Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lamun-lusk-sanchez Texas State Veterans Home during CMS and state inspections, most recent first.
The facility's kitchen staff failed to adhere to food safety standards, with multiple dietary aides and a CNA not practicing proper hand hygiene and hairnet use. Observations revealed staff entering and exiting the food preparation area without washing hands and wearing hairnets incorrectly, despite being trained on these practices. Interviews confirmed a lack of awareness and adherence to the facility's policies, highlighting a failure in maintaining food safety standards.
The facility failed to serve meals at a palatable and safe temperature, as multiple residents reported receiving cold food during lunch. Despite the kitchen manager's assurance that food temperatures were checked, a test tray confirmed the meals were not warm enough. Staff frequently had to reheat meals, indicating a recurring issue with meal service.
A facility failed to accommodate dietary restrictions for three residents, leading to one resident experiencing anaphylaxis after consuming cheese, despite having a documented allergy. Another incident involved two residents receiving each other's meal trays, highlighting issues with meal distribution. These failures placed residents at risk and demonstrated a pattern of non-compliance with dietary management.
A long-term care facility failed to ensure that residents had properly completed Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms, with missing signatures and dates identified for several residents. This deficiency could lead to residents' end-of-life wishes not being honored. Facility staff interviews revealed that social workers were responsible for ensuring the accuracy of these forms, but they were unavailable for interviews.
The facility failed to provide food at a safe and appetizing temperature for residents, with issues observed across Regular, Mechanical Soft, and Pureed meals. Despite efforts to address complaints, residents continued to report cold meals, particularly those eating in their rooms. The Dietary Manager acknowledged the problem and noted the use of an induction cooking system, but uncertainty remained about the effectiveness and adherence to policies regarding food distribution.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to hand hygiene protocols during medication administration and laundry handling. Several staff members did not wash their hands or use hand sanitizer before preparing or administering medications, and a laundry staff member failed to wash hands before folding clean laundry. These lapses could lead to contamination and the spread of infections.
The facility failed to maintain clean lint traps in all three dryers in the laundry room, as observed during a survey. The Laundry Manager found the lint traps deeply covered with lint, requiring extensive cleaning. Interviews with the Administrator and Corporate District Manager confirmed that the facility's policy required lint traps to be cleaned after every load and every hour, with staff receiving quarterly in-service training on this procedure. The Corporate District Manager emphasized the potential fire hazard posed by uncleaned lint traps.
The facility failed to manage personal laundry effectively, resulting in unresolved grievances from two residents about missing clothing. Observations revealed a large bin of unmarked or missing clothing, and interviews with staff indicated a lack of systematic approach to returning items. The facility's policy on resolving missing clothing grievances within 24-48 hours was not followed, leading to an accumulation of unclaimed clothing.
A resident with edema did not receive consistent skin treatment as ordered by a physician, leading to discomfort and potential health risks. Miscommunication among staff regarding responsibility for the treatment resulted in it not being performed on a specific day, despite documentation indicating otherwise. The facility's policy required adherence to physician orders, but staff actions did not align with these expectations.
A resident had a PRN order for Doxepin 10mg that continued beyond 14 days without a physician's evaluation for continued treatment. Facility staff, including an LVN, the DON, and the Pharmacy LVN, were unaware of the oversight, despite being responsible for ensuring psychotropic PRN medications did not exceed 14 days without evaluation. The facility's policy emphasized compliance with regulations, which was not followed in this instance.
A resident with severe bilateral glaucoma did not receive prescribed eye drops as per physician orders, leading to a significant medication error. The resident expressed concern about the potential for increased eye pressure and blindness. The DON confirmed that staff were trained on medication administration, but the facility failed to ensure timely administration of the medication.
During a survey, five expired medications were found in a facility's medication room, including aspirin and Ferrous Gluconate. The RN verified the expiration dates and disposed of the medications. Interviews revealed uncertainty about staff routinely checking expiration dates, and no policy on expired medications was provided.
A resident with multiple health conditions did not receive consistent skin treatments as ordered by a physician, leading to discomfort and itching. The LNAR inaccurately showed the treatment as completed, which was confirmed to be false by staff interviews. The facility lacked a specific policy on documentation, contributing to the issue.
Non-Compliance with Food Safety Standards in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the kitchen, as observed during a survey. Multiple dietary aides and a CNA were observed not practicing proper hand hygiene and not wearing hairnets correctly while performing their duties in the food preparation area. Specifically, Dietary Aide A and B were seen with hair exposed outside their hairnets, and they repeatedly entered and exited the food preparation area without washing their hands. Dietary Aide C was observed performing multiple tasks without changing gloves or washing hands, and CNA D entered the food preparation area without a hairnet and did not perform hand hygiene. Interviews with the staff revealed a lack of awareness regarding their non-compliance with the facility's policies on hand hygiene and hairnet use. Dietary Aide A and B admitted to not noticing their lapses in handwashing and hairnet use, despite being familiar with the facility's policies. They acknowledged the importance of these practices in preventing contamination and foodborne illness. CNA D also admitted to not wearing a hairnet due to a lack of availability and did not perform hand hygiene upon entering the food preparation area, although she was aware of the policy requirements. The facility's policies and training records indicate that staff had been trained on proper hand hygiene and hairnet use. However, the observations and interviews suggest a failure in consistently applying these practices. The facility's system for monitoring compliance included in-services and daily monitoring, but the lapses observed during the survey indicate that these measures were not effectively ensuring adherence to food safety standards.
Deficiency in Serving Palatable and Warm Meals
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature during a lunch meal. Observations and interviews revealed that multiple residents, including those eating in the dining room and in their rooms, consistently received meals that were cold or not warm enough. This issue was highlighted by complaints from residents and family members, as well as a test tray observation that confirmed the food was not served at the appropriate temperature. Interviews with residents and staff indicated that the problem of cold food was a recurring issue. Residents reported that their meals were often served cold, affecting their enjoyment and potentially their intake. Staff members, including CNAs and LVNs, acknowledged that residents frequently complained about the temperature of their food, and nursing staff often had to reheat meals to meet residents' preferences. The kitchen manager (KM) and other administrative staff were aware of the complaints but did not provide a satisfactory explanation for the cold food. The KM stated that food temperatures were checked before serving, but the test tray results contradicted these claims. The facility's policy required food to be served at safe and appetizing temperatures, yet the process of delivering meals, especially to residents' rooms, seemed to contribute to the temperature issues. The lack of heated carts and the time taken to distribute meals may have contributed to the deficiency.
Failure to Accommodate Dietary Restrictions
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, or preferences for three residents. One resident, who had a documented allergy to cheese, experienced anaphylaxis symptoms after consuming a sandwich that allegedly contained cheese. Despite multiple preventive measures in place, including allergy information on meal tickets and staff training, the resident was served a meal that triggered a severe allergic reaction, requiring the administration of an EpiPen. The resident expressed distrust in the facility's ability to manage his dietary restrictions, citing previous incidents where cheese was served. Another incident involved two residents receiving each other's meal trays, leading to one resident consuming a meal not intended for them. This mix-up occurred despite procedures for checking tray tickets and verifying meal contents. The staff involved acknowledged the error, and it was noted that similar incidents had occurred previously, raising concerns about the facility's meal distribution process. The facility's failure to adhere to dietary restrictions and ensure accurate meal distribution placed residents at risk of adverse reactions. Interviews with staff and residents highlighted ongoing issues with meal preparation and distribution, as well as a lack of confidence in the facility's ability to manage dietary needs effectively. The incidents were identified as a pattern of non-compliance, with potential for more than minimal harm to residents.
Incomplete DNR Forms in LTC Facility
Penalty
Summary
The facility failed to ensure that all residents had properly completed Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms, which are crucial for honoring residents' end-of-life wishes. This deficiency was identified for five residents, whose forms were either missing required signatures or dates. For instance, Resident #5's OOH-DNR form lacked a date next to the legal guardian's declaration and the physician's signature. Similarly, Resident #54's form was missing a date next to the resident's signature, and Resident #84's form had no signatures from the resident or witnesses. The deficiency was further highlighted by the incomplete OOH-DNR forms for Residents #120 and #124. Resident #120's form was missing a date next to the second witness's signature, while Resident #124's form lacked witness signatures and signatures from the resident representative. These omissions could potentially lead to the residents' end-of-life wishes not being honored, as the forms were not filled out thoroughly and accurately. Interviews with facility staff, including the Administrator (ADM) and a Nursing Assistant Certified (NAC), revealed that the responsibility for ensuring the completion and accuracy of DNR forms lay with the facility's social workers. However, the social workers were unavailable for interviews as they were on leave. The ADM acknowledged the issue and confirmed that the facility was working on updating incomplete or incorrect DNR forms. The facility's policy on advance directives emphasized the importance of having current copies of all advance directives, but the failure to adhere to this policy resulted in the identified deficiencies.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable and at a safe, appetizing temperature for residents across three different food forms: Regular, Mechanical Soft, and Pureed. This deficiency was observed during a lunch meal on July 10, 2024, where the food served was not at the appropriate temperature, with the Mechanical Soft and Pureed meals being lukewarm. Residents reported consistent issues with food being served cold, which was corroborated by the Resident Council Minutes and multiple resident interviews. The Dietary Manager acknowledged awareness of complaints regarding cold food and mentioned efforts to address these issues, including the use of an induction cooking system and plate warmers. However, the system's effectiveness was questioned as residents, particularly those eating in their rooms, continued to report cold meals. The Dietary Manager also noted that the nursing staff was responsible for transporting food trays to residents' rooms, but there was uncertainty about any specific policy or procedure dictating the timeframe for tray distribution. The facility's policy on food quality and palatability emphasized the importance of serving food at safe and appetizing temperatures. Despite this, the facility's practices did not align with the policy, as evidenced by the test tray results and resident feedback. The potential negative outcomes of serving cold food, such as decreased food intake and unwanted weight loss, were acknowledged by the Dietary Manager and the ADM, highlighting the significance of the deficiency.
Infection Control Lapses in Medication Administration and Laundry Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to hand hygiene protocols during medication administration and laundry handling. Specifically, CMA A, LVN B, and MA A did not wash their hands or use hand sanitizer before preparing or administering medications to residents. This lapse in protocol was observed during medication passes for residents with various medical conditions, including Parkinson's disease, schizophrenia, type 2 diabetes, and hypertension. Additionally, the laundry staff member failed to wash her hands before folding clean laundry and after handling dirty laundry. She was observed dragging clean clothes on the floor and folding them against her body, which could lead to contamination. The staff member admitted to not following proper hand hygiene practices and stated that she had been trained to fold clothes inappropriately by a former employee. CNA A also did not sanitize her hands between glove changes during incontinent care for a resident. Despite being trained on hand hygiene, she failed to perform the necessary steps during the procedure. Interviews with staff and management revealed that while training on infection control practices was provided, there were lapses in adherence to these protocols, potentially leading to the spread of infections.
Failure to Maintain Clean Lint Traps in Laundry Room
Penalty
Summary
The facility failed to maintain clean lint traps in all three dryers located in the laundry room, as observed during a survey. The Laundry Manager was asked to inspect the lint traps, revealing that they were deeply covered with lint underneath the lint baskets and around the fan motor. The amount of lint was significant enough to fill a five-gallon bucket, requiring the use of a shop vac to complete the cleaning process. The Laundry Manager expressed disbelief that the lint traps had not been cleaned, as staff had been instructed to clean them after every load or every hour. Interviews with the Administrator and Corporate District Manager confirmed that the facility's policy required lint traps to be cleaned after every load and every hour, with staff receiving quarterly in-service training on this procedure. The Corporate District Manager emphasized the potential fire hazard posed by uncleaned lint traps and reiterated the importance of thorough cleaning, including using a vacuum to reach all areas. A review of the facility's in-service documentation and policy highlighted the critical nature of regular lint trap maintenance to prevent fire hazards and ensure safe dryer operation.
Deficiency in Laundry Management and Resident Grievance Handling
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in the management of personal laundry. Two residents reported issues with missing personal clothing items, which were not addressed by the facility staff. Despite the clothing being marked with the residents' names, the items were not returned, and the residents expressed concerns about their limited financial means to replace the missing clothing. The residents felt that their clothing was not secure in the facility's laundry process. Observations during the survey revealed that the facility did not have an effective plan for managing missing or lost laundry. A large bin filled with unmarked or missing clothing was found in the laundry room, indicating a lack of organization and follow-up. Interviews with the laundry staff and management highlighted that there was no systematic approach to returning missing clothing to residents. The staff admitted to not having enough time to take clothing around to residents for identification, and there was no schedule in place for such activities. The facility's policy on laundry operations, which requires missing clothing grievances to be resolved within 24-48 hours, was not being followed. The policy also mandates that unmarked clothing should not accumulate in the laundry, and any unmarked items should be brought to the units for identification by CNAs. However, the facility's current practices did not align with these guidelines, leading to a significant accumulation of unclaimed clothing and unresolved grievances from residents.
Failure to Administer Ordered Skin Treatment
Penalty
Summary
The facility failed to provide necessary care and services to Resident #109, who was at risk for skin impairment due to pitting and weeping edema. Despite physician orders to cleanse and wrap the resident's legs daily, the facility did not consistently follow these orders. On 07/10/24, Resident #109 reported that the skin treatment was not performed, and observations confirmed that his legs were not wrapped as required. The resident expressed discomfort and frustration due to the inconsistency in care, which he felt hindered the improvement of his condition. Interviews with staff revealed confusion and miscommunication regarding the responsibility for administering the skin treatment. LVN B, the charge nurse, believed the treatment was the responsibility of the TN, while the TN indicated that the task was listed on the LNAR, which was under the charge nurse's duties. This miscommunication led to the treatment not being performed on the specified date, despite documentation indicating otherwise. The ADNS and DON acknowledged the oversight and the failure to ensure that physician orders were followed. The facility's policy required adherence to physician orders and professional standards of practice, yet the staff's actions did not align with these expectations. The lack of proper documentation and pre-charting of tasks before completion further contributed to the deficiency. The failure to provide the ordered skin treatment placed Resident #109 at risk for complications, such as skin breakdown and infection, as noted by the staff during interviews.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had an approved diagnosis and that PRN orders for psychotropic drugs were limited to 14 days unless evaluated and extended by a physician. Specifically, a resident had a PRN order for Doxepin 10mg that continued beyond 14 days without a physician's evaluation for continued treatment. This oversight was identified during a review of the resident's records, which showed no documentation of evaluation for the PRN Doxepin. Interviews with facility staff, including an LVN, the DON, and the Pharmacy LVN, revealed a lack of awareness and oversight regarding the PRN order for Doxepin. The staff acknowledged that they were responsible for ensuring psychotropic PRN medications did not exceed 14 days without evaluation, but the order for Doxepin was overlooked. The facility's policy on psychotropic medications emphasized compliance with state and federal regulations, including regular review and monitoring, which was not adhered to in this case.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of eye drops. The resident, a male with a history of type 2 diabetes, bilateral absolute glaucoma, and other health conditions, was not administered Brimonidine Tartrate Ophthalmic Solution 0.2% as per physician orders. The medication was supposed to be given twice daily, but records show that it was missed on multiple occasions over several days. The resident expressed concern during an interview, stating that he had not received two of his three prescribed eye drops for several days. He reported that staff informed him that the medication was out of stock and were unsure when it would be available. The resident was worried about the potential for increased eye pressure, which could lead to irreversible blindness, adding to his stress. The Director of Nursing (DON) confirmed that all medications were expected to be administered as prescribed and that staff had been trained on medication administration. The facility's policy on medication errors emphasized the importance of reporting and documenting any errors, including omissions. However, the failure to administer the prescribed eye drops was not addressed in a timely manner, leading to a significant medication error.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, including the appropriate accessory and cautionary instructions and expiration dates. During an observation on July 10, 2024, five expired medications were found in the medication room on C wing. These included aspirin, Ferrous Gluconate, and Gas Relief tablets, all of which had passed their expiration dates. The RN present verified the expiration dates and agreed to dispose of the expired medications by taking them to the ADON. Interviews with the RN, Administrator, and DON revealed that while staff are responsible for discarding expired medications, there was uncertainty about whether all staff routinely check expiration dates. The RN mentioned that she had been trained in medication storage monthly, and the ADON typically checks medications once a month. However, no policy on expired medications was provided before the survey exit, despite attempts to obtain it.
Inaccurate Documentation of Skin Treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding physician-ordered skin treatments. The resident, a male with multiple health conditions including chronic obstructive pulmonary disease, type 2 diabetes, and chronic kidney disease, was admitted to the facility with a care plan that included skin treatments for edema. However, the facility did not consistently provide these treatments, as evidenced by the resident's complaints of discomfort and itching due to inconsistent care. The licensed nurse medication administration record (LNAR) indicated that the skin treatment was documented as completed, but interviews with the charge nurse and other staff revealed discrepancies. The charge nurse admitted to possibly marking the task as completed by mistake, and the assistant director of nursing services (ADNS) confirmed that the treatment was not performed as the resident's legs were not wrapped. The staff were trained to document tasks only after completion, yet the charge nurse's initials were recorded on the LNAR, suggesting the task was done when it was not. Interviews with the director of nursing (DON) and the administrator (ADM) highlighted a lack of awareness and policy regarding accurate documentation. The facility's policy on quality of care emphasized the importance of professional standards, but there was no specific policy on documentation. This lack of documentation accuracy could lead to residents not receiving necessary care, as tasks might be marked as completed when they were not, potentially affecting the residents' health outcomes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Big Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Big Spring Center For Skilled Care | 4 mi | ★★★★★ | 7 | 0 |
| Mitchell County Nursing And Rehabilitation Center | 34.6 mi | ★★★★★ | 9 | 0 |
| Focused Care At Hogan Park | 39.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lamun-lusk-sanchez Texas State Veterans Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.