask was on his nightstand. Resident #1 was observed in the main resident area of memory care attending activities. Resident # was not interviewed about CPAP treatments and care tasks, due to severe cognitive impairment. Record review of Resident #1's face sheet dated 2/10/2026 reflected he was an [AGE] year-old male admitted on [DATE]. DX: Alzheimer's (severe cognitive decline.) Sleep Apnea (serious sleep disorder), Depression (mood disorder), Obstructive sleep apnea (serious sleep disorder causing changes in blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive sleep apnea (a condition in which breathing stops involuntarily for brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected he was an [AGE] year-old male admitted on [DATE]. The resident's diagnoses included: Alzheimer's disease (progressive mental deterioration that can occur in middle or old age that affects memory, thinking, and behavior); obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included:Record review of Resident #1's Face Sheet, dated 02/05/26, reflected the resident was an [AGE] year-old male admitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 01/23/26, reflected the resident had diagnoses of Alzheimer's Disease (progressive brain disorder that causes memory loss and confusion), PTSD (mental health condition caused by experiencing or witnessing a traumatic event), and Gastro-esophageal reflux disease (condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.