Richard A. Anderson (state Of Texas Veterans Land

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record review of Resident #4's admission Record generated on 9/10/25 revealed he was admitted to the facility on [DATE] and had diagnoses of dementia (causes memory loss in older adults), parkinsonism ( a clinical syndrome characterized by tremor, rigidity and postural instability), weakness, gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), diabetes type II (a long-term 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record review of Resident #3's admission Record generated on 9/11/2025 revealed he was admitted to the facility on [DATE] and had diagnoses of vascular dementia (causes memory loss in older adults) and diabetes type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). He was [AGE] years of age. Record review of Resident #3's Care Plan dated 8/28/2023 revealed he was at risk of hyperglycemia (abnormally high level of glucose in the blood) or hypoglycemia (a condition in which the body's blood sugar…

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 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. Findings include: Record review of the admission Record (copied 08/22/24) for Resident #1 revealed he was [AGE] years old and was admitted to the facility…

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 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. Findings included: Record review of CR #1's face sheet dated 6/20/24 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinson's disease with dyskinesia (a disorder of the central nervous system that affects movement, often including tremors), quadriplegia,…

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 ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 12 residents (Resident #1) reviewed for quality of care. LVN A failed to ensure Resident #1's scalp wound was treated and dressed as ordered by his physician. This failure could place residents with skin injuries at risk of worsening skin injury, infection, and pain. Findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis (a life-threatening condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence), cognitive communication deficit (problems with communication that have and underlying), squamous cell carcinoma (abnormal, accelerated growth of squamous cells) of the…

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 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. Findings included: Resident #29 Record review of Resident #29's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain),…

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 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. Findings include: Record review of Resident #29's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record…

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.

Based 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. - The facility failed to ensure RN A did not leave breathing treatment medication for Resident #13 in room for the resident to administer himself. These failures could place residents at risk of…

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 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. - The facility failed to ensure Laundry Aide followed proper hand hygiene when he demonstrated hand washing. These deficient practices could affect residents and place…

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 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. Findings included: Resident #15 Record review of Resident #15's admission record revealed a [AGE] year-old resident admitted on [DATE]. The admission record documented he had diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) diagnosed 7/30/2020, psychotic disturbance (a collection of symptoms that affect the mind, where there…

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 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. Findings included: Record review of Resident #13's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (loss of cognitive function, thinking,), chronic obstructive pulmonary disease, chronic respiratory failure, and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #13's…

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.

Based 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. Findings include: Observation on 06-20-23 at 8:30 am, with the Food Service Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had a 2 commercial -size dumpsters and the lids and doors were opened. Interview on 06-20-23 at 9:00 am, with the Food Service Manager she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She also stated that she is responsible for all requirements be met in the Food Service Department. She will in-service the dietary staff on following Policy and Procedure for Garbage Disposal Record review of the facility policy and procedure dated June 1, 2019, revealed that outdoor storage shall be constructed…

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 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. Findings include: Record review of Resident #15's admission record revealed a [AGE] year-old resident admitted on [DATE]. The admission record documented he had diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) diagnosed 7/30/2020, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) diagnosed 7/30/2020, mood disturbance (affective disorders are a set of psychiatric diseases, also called mood…

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.