Richard a. Anderson (State of Texas Veterans Land

In the surveyor’s words

From the most serious findings on record at Richard a. Anderson (State of Texas Veterans Land, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 23, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 2 (Resident #1 and Resident #2) of 7 residents reviewed for accidents hazards/supervision in that: -Resident #1 who resided in the Memory Care Unit was let out of the facility by CNA A on 2/16/24 at 6:45 pm and located by the Resident Representative around 8:30 pm on the corner of a major high traffic street corridor approximately 1/2 mile away. -The facility failed to prevent Resident #2 in Memory Care Unit from ingesting shampoo on 5/17/24 which resulted in emergency treatment services at the local hospital. An Immediate Jeopardy was identified on 06/21/24 at 3:49 pm. […]

• Immediate jeopardy, isolatedF689Jun 14, 2021

  Based on interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of 10 residents (CR #1) reviewed for accidents and hazards. CR #1 who was cognitively impaired and unable to walk due to previous fall with fracture was not provided effective interventions to prevent accidents and he sustained multiple unwitnessed falls and injures of unknown origin in the facility which included head/face lacerations, subdural hematoma, skin tears, and fractured clavicle . CR #1 was observed by a nursing staff crawling out of his room on the floor and staff failed to intervene and/or provide continued supervision to ensure his safety. […]

• No harm, potential for more than minimal, patternF692Sep 11, 2025

  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. […]

• No harm, potential for more than minimal, patternF609Jun 23, 2024

  Based on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately or no later than 24 hours after the allegation was made for 2 of 7 residents (CR#1 and Resident #2) reviewed for reporting in that: -The facility failed to report to the State agency CR #1's fall incident with serious injury (a left distal clavicle fracture) resulting in hospitalization on [DATE]. -The facility failed to report to the State agency Resident #2's incident of ingesting a non-food item and was transported via emergency services for hospital treatment. These failures could affect all residents and could result in undetected neglect and emotional distress leading to serious harm/injury. […]

• No harm, potential for more than minimal, patternF690Jun 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder and had a catheter upon admission, received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #29 and #50) of 3 residents reviewed for incontinent care. -The facility failed to ensure Resident #29's foley bag and tubing was not placed on the floor. -The facility failed to ensure CNA C followed appropriate infection control procedures during foley care for Resident #29. -The facility failed to ensure Resident #50's foley bag was positioned below the bladder. These failures could place residents at risk for pain, infection, injury, and hospitalization . […]