Health inspection·September 11, 2025

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 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 level goes below the standard range) related to a diagnosis of diabetes. Interventions included administer insulin (a treatment that helps keep blood sugar under control and prevent diabetes complications) as ordered. Record review of Resident #3's physician orders dated 7/1/25 revealed an order for Insulin Glargine Solution 100 U/mL, inject 40 units subcutaneously (administering medication into the fatty tissue just underneath the skin) one time a day for diabetes. Record review of Resident #3's Medication Administration Record dated July 2025 revealed he received Insulin injections daily between 7/1/25 and 7/31/25. Record review of Resident #3's MDS assessment dated [DATE] revealed Section N0300 regarding injections indicated he received 0 injections of any type in the last 7 days. In an interview on 9/11/25 at 9:37am, MDS Coordinator A said when she completed Section N (Medications) of the MDS assessment, she reviewed the resident's medication administration record and referenced the last 7 days. She said injection medications would include insulin. When asked about Resident #3's MDS assessment, she said she would review it for accuracy. In an interview on 9/11/25 at 9:55am, MDS Coordinator A said Resident #3 received injectable insulin during the 7-day lookback period. She said the MDS was miscoded. In an interview on 9/11/25 at 10:55am, the DON said she signed the MDS assessments to indicate they were complete. She said she did not review them for accuracy. Record review of the facility policy regarding MDS Accuracy (undated) stated, Accurate MDS assessments support individualized care planning, compliance with federal and state regulations, and appropriate reimbursement under Medicare/Medicaid.It is the policy of (company) that all MDS assessments: Accurately reflect the resident's clinical status. Residents Affected - Few Page 1 of 3 676479 676479 09/11/2025 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **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 in which the body has trouble controlling blood sugar and using it for energy) and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing a terrifying event). He was [AGE] years of age. Record review of Resident #4's Quarterly Nutrition assessment dated [DATE] completed by the Dietician revealed he was eating about 76-100% of his meals. She indicated he was at risk of malnutrition after completing a mini nutritional assessment. Record review of Resident #4's Dietary Recommendations dated 7/17/25 revealed the dietician recommended Resident #4's physician (Physician A) to order a fortified meal plan. Physician A agreed and the document was signed on 7/22/25. Record review of Resident #4's Physician Order dated 7/22/25 revealed Physician A wrote an order for Resident #4 to receive a fortified meal plan. The order was created by the ADON. Record review of Resident #4's Care Plan dated 7/23/25 revealed he required a low concentrated sweets diet with regular texture and was on a fortified meal plan. The goal was for the resident to adhere to the diet through the next review date with a target date of 10/26/25. Record review of Resident #4's Weight Summary revealed he weighed 194.2 lbs on 7/17/25 and weighed 199.8 lbs on 9/5/25. In an interview on 9/10/25 at 3:54pm, the Dietary Manager stated a fortified meal plan help residents gain weight. She said typically, the fortified meal plan consists of oatmeal for breakfast, mashed potatoes at lunch and soup for dinner. She said they also provided an ice cream nutritional supplement. She said they saw a resident's diet or meal plan printed on the ticket. She said normally, the diets would auto-transfer to the meal tickets. She said for an unknown reason, some of the fortified meal plan orders did not always transfer to the ticket. She said she double checked the meal tickets and, in some instances, had to type a note and added the fortified meal plan indicator to the ticket. She said she would provide a list of residents who were receiving a fortified meal plan. Record review of the meal tickets provided by the Dietary Manager revealed Resident #4 was not listed as receiving a fortified meal plan. In an observation and record review on 9/10/25 at 5:15pm, Resident #4 was eating dinner in the dining room. His meal consisted of a chili hot dog with a bun, tater tots, cole slaw and apple cobbler. Record review of his meal ticket next to his tray revealed it did not indicate he received a fortified meal. In an interview on 9/10/25 at 5:22pm, the ADON stated the fortified meal plan was used for weight loss to help residents boost their weight. She said when she entered a new dietary order, they communicated the new order to the Dietary Manager by printing out the order and letting her know. She said she would review Resident #4 to determine if he had received a fortified meal plan. In an interview on 9/11/25 at 10:55am, the DON said a fortified meal plan adds more calories to a meal by adding extra butter or sugar. She said once they put the order in the system, it automatically generated on the meal ticket. She said there was an error in the system for Resident #4. She was not sure why the Residents Affected - Some 676479 Page 2 of 3 676479 09/11/2025 Richard A. Anderson (State of Texas Veterans Land 14041 Cottingham Road Houston, TX 77048

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some fortified meal order did not transfer to the meal ticket. In an interview on 9/11/25 at 11:30am, the Dietician stated when she recommended a fortified meal plan, residents are eating parts of their tray but could use extra calories to maintain nutrition status. She said sometimes, they are not eating a lot but likes to add fortified, so they get extra calories. When asked about the risk of not receiving a fortified diet when one was ordered by the physician, she said it depended on each resident's situation. She said Resident #4 was gaining weight. She said she tracked resident's weights and would have changed interventions if she noticed weights trending down. In an interview on 9/11/25 at 4:05pm, the Dietary Manager stated she could not explain why Resident #4's fortified meal plan was not listed on his meal tickets. She said when plating, the cooks would not have known to provide him with fortified foods, so he was not receiving them. Record review of a facility policy regarding Nutrition Supplementation dated 6/1/2019 stated, The facility is committed to assisting residents in maintaining and maximizing their nutritional status. Supplemental nutrition will be provided in a manner that maximizes intake of the oral diet before adding other supplementation. use of fortified foods should be used to provide additional calories and protein for residents unable to meet estimated calorie and/or protein needs with current intake. 676479 Page 3 of 3