Health inspection·September 13, 2024

F 0684 Record review of Resident #1's clinical record revealed a care plan with the following: Level of Harm - Minimal harm or potential for actual harm Problem: I am incontinent of bowel and r/t Multiple Sclerosis with loss of peritoneal tone and muscle control. I will remain free from skin breakdown due to incontinence. breakdown, if I am not cleaned properly and regularly. Related To: MS. Check me during rounds and as required for incontinence. Provide peri care with each incontinent episode. Change clothing PRN after incontinent episode. Revised on 9/03/24 observe skin while providing peri care and report signs of breakdown to the Nurse. Residents Affected - Few Record review of Resident #1's clinical record revealed Active Orders with start dates from 5/21/24, 6/29/24. There were orders for catheter care, monitoring, or maintenance. Suprapubic Catheter 24Fr 10cc, change monthly and PRN every 1 hours as needed. Record review of Resident #1's Progress Note on 09/13/24 at 9:22 am revealed his foley was leaking around the insertion site. The foley was changed using sterile technique. During an observation on 09/12/24 at 9:19 AM, Resident #1 was in bed sleeping. A urinary catheter was noted hanging from the side of Resident #1's bed in a privacy bag. Observations and Interviews revealed sampled resident were clean and dry. During an observation on 09/13/24 am, Resident #1 was lying in bed watching TV. CNA G checked resident #1s catheter to ensure it was not leaking. During an interview on 09/12/24 at 11:43 AM, the DON stated a resident with a catheter should have orders for the catheter. Yes, they should have an order for a catheter and the care. The DON said the alleged CNA L on 08/20/2024 did not check Resident #1 during her rounds that morning. Resident 1 was found with a saturated brief and bed linens. The DON said the CNA L was terminated. During an interview on 09/12/24 at 3:30 pm, ADM stated CNA L did not do her job on 8/20/24 and was suspended due to pending investigation and then was terminated on 8/30/2024. During an interview on 09/12/24 at 9:23 am, RN B she said she completed a full skin assessment Resident #1 on 8/20/2024 after the CNAs finished cleaning him up. RN B stated the skin assessment did not reveal any skin breakdown and that Resident #1's skin was clear. RN B stated that there were multiple areas of blanchable redness with no skin breakdown. During an interview on 9/13/24 at 9:51 am, CNA I stated that when she was passing meal trays on 8/21/24 around 11:30 am, she found Resident #1 soaking in urine in his bed. CNA I stated she reported the incident to the nurse. CNA I stated the nurse assessed the resident after they cleaned him up. Record review of the facility's Provider Investigation Report revealed the following. The Provider Investigation Report was completed and signed on 8/26/24. The facility's investigation revealed that CNA L failed to check on Resident #1 in the morning of 8/20/24, resulting in Resident #1 being left unattended for an extended period of time. When assessed by RN B, Resident #1 was noted to have a large urine stain under him on the bottom sheet. RN B assessed Resident #1's suprapubic catheter and found it to be leaking. A skin assessment performed by RN B noted multiple areas of blanchable redness, no open areas. The Provider Investigation Report further documented that CNA L was immediately suspended pending the outcome of the investigation. The Provider Investigation Report documented this interview with CNA L by Admin: 8/20/24 2:15pm {Admin} met with {CNA L} related to an alleged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 2 of 3 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 676157 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124 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 abuse/neglect allegation .{Adm} asked {CNA L} if she had checked on Resident #1 this morning. {CNA L} replied that she did not go into Resident #1's room as she got busy Record review of Resident #1's nursing progress notes dated 8/20/24 at 12:44pm by RN B revealed, This nurse assessed resident head to toe after report of not being changed . Residents Affected - Few Record review of facility provided in-service titled Resident Rights-Abuse/Neglect, Rounding, Catheter Care conducted on 8/21/24 revealed the facility's abuse/neglect policies were reviewed. Record review of the facility provided policy titled, Resident Rights undated, revealed the following: Right of the Elderly. b. An elderly individual has the right to be treated with dignity and respect . 2. has the right to be free from abuse, neglect . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676157 If continuation sheet Page 3 of 3