Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility to ensure that the residents had the right to and that
the facility promoted and facilitated resident self-determination through support of resident choice for 1 of 1
resident (Resident #61) whose care was reviewed, in that:
Resident #61's preference was to have a shower on the shower bed instead of a bed bath but the resident
did not receive showers because the shower bed was damaged.
This deficient practice could place residents with the ability to make choices at risk of having their rights
violated, diminished quality of life and unmet needs.
The finding were:
Record review of Resident #61's face sheet, dated 12/15/2023, revealed the resident was initially admitted
on [DATE] and readmitted on [DATE], with diagnoses that included: Quadriplegia, C1-C4 incomplete, acute
kidney failure, major depressive disorder, recurrent; insomnia, colostomy status, dry eye syndrome.
Record review of Resident #61's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of
15, which indicated the resident was cognitively intact.
Interview on 12/13/2023 at 3:45 PM with Resident #61 stated he had received bed baths for his last 5
scheduled showers and possibly more. Resident #61 stated the shower schedule he had been given was
every Tuesday, Thursday and Saturday. Resident #61 stated CNA C told him the shower bed was broken
therefore the resident would be given a bed bath. The resident stated he supposed to get a shower as that
was his preference and he had made that known to the facility staff. Resident #61 stated, if I do not get a
shower I itch all over and the only part of my body I can really move are my hands from the neck down due
to my condition, I asked [CNA C] when the shower bed was going to be fixed and she said she did not
know she had reported it to the nurse but that nurse does not work here anymore; I need showers and not
bed baths, I do not want to itch all over, my skin stays dry and I will get sores that I can't scratch because
my condition does not allow me to scratch.
Observation and interview on 12/14/2023 at 4:25 PM with CNA C stated the CNA had given Resident #61 a
bed bath for the last 5 scheduled shower times as Resident #61 had stated. CNA C stated the shower bed
had been broken and walked to the shower room for an observation of the shower bed. CNA C said, He
does prefer a bed on the shower bed but the gurney is torn and that could hurt him if we put him on it the
way it does now because it is not safe for him to use. He does have a shower chair but I
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
675863
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
cannot use that with him safely either and he prefers the shower bed. CNA C stated she had reported the
shower bed as broken to her charge nurse at the time and she was sure the nurse put the information in
the facility work order database. CNA C stated, CNAs do not put work orders in the facility work order
database.
Interview with the DON on 12/20/2023 at 4:41 PM, the DON stated they were aware Resident #61's
preferred a shower and not a bed bath. The DON stated, Resident #61 should get a shower, I am not aware
of any shower bed being broken. He is a reliable reporter and if he said he did not get a shower than he
didn't. I don't know of any skin condition he has but I can understand him not being able to scratch himself
being frustrating. The DON further stated Resident #61 should have gotten a shower if that was what he
wanted because it was his preference.
Interview with the MS on 12/14/2023 at 5:05 PM, the MS stated he did not have any reports of a shower
bed in the facility being broken currently through the facility work order database or through verbal report.
The MS stated if he would have known he would have purchased a new one. The MS stated in this case the
equipment was not working so the resident did not get what they wanted and the residents should.
Interview with the Administrator on 12/14/2023 at 5:30 PM, the Administrator stated she was unaware of
any shower beds in the facility being broken or any resident not receiving their preferred method of a bath
or shower. The Administrator stated all work orders or requests were put in through the facility work order
database, there was no policy for the use of the facility work order database, it was the system they used to
track needed services and/or equipment. The Administrator further stated the, Maintenance Supervisor and
I have run reports to see if the broken shower bed had been reported by any nurse and we could not find
where it had been, in this case I think the nurse who no longer works here may have just forgotten to put it
in, she could have told someone but we have not been able to identify any maintenance staff that were
aware of a broken shower bed in the facility at this time. The Administrator further stated that in this case
Resident #61 did not receive his preferred method of bathing and should have because it was his right.
Record review of the facility's policy titled, Statement of Resident Rights, revised 10/2022, revealed,
Resident/Patient Rights include: 1. To all care necessary for them to have the highest possible level of
health; 4. To be treated with courtesy, consideration and respect.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to provide the necessary services for residents
who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1
(Resident #124) of 8 residents reviewed for ADLs.
Residents Affected - Few
The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #124.
These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity,
risk for infections, and a diminished quality of life.
The findings included:
Record review of Resident #124's admission Record revealed he was a [AGE] year-old male admitted on
[DATE].
Record review of Resident #124's comprehensive MDS assessment dated [DATE], revealed Resident
#124's primary reason for admission was traumatic spinal cord dysfunction. Resident #124 had a BIMS
summary score of 15, indicative of intact cognition. Resident #124 was coded as needed some help with
self - care in prior functioning; functional abilities at admission were coded as substantial/maximal
assistance for shower/bathe self. Resident #124 had upon admission a Stage 4 pressure injury.
Record review of Resident #124's care plan revealed a focus area of self-care deficit, with associated
interventions/tasks of: .showered 2-3 times weekly 2 or 3 days of week, with one person assistance,
initiated on 11/30/2023, and revised on 12/12/2023.
Record review of facility census revealed Resident #124 resided in an even numbered room.
Record review of 30 day look back of Task related to bathing revealed Resident #124's first shower was 5
days after admission on [DATE]. Resident #124 did not receive scheduled showers on 12/01/2023,
12/04/2023, 12/08/2023. Resident #124 did not receive a shower for 4 days between 12/6/2023 and
12/11/2023.
In an observation on 12/12/2023 at 11:39 AM Resident #124 was sitting up at the edge of the bed, awake
and conversing with his roommate. Resident #124 was wearing pajama pants and a T-shirt. Resident #124
presented with uncombed and greasy hair.
In an interview on 12/14/2023 at 8:49 AM, Resident #124 stated he had received a bath yesterday
[12/13/2023] but that it had been nearly a week since the last one. Resident #124 stated that it was nearly a
week after he checked in before he got bath. Resident #124 stated he needs at least one person to help
him with baths due to his mobility and flexibility issues. Resident #124 stated he felt like he had been
forgotten.
In an interview on 12/15/2023 at 4:19 PM, CNA I stated she had worked at this facility for the previous four
years. CNA I stated she normally worked the hallway where Resident #124 resided but had frequently been
pulled to other areas in the facility halfway through her shift in the recent past. CNA I stated that Resident
#124 had told her on 12/11/2023 that it had been a long time since his last
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
bath. CNA I stated she did not think it was his regular scheduled bath day, but she made sure to get him a
bath that day. CNA I stated there were several residents, who no longer reside on C hall, who insisted that
she was the aide that provided a bath. CNA I stated that many of the facility residents had expressed that
they would prefer her, or other facility staff provided care over agency staff. CNA I stated she believed this
was why she was pulled to work other areas after the start of her shift. CNA I stated that bathing was
documented in the point of care system for the EHR. CNA I stated that there was a check mark to indicate if
the resident was out of the building or if they refused. CNA I stated, agency staff were expected to provide
baths and document it, but they do not care the way we do. CNA I stated Resident #124 was not the type of
resident to refuse, and he asserted his needs and wants in other areas. CNA I stated, I believed Resident
#124 when he said he was forgotten and did not get a bath.
In an interview on 12/15/2023 at 4:41 PM, the ADON stated the bathing schedule was all even numbered
rooms both bed A and bed B were Mondays, Wednesdays, Fridays; all odd numbered rooms both bed A
and bed B were Tuesdays, Thursdays, Saturdays. ADON stated she had assisted Resident #124 multiple
times in settling into his room since his admission. ADON stated he had not mentioned his concern to her
at any point about missing or wanting a bath. ADON stated that there were some issues with the new
system of documenting, and it was possible that Resident #124 received a bath as scheduled but it went
undocumented by mistake.
Record review of Statement of Resident Rights revised October 2022, revealed statements that the
Resident had a right to all care necessary for them to have the highest possible level of health.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record reviews the facility failed to ensure that residents receive treatment and
care in accordance with professional standards of practice, the comprehensive person-centered care plan,
and the residents' choices for 1 of 8 (Resident #56) residents in that:
Residents Affected - Few
Resident #56's compression socks were not on as ordered.
This could affect all residents with compression socks ordered and could result in swelling.
The findings were:
Record review of Resident #56's admission Record dated 12/14/2023 revealed he was admitted on [DATE],
readmitted on [DATE] with diagnoses of congestive heart failure (chronic condition in which the heart
doesn't pump blood as well as it should), disorder of peripheral nervous system (the nervous system
outside the brain and spinal cord), edema, (swelling caused by too much fluid trapped in the body's tissues)
and diabetes II. (can cause swelling).
Record review of Resident #56's consolidated orders for December 2023 revealed compression socks on
when out of bed and off when in bed at bedtime, every shift for edema.
Record review of Resident #56's Quarterly MDS assessment dated [DATE] revealed his cognition was
15/15 (cognition intact).
Record review of Resident #56's care plan dated 11/14/2023 revealed he had altered cardiovascular status
related to hypertension, VA and hyperlipidemia. The interventions were notify MD for sign or symptoms
edema-compression socks.
Observation on 12/13/2023 at 3:54 PM in Resident #56's room revealed he was sitting in his wheelchair
and watching television. Resident #56 was not wearing compression socks on either leg.
Observation on 12/13/2023 at 4:02 PM with LVN B in Resident #56's room revealed he had no
compression socks on either leg.
Interview on 12/13/2023 at 3:55 PM with Resident #56 stated he was not sure if he had compression socks
and lifted his pants up, showing no compression socks on.
Interview on 12/13/2023 at 3:59 PM with CNA A, stated she had not seen Resident #56's compression
socks or placed them on him. CNA A stated she was not sure he had an order for compression socks and
had not been in his room.
Interview on 12/13/2023 at 4 PM with LVN B stated he did not know Resident #56 still had orders for
compression socks. LVN B stated he recalled Resident #56 did have compression socks when he was a
CNA.
Interview on at 12/14/23 04:18 PM DON was not aware Resident #56 did not have compression socks and
would investigate.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Record review of the policy Standards of Nursing practice observations and Data Collections dated January
2023 revealed Our community espouses the use of the nursing proceed in order to deliver appropriate care
and services for each resident. The delivery of nursing care in the community is based on an assessment of
the resident to identify his or her care needs.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observations, interviews, and record reviews, the facility failed 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 of 6 medication carts (nurses medication cart for the 200 hall) reviewed for
security, in that;
The facility failed to ensure the narcotic box was separately locked inside the nurses medication cart for the
200 hall.
This failure could place residents at risk of having access to unauthorized narcotic medications and/or lead
to possible harm, drug overdose, or drug diversions.
The findings included:
In an observation and interview on 12/15/2023 at 10:48 AM, with RN F present, the nurses medication cart
for the 200 hall was approached for inspection related to medication storage and labeling. The cart was not
in use at the time and was unattended. The cart required key access, however the narcotic box, an internal
bin for controlled substances, was unlatched and unlocked. RN F stated the bin was not closed inside the
drawer. LVN G stated the cart was her responsibility. LVN G stated, sometimes the lid [to the controlled
substances bin] does not close all the way; you have to press it down until it pops in.
In an interview on 12/15/2023 at 1:51 PM, the DON stated her expectation for nurses and certified
medication aides is to keep the medication cart locked when not in active use. The DON stated the certified
medication aides do not administer narcotics and narcotics are not kept in the medication aide carts. The
DON stated her expectation was that the narcotic box should be locked when not being used. The DON
stated narcotic security is Nursing 101, but it is trained during the on-boarding process at new hire
orientation, during annual competency, and on an as needed basis in in-servicing training sessions. The
DON stated she thought the risk of harm to residents would be low, since the cart required keyed entry to
first access the drawer where the narcotic box was.
Record review of Medication Cart Use & Storage policy dated 3/15/2019; revealed under Guidelines, 1.)
Security: The medication cart and its storage bins are kept locked until the specified time of medication
administration.
Review of Lippincott procedures, Medication Delivery Acceptance: Long Term Care, revised 5/21/2023,
accessed 12/24/2023,
https://procedures.lww.com/lnp/view.do?pId=4420028&hits=delivery,drug,deliveries&a=true&ad=false&q=drug%20delivery
revealed under the heading Implementation: Ordering and receiving controlled substances, immediately
place the accepted medications into your facilities-controlled substance management system.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, and record reviews the facility failed to maintain medical records on each resident,
in accordance with accepted professional standards and practices, that were complete and accurate for 1
(Resident #74) of 13 residents reviewed for resident records.
The facility failed to ensure Resident #74's Medication Administration Record (MAR) reflected
documentation of all administered doses of Morphine [an opioid medication to treat pain] in his Electronic
Health Record (EHR).
This failure could place all residents who receive medications at risk of having errors in care and treatment.
The findings included:
Record review of Resident #74's admission Record revealed he was an [AGE] year-old male admitted on
[DATE].
Record review of Resident #74's quarterly MDS assessment dated [DATE], revealed Resident #74 primary
reason for admission was medically complex condition related to chronic kidney disease. Resident #74 had
a BIMS summary score of 5, indicative of severely impaired cognition. Resident #74's active diagnoses
included end stage kidney disease. Resident #74's received scheduled and as needed pain medications in
the 5-day-look-back period, assessed as almost constantly, affecting sleep, limited therapy sessions.
Resident #74's Care plan included a focus area for scheduled and as need pain [medication] for end-of-life
care, initiated 5/16/2023.
Record review of Resident #74's Order Summary sheet, printed 12/15/2023 at 1:47 PM revealed Resident
#74 had four active orders for Morphine Solution 20 mg/ml with a start date of 12/12/2023:
1.)
Give 0.25 ml by mouth every 1 hours as needed for Pain/SOB [shortness of breath].
2.)
Give 0.5 ml by mouth every 1 hours as needed for Pain/SOB.
3.)
Give 0.75 ml by mouth every 1 hours as needed for Pain/SOB.
4.)
Give 1 ml by mouth every 1 hours as needed for Pain/SOB.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Record review comparing the EHR MAR for December 2023 to the Narcotic Control Sheet [not considered
part of a residents' medical record] for Morphine Solution 20 mg/ml received 12/8/2023 revealed the
following undocumented doses in the EHR:
1.)
Residents Affected - Few
12/08/2023 9:15 PM 0.5 ml; administered by LVN H
2.)
12/09/2023 4:45 PM 0.75 ml; administered by LVN D.
3.)
12/09/2023 8:45 PM 0.75 ml; administered by LVN D.
4.)
12/10/2023 12:00 AM 0.75 ml; administered by LVN D.
5.)
12/10/2023 3:00 AM 0.75 ml; administered by LVN D.
6.)
12/10/2023 4:00 AM 0.5 ml; administered by LVN D.
7.)
12/10/2023 8:00 PM 1 ml; administered by LVN D.
8.)
12/10/2023 10:00 PM 1 ml; administered by LVN D.
9.)
12/10/2023 [incorrect date, should be 12/11/2023] 12:00 AM 0.5 ml; administered by LVN D.
10.)
12/11/2023 2:00 AM 0.5 ml; administered by LVN D.
11.)
12/11/2023 5:00 AM 0.5 ml; administered by LVN D.
In an observation on 12/12/2023 at 11:30 AM, at the C Wing nurses medication cart, the Morphine
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675863
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Frank M Tejeda Texas State Veterans Home
200 Veterans Dr
Floresville, TX 78114
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Solution 20 milligram per milliliter [mg/ml] Narcotic Control Sheet for Resident #74 revealed documentation
of a future dose of the Morphine Solution as 12/12/2023 at 11:40 AM. The Narcotic Control Sheet revealed
there should be 10.5 ml in the Morphine Solution 20 mg/ml container.
In an observation and interview on 12/12/2023 at 11:49 AM, LVN E exited Resident #74's room. LVN E
stated she had been in the room for the previous 10-15 minutes by her best guess. LVN E stated she had
just administered 0.5 ml of Morphine to Resident #74, and stated she believed he seemed much more
comfortable with the increased frequency of the medication. LVN E unlocked the cart, and then unlocked
the separately locked narcotic box, an internal bin for controlled substances. LVN E stated the amount in
the morphine solution should be equal or above the graduation mark for 10.5 milliliters at this time. The
observed amount in the bottle was 10.5 milliliters. LVN E stated she had logged out the dosage on the
Narcotic Control Sheet prior to administration of the medication. LVN E stated she would now need to
access the MAR to complete the entry in Resident #74's EHR.
In an interview on 12/14/23 at1:06 PM, the DON stated staffing was adequate for C Wing. The DON stated
the nurse, LVN D, covering C Wing had not normally worked that hall but normally worked another area of
the facility. The DON stated LVN D was probably familiar with facility policy but maybe not as familiar with
specific residents on C Wing. The DON stated the pharmacy nurse, RN F, does spot checks about every
other week to check accuracy, which included accuracy of narcotic count, and comparing the Control
Sheets with the MARs.
In an interview on 12/15/2023 at 1:51 PM, the DON stated she had spoken to LVN D, and understood that
the Resident #74 required extensive time by LVN D when his condition worsened and needed nearly hourly
dosing of Morphine to remain comfortable. [Attempted several interviews with LVN D and LVN H but did not
receive a phone call back prior to exit.] The DON stated she understood that LVN D administered the
medication, documented on the associated Control Sheet, but failed to document in the EHR MAR. The
DON stated in-servicing with LVN D and LVN H would be mandatory prior to either of them providing care
to residents. The DON stated all nursing staff would be in-serviced on this topic.
Record review of Cart Use & Storage, implemented 3/15/2019, revealed in Procedure step 7.) Document
administration in the e[HR] MAR record and update the individual control record for controlled drugs.
Review of Lippincott procedures, Oral drug administration, revised 5/21/2023, accessed 12/24/2023,
https://procedures.lww.com/lnp/view.do?pId=4420477&hits=oral,administration,drug,drugs&a=true&ad=false&q=oral%20dr
revealed under Implementation: Verify the order on the patient's MAR by checking it against the
practitioner's order. Additionally, reconcile the patient's medication at each care transition .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675863
If continuation sheet
Page 10 of 10
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the December 15, 2023 survey of Frank M Tejeda Texas State Veterans Home?
This was a inspection survey of Frank M Tejeda Texas State Veterans Home on December 15, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Frank M Tejeda Texas State Veterans Home on December 15, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.