Health inspection·November 20, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few prepared by LVN B revealed the following: IDT (Interdisciplinary team) reviewed circumstances surrounding resident skin integrity issue. DON went to look at resident's skin, three bruises noted to left hand, two approximately 2cm by 2cm with light purple and yellow discoloration, one 1cm by 3cm dark purple in color. Resident #1 was asked if she knew how bruise occurred. Resident shook her head no. Resident stated she had mild pain to hand. ROM [Range of Motion] WNL [Within Normal Limits], no swelling noted. Resident #1 reported that the night nurse from the previous shift tried to take away resident's medications, which were hers since she had paid for them, so the medications belonged to her. Resident #1 noted with mild confusion. Psychiatric NP notified about behavior from night shift and confusion this am. Lab work and UA order obtained, order for anxiety medication also obtained. Order for aricare ointment for bruise ordered from NP, which was an ointment used to temporarily treat pain and bruises. Facility does not suspect abuse, neglect, or exploitation. Incident Report, under Incident Description, Nursing Description: Noticed bruising to her left hand after the resident with aggressive behavior was throwing punches towards staff as she hit the table and side rail several times. Resident Description: Resident voicing staff was taking advantage of resident. The document reflected, the resident refused care for her bruising, and she was not taken to the hospital. Incident Report noted under Injuries Observed at Time of Incident Abrasion, back of left hand.Record review of Resident #1's progress notes dated 10/01/25 at 10:58 AM documented by LVN A revealed: Several bruises noted to resident's left hand this morning. Bruises to front of hand and on side of hand. Resident voiced pain to hand. Resident stated her hand was ‘squeezed' early this morning when she did not want to give back the nurse a pill she had given her. This nurse notified RN Supervisor and NP. [RN Supervisor D] notified DON and DON notified administrator. NP gave order for XRAY to left hand. [POA] notified. Pending x-ray to be done. Resident [#1] notified of orders. This nurse tried to do head to toe assessment on Resident [#1] but resident refused. Resident is stable at this time. Refused Valproic Acid [medication used to treat seizures, migraines, and bipolar disorder which was a mental condition that is characterized by extreme mood swings] capsule this morning but did take the rest of her medications. Compliant with care. Record review of Resident #1's progress notes dated 10/01/25 at 3:23 PM documented by LVN C, revealed x-ray results of no acute fractures or findings.On 10/27/25 at 10:23 AM, the investigator attempted to interview Resident #1, and she declined.In an interview on 10/27/25 at 11:37 AM, LVN A stated she received a report from LVN B during shift change on day of the incident, 10/01/25. LVN A stated LVN B reported Resident #1 had a bruise on her left hand. LVN A stated LVN B reported Resident #1 refused to take her medications that were in a medication cup on the table, and Resident #1 stated she paid for medications, so she refused to give them back to LVN B and Resident #1 refused to take them. LVN A stated LVN B reported Resident #1 attempted to hit LVN B and hit herself on the side rail or the side table. LVN A stated she observed Resident #1 visibly upset that morning 10/01/25 at approximately and LVN A asked the resident what was wrong. LVN A stated Resident #1 reported the night nurse squeezed the resident's hand to take the medications Resident #1 had. LVN A stated Resident #1 physically demonstrated how her hand was grabbed which LVN A believed consisted with the bruises observed on Resident #1's left hand. When asked of the sizes of the bruises by, LVN A stated the 3 bruises on top of Resident #1's left hand looked like fingerprints, and all 3 bruises were purple in color. During a follow up interview on 10//27/25 at 3:17 PM, LVN A stated she attempted to notify the Administrator of Resident #1's allegation against LVN B. She stated the Administrator was the Abuse Coordinator and he was to be notified of all abuse, neglect, and exploitation allegations immediately. LVN A stated she called the Administrator that morning on 10/01/25 immediately after Resident #1 made her allegation of abuse, but he did not answer at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 2 of 5 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 11/20/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that time which was approximately 7 AM. She stated she notified RN Supervisor D, and she notified the DON and the DON notified the Administrator immediately. LVN A stated the DON was aware of Resident #1's allegation against LVN B, alleging LVN B squeezed her hand and there was a bruise. LVN A stated allegations of abuse or neglect were to be immediately reported to the Abuse Coordinator or the immediate supervisor, and the alleged preparator was to be removed off the facility and suspended pending investigation. LVN A stated she observed LVN B arrive on her assigned night shift the following day.During a telephone interview on 10/27/25 at 1:15 PM, LVN B stated it was approximately 5:30 AM and she tried to administer Resident #1's medications. LVN B stated Resident #1 stated she would take the medications when she wanted to. LVN B stated she would not be able to leave the medications unattended and that Resident #1 left the medication cup with the medications on the side table. LVN B stated the side table was located at Resident #1's left side in front of her while the resident was in bed. LVN B stated she attempted to reach for the medication cup and Resident #1 began to scream and swinging, and thought Resident #1 could have got her bruises from the side rail or the table because Resident #1 swung her arms. LVN B stated Resident #1 was screaming and punching LVN B, which connected and resulted in a bruise on LVN B. She stated she called RN Supervisor E via phone while LVN B continued to be at Resident #1's bedside. LVN B denied ever touching the resident, including her hand or wrist. LVN B stated Resident #1 was screaming while LVN B was on the phone with RN Supervisor E. She stated RN Supervisor E came into Resident #1's room and LVN B removed herself from the situation. LVN B stated she was documenting that morning 10/01/25 when she was made aware by DON that Resident #1 alleged LVN B squeezed her hand. LVN B stated she notified the DON of the incident, Resident #1's behavior which included the swinging of arms. She stated there was an internal investigation conducted. LVN B stated the nursing facility conducted weekly or bi-weekly abuse, neglect, or exploitation in-services, and her most recent ANE in-service was last week. She stated the Administrator was the Abuse Coordinator. She stated she observed 2 bruises by the knuckles and the other bruise was on top of the hand; all 3 bruises were smaller than a penny. LVN B stated the bruises were all purple from what she could recall, but it had been a month since the incident and the investigator could refer to her documentation. In an interview on 10/27/25 at 2:22 PM with the Director of Human Resources, she stated LVN B was not suspended at any time after Resident #1 made the abuse allegation on 10/01/25.In a phone interview on 10/27/25 at 2:39 PM with Resident #1's Power of Attorney (POA), she stated she was called and notified of the incident regarding the resident's behavior. She stated she was also notified by the nursing facility staff of Resident #1's allegation. The POA stated she offered to assist the facility staff by being present as Resident #1 calmed down and did well when family was present at the bedside. The POA stated the staff agreed and she was there that morning but unable to recall the time. The POA stated she was there at Resident #1's bedside that morning of 10/01/25, and she observed Resident #1 being uncooperative with nursing staff when they attempted to assist Resident #1 with changing her shirt. The POA stated Resident #1 was upset and informed the POA of her allegation, but the POA stated Resident #1 did not cooperate with staff. She stated she had observed Resident #1 being agitated when uncooperative with nursing staff for some weeks before 10/01/25, which she believed contributed to Resident #1's bruising on her left hand. The POA stated she did not examine the bruising because Resident #1 was agitated, but the bruises were all the colors of bruises. all the purples and greens. The POA denied concern with Resident #1's care provided by the nursing facility, and she denied concerns regarding abuse.In an interview on 10/27/25 at 3:27 PM with the DON, she stated she was notified by RN Supervisor D that Resident #1 reported someone had squeezed Resident #1's hand and there was a bruise. The DON stated she spoke with Resident #1 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 3 of 5 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 11/20/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had LVN A present. The DON stated Resident #1 did not report any allegations of abuse to her and the resident declined to speak with the DON about her bruise. The DON stated she did not observe the resident distressed. The DON stated the police were notified of Resident #1's allegation, but they did not take the case. The DON stated there were a total of 4 bruises observed on Resident #1's left hand, and they were in different stages of healing. She stated 2 bruises, one on the top of the left hand and the other on the side of hand, were deep purple. She stated another bruise on the hand was yellow, and the last bruise on the hand was red and purple. She stated the 3 bruises on the top of the left hand were small circles, approximately 2 cm. The DON stated she did not think the incident was to be reported to the State Survey Agency since LVN B documented the resident's combative behavior during medication administration that morning 10/01/25. The DON stated Resident #1's POA, and Physician were notified of the behaviors and of the allegation. She stated there was an order for x-ray for Resident #1's left hand which there were no acute findings or fractures. The DON stated the facility conducted a safe survey for residents on 10/13/25 and conducted an ANE in-service for the nursing facility staff on 10/13/25. The DON stated she and the Administrator became aware that an employee called the facility's corporate hotline for employees due to an anonymous employee was concerned about the lack of reporting, investigation, and suspension of the alleged perpetrator, LVN B, after Resident #1 made an abuse allegation. The DON stated she was aware that Resident #1 alleged to LVN A that LVN B had squeezed Resident #1's hand on 10/01/25, but it was not presented as an allegation of abuse. The DON stated she discussed the allegation of Resident #1's hand being squeezed with the Administrator and corporate, which was deemed not as abuse because of LVN B's documentation of Resident #1's behaviors. She stated the behaviors made sense as being a possible cause for the bruises, as Resident #1 had behaviors for approximately 1-2 months before 10/01/25. The DON stated LVN B was not suspended during the self-report on 10/13/25, nor on day of the allegation on 10/01/25, because the facility staff, the DON and Administrator had evidence to unsubstantiate Resident #1's allegation. The DON stated the Administrator was the Abuse Coordinator and he was responsible for reporting all allegations of ANE to the State Survey Agency per the policy's time frame. She stated if he were unable to, it would be her responsibility to as the DON. She stated the purpose of reporting allegations of ANE to the State Survey Agency were to protect the residents and to ensure the residents were free from ANE. In an interview on 10/27/25 at 4:00 PM with the Administrator, he stated he was notified of Resident #1's allegation of bruise and her hand being squeezed on 10/01/25 by RN Supervisor D. The Administrator stated the DON spoke and assessed Resident #1, which the DON did not identify any concerns. He stated Resident #1 did not report concerns or allegations of abuse to the DON. He stated himself and the DON were not notified of allegations of abuse but were made aware of Resident #1 alleged her hand was squeezed by LVN B on 10/01/25. He stated himself and the DON reviewed documentation which LVN B noted Resident #1's combative behavior on 10/01/25 during that night shift. He stated no issues were identified. The Administrator stated he was notified by the corporate compliance line of an employee reporting their concern that Resident #1's alleged perpetrator was not suspended after Resident #1's allegation. He stated that was when it was presented as abuse. The Administrator reviewed the nursing facility abuse policy and read it was the responsibility of the facility to report allegations of abuse with no serious injury within 24 hours from allegation was made. He stated he was the Abuse Coordinator. He stated safe surveys for residents were completed after self-reporting on 10/13/25, and no issues were identified. He stated no allegations of ANE were reported to him or the DON on 10/01/25. The Administrator stated staff were trained to report allegations of ANE to himself as the Abuse Coordinator, the DON, and their immediate supervisor. He stated LVN B was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676060 If continuation sheet Page 4 of 5 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 11/20/2025 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete not suspended because the initial and the 5-day paperwork were submitted within 30 minutes on 10/13/25. He stated that himself and the DON investigated there was no abuse on 10/01/25 by reviewing progress notes, speaking with LVN B, and Resident #1 did not report allegations of abuse and Resident #1 denied that her hand was squeezed on 10/01/25, though the Administrator stated he did not speak with Resident #1 on 10/01/25.Record review of the nursing facility's policy Abuse dated October 2022, revealed the purpose of the policy was to identify, prohibit, and prevent resident abuse. Under procedure, Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual including caretaker, of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. It reflected, 4. The facility will ensure the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The policy reflected, 6. Any allegation of abuse will be immediately reported to the Administrator. The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency, law enforcement, and other officials in accordance with state law. The policy also reflected 8.a. Any reasonable suspicion of a crime will be reported to the state agency and law enforcement immediately, but no later than 2 hours after forming the suspicion if results in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Lastly, the policy reflected 9. Covered individual is anyone who is an owner, operator, employee, manager, or agent or contractor of facility. The covered individual will report the suspicion of a crime to the state agency and law enforcement within the required regulatory timeframes.Record review of the nursing facility policy Abuse Reporting with revision date October 2022, revealed the purpose of abuse reporting was to ensure allegations of abuse are reported immediately to the Administrator and/or Director of Nursing and required Agencies. Under procedure, it noted: 1. The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations of abuse to the state agencies, law enforcement, and other officials in accordance with state law. It also reflected, 4. The facility will have a process in place to report allegations of abuse, neglect, exploitation, or mistreatment including injuries of unknown origin and misappropriation of resident property, and suspected crimes to the required agencies within twenty-four (24) hours of identification if the events that cause the allegation do not involve abuse or result in serious bodily injury. Event ID: Facility ID: 676060 If continuation sheet Page 5 of 5