Health inspection·February 5, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to remove previously applied Rivastigmine Patches for Resident #1 as ordered by the physician.This failure could place residents at risk for medication duplication, adverse drug reactions, and potential side effects. Findings included:Record review of Resident #1's Face Sheet, dated 02/05/26, reflected the resident was an [AGE] year-old male admitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 01/23/26, reflected the resident had diagnoses of Alzheimer's Disease (progressive brain disorder that causes memory loss and confusion), PTSD (mental health condition caused by experiencing or witnessing a traumatic event), and Gastro-esophageal reflux disease (condition where stomach acid flows back into esophagus). The MDS also reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #1's Care Plan, undated, reflected the resident was at risk for adverse side effects related to medications with a goal that Resident #1 would be free of side effects related to psychoactive medications. The care plan also reflected Resident #1 had an ADL self-care performance deficit related to Alzheimer's and disease related medications. Further record review reflected Resident #1 had impaired cognitive function or impaired thought processes related to Alzheimer's with an intervention to administer medications as ordered and monitor for/document side effects and effectiveness. Record review of Resident #1's Physician Orders, dated 02/05/26, reflected the following order, Exelon Transdermal Patch 24 hour 9.5MG/24HR (Rivastigmine) Apply 1 patch transdermally [on the skin] one time a day. and remove per schedule. Record review of Resident #1's MAR, dated 02/2026, reflected the Rivastigmine patch (Medication used to help improve memory and thinking in people with dementia) was to be removed daily at 8:59 a.m. and applied daily at 9:00 a.m Record review of Resident #1's MAR further reflected on 02/04/26 the patch was removed at 8:13 a.m. from the right scapula and a new patch was applied at 8:13 a.m. to the left scapula by MA B. This MAR reflected no Rivastigmine patch applications documented to Resident #1's left arm. During an observation on 02/05/26 at 9:29 a.m. LVN A applied Resident #1's Rivastigmine 9.5 mg patch. LVN A performed hand hygiene prior to entering room, applied clean gloves and assisted Resident #1 with removing his jacket. LVN A performed a skin assessment, and a Rivastigmine patch was located on the back of Resident #1's upper left arm. Observation revealed the date on the patch appeared smeared and was illegible. LVN A then located a second Rivastigmine patch on Resident #1's left scapula dated 2/4. LVN A removed both patches and applied a new Rivastigmine patch to Resident #1's right upper arm. LVN A removed gloves and performed hand hygiene prior to exiting the room. During an observation and an attempted interview on 02/05/26 at 9:40 a.m., Resident #1 was in the common area in his wheelchair. Resident #1 was a poor historian and unable to answer questions. (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 2 Event ID: 745057 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 745057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tuskegee Airmen Texas State Veterans Home 2200 Joe B Rushing Road Fort Worth, TX 76119 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)