Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: May 16, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically reviewing compliance with transmission-based precautions and PPE use for Resident #1 who required enhanced barrier precautions.
Findings
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff members (LVN I and CNA M) not donning appropriate PPE before entering Resident #1's room on two separate occasions, potentially placing residents at risk for infection through cross-contamination.
Deficiencies (2)
LVN I failed to don appropriate PPE before entering Resident #1's room and administering medication on 03/10/25 at 7:27 PM.
CNA M failed to don appropriate PPE before entering Resident #1's room to provide care on 05/11/25 at 8:02 PM.
Report Facts
Residents reviewed for infection control: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN I | Licensed Vocational Nurse | Failed to don appropriate PPE before entering Resident #1's room and administering medication |
| CNA M | Certified Nursing Assistant | Failed to don appropriate PPE before entering Resident #1's room to provide care |
| DON | Director of Nursing | Acknowledged PPE failures by LVN I and CNA M and confirmed staff in-service training on infection control |
| CNA B | Interviewed regarding PPE use for residents on Enhanced Barrier Precautions | |
| CNA C | Interviewed regarding PPE use for residents on Enhanced Barrier Precautions | |
| CNA K | Interviewed regarding PPE use for residents on Enhanced Barrier Precautions | |
| LVN F | Interviewed regarding PPE use during medication administration | |
| ADON E | Assistant Director of Nursing | Reported frequent in-services and spot checks on PPE and incontinent care |
| ADON G | Assistant Director of Nursing | Reported ongoing EBP training and spot checks for medication administration |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 21, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medical record accuracy, infection prevention and control, and environmental safety at Alfredo Gonzalez Texas State Veterans Home.
Findings
The facility failed to maintain accurate medical records for Resident #1 by continuing to log refrigerator temperatures after the refrigerator was removed. The facility also failed to ensure proper use of PPE by a licensed vocational nurse during care of Resident #1's PEG tube, risking infection transmission. Additionally, the facility did not maintain a sanitary environment in one resident's shower where a dirty towel was left for an extended period.
Deficiencies (3)
Failure to accurately document refrigerator temperatures after the refrigerator was taken home by Resident #1's family.
Failure to don appropriate PPE (gown and gloves) by LVN A when providing care to Resident #1's PEG tube on multiple occasions.
Failure to maintain a sanitary environment in room [ROOM NUMBER]'s shower due to a dirty towel with brown colorations left in the shower area.
Report Facts
Residents reviewed: 5
Dates of PPE failures: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to wear proper PPE when providing care to Resident #1's PEG tube |
| LVN C | Licensed Vocational Nurse | Documented progress note when Resident #1's refrigerator was taken home |
| DON | Director of Nursing | Provided interviews regarding PPE use and refrigerator documentation issues |
| ADM | Administrator | Provided interview regarding refrigerator temperature documentation and environmental concerns |
| ADON | Assistant Director of Nursing | Provided interviews and in-services on infection control and PPE; confirmed PPE failures by LVN A |
| HK J | Housekeeper | Interviewed about cleaning practices related to room [ROOM NUMBER] |
| HK S | Housekeeper | Interviewed about cleaning practices and dirty towel in room [ROOM NUMBER] |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 30, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to have physician orders for residents' immediate care at admission, failure to follow policy on storage of personal food brought by visitors, and failure to implement an infection prevention and control program.
Complaint Details
The complaint investigation found substantiated deficiencies related to missing physician orders for enhanced barrier precautions for Residents #4 and #5, failure to follow personal food storage policies for Resident #3, and failure of staff to wear appropriate PPE during care of Residents #3 and #5 on enhanced barrier precautions.
Findings
The facility failed to have physician orders for enhanced barrier precautions for two residents at admission, failed to properly document temperature checks for a resident's personal refrigerator, and failed to ensure staff wore appropriate PPE during care of residents on enhanced barrier precautions, placing residents at risk of infection.
Deficiencies (3)
Failure to have physician orders for enhanced barrier precautions for Resident #4 and Resident #5 at time of admission.
Failure to follow policy regarding storage and temperature monitoring of foods brought by family for Resident #3, with incomplete temperature logs.
Failure to provide and implement an infection prevention and control program, including staff not wearing appropriate PPE during care of Residents #3 and #5 on enhanced barrier precautions.
Report Facts
Residents reviewed for physician admission orders: 5
Days with logged temperature checks: 4
Residents reviewed for infection control: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Observed failing to don appropriate PPE when providing care to Resident #5's PEG tube; received retraining after observation. |
| LVN B | Licensed Vocational Nurse | Observed failing to don appropriate PPE when providing care to Resident #3's midline; acknowledged forgetting gown and undergoing retraining. |
| ADON D | Assistant Director of Nursing | Confirmed Residents #4 and #5 should have orders for enhanced barrier precautions; input orders after surveyor notification; discussed staff training and policy adherence. |
| DON | Director of Nursing | Confirmed policy requirements for enhanced barrier precautions orders and PPE use; acknowledged facility policy was not followed; described staff training and oversight. |
| RN E | Infection Preventionist Nurse | Reported LVN A's failure to wear gown during care of Resident #5; provided retraining; described importance of PPE and facility policy. |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted to assess compliance with respiratory care standards and nurse staffing posting requirements at the Alfredo Gonzalez Texas State Veterans Home.
Findings
The facility failed to ensure a resident (Resident #49) received oxygen at the prescribed rate, posing a risk for respiratory distress. Additionally, the facility failed to post nurse staffing information daily on 10/2/24 and 10/3/24, risking lack of transparency for residents and visitors.
Deficiencies (2)
Failed to provide safe and appropriate respiratory care by not ensuring Resident #49 received oxygen at the prescribed rate.
Failed to post nurse staffing information every day, specifically on 10/2/24 and 10/3/24.
Report Facts
Residents reviewed for respiratory care: 4
Oxygen flow rate prescribed: 2
Oxygen flow rate observed: 3
Days nurse staffing information not posted: 2
Days reviewed for nurse staffing information: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Nurse assigned to Resident #49 who checked oxygen rate and vital signs. |
| LVN C | Licensed Vocational Nurse | Nurse responsible for ensuring oxygen rates were accurate for her residents. |
| ADON D | Assistant Director of Nursing | Provided information on nurse responsibilities for oxygen rate accuracy. |
| DON | Director of Nursing | Stated nurses are responsible for ensuring oxygen flow rates and staffing postings. |
| CNA A | Certified Nursing Assistant | Responsible for updating nurse staffing information but failed to update on 10/2/24. |
| Administrator | Acknowledged staff posting was a regulation and admitted it was not updated daily. |
Inspection Report
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether a comprehensive person-centered care plan was developed and implemented for residents, including addressing specific needs such as smoking.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and time frames for one resident (Resident #1), specifically failing to address his smoking needs. Interviews with staff confirmed that smoking should be included in the care plan, but it was not documented.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically not addressing Resident #1's smoking needs.
Report Facts
Residents affected: 1
Residents reviewed: 5
Cigarettes smoked per day: 4
Inspection Report
Routine
Deficiencies: 7
Date: Jul 17, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, accommodation of resident needs, care planning, supervision to prevent accidents, medication management, infection control, and smoking policies.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inadequate accommodation of resident needs, incomplete care plans, inadequate supervision leading to elopements, expired medications in storage, failure to follow infection prevention protocols, and failure to adhere to smoking policies.
Deficiencies (7)
Failure to ensure residents were treated with respect and dignity, including failure to cover catheter drainage bags and knock before entering rooms.
Failure to reasonably accommodate resident needs, including inaccessible restroom door handles and call lights out of reach.
Failure to develop and implement a comprehensive person-centered care plan addressing resident smoking needs.
Failure to provide adequate supervision to prevent elopements for residents with exit-seeking behaviors.
Failure to ensure all drugs and medical devices were labeled and stored properly, including expired medications found in medication rooms.
Failure to establish and maintain an infection prevention and control program, including failure of staff to perform hand hygiene and change gloves appropriately.
Failure to follow established smoking policies, including residents possessing cigarettes and lighters unsupervised.
Report Facts
Residents reviewed for dignity issues: 13
Residents reviewed for accommodation of needs: 8
Residents reviewed for care plans: 5
Residents reviewed for elopement and supervision: 8
Expired Acetaminophen suppositories: 24
Expired intravenous fluid bag: 100
Residents observed for infection control: 25
Residents reviewed for safe smoking: 6
Residents who smoke: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Named in findings related to failure to knock before entering Resident #114's room and catheter bag privacy | |
| CNA A | Named in findings related to catheter bag privacy and call light placement for Resident #114 | |
| DON | Director of Nursing | Provided statements on dignity, privacy, catheter bag coverage, call light placement, and infection control |
| CNA B | Provided statements on catheter bag privacy and call light placement | |
| ADON D | Assistant Director of Nursing | Provided statements on catheter bag privacy and call light placement |
| Maintenance A | Mentioned in relation to Resident #54's restroom door handle issue | |
| Maintenance Supervisor | Mentioned in relation to Resident #54's restroom door handle issue | |
| RN B | Registered Nurse | Responsible for checking medication rooms for expired medications |
| CNA C | Named in infection control deficiency related to glove use and hand hygiene | |
| CNA D | Named in infection control deficiency related to glove use and hand hygiene | |
| LVN P | Mentioned in elopement incident involving Resident #76 | |
| RN L | Mentioned in elopement incident involving Resident #93 | |
| Floor Tech D | Mentioned in elopement incident involving Resident #93 | |
| LVN A | Mentioned in relation to Resident #1's smoking materials |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 1, 2022
Visit Reason
Annual inspection survey of Alfredo Gonzalez Texas State Veterans Home to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Viewing
Loading inspection reports...
