Health inspection·May 31, 2024

F 0641 Ensure each resident receives an accurate assessment. 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 review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 16 residents (Resident #8 and Resident #16) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Resident #8's MDS accurately reflected his g-tube status. The facility failed to ensure Resident #16's MDS accurately reflected his behaviors. These failures could place residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. Findings included: Record review of Resident #8's face sheet dated 05/29/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis of altered mental status (change to your average mental function). Record review of Resident #8's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11, indicating he was cognitively intact. The assessment did not account for enteral feeding. Record review of Resident #8's care plan revealed focus area for requires feeding related to dysphagia with goal will maintain adequate nutritional and hydration status. Record review of Resident #16's face sheet dated 05/31/24 revealed a [AGE] year-old male who was admitted on [DATE] with diagnoses of Parkinson's disease (type of brain disorder that causes problems with memory, thinking, and behavior) with dyskinesia (involuntary, erratic movements of different body parts, such as the face, arms, legs, or trunk), and anxiety (a feeling of dread, fear, or apprehension, often with no clear justification). Record review of Resident #16's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating h he was cognitively intact. His behavior of false accusations was not accounted for under the behavior section of assessment. Record review of Resident #16's care plan revealed a focus area for behavior expresses repeated criticism of staff. During an interview on 05/31/24 at 9:16 am, the Unit Manager stated Resident #8 did have a g-tube (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 4 Event ID: 676060 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 676060 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ambrosio Guillen Texas State Veterans Home 9650 Kenworthy St El Paso, TX 79924 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)