Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ussery Roan Texas State Veterans Home during CMS and state inspections, most recent first.
Missed Daily Glucometer QC Checks: The facility failed to complete required nightly QC checks on glucometers for 3 of 4 med carts reviewed, with missing control log entries across multiple months for Hall 400, Hall 500, and Hall 600. Staff stated the checks were to be done every night shift, and the manufacturer’s guidance for the Assure Platinum glucometers used on all carts required QC every 24 hours.
Outdated Daily Menu Posted on Locked Unit: The facility failed to keep the posted menu current in a locked unit dining area, where the same Saturday menu remained displayed for several days instead of the correct daily menu. CNA, LVN, DM, and ADM all confirmed the menu should have been updated daily by dietary staff, and staff noted residents became frustrated when the meal served did not match the posted menu.
Food Items Stored Without Labels or Dates: Surveyors observed multiple items in the prep area, pantry, freezer, and refrigerator that were not labeled or dated, including bread, snacks, cereal, frozen meats, shrimp, eggs, milk, and health shakes. Staff and the DM stated that labeling and dating food was everyone's responsibility, and facility policies required leftovers, dry storage items, refrigerated foods, and frozen foods to be labeled and dated.
Uncovered catheter bag visible during meal service: A resident with severe cognitive impairment, hemiplegia, obstructive/reflux uropathy, BPH, and an indwelling Foley had his catheter bag left uncovered and visible in the dining room during the noon meal, with urine seen in the bag and nearby residents able to observe it. A CNA stated the bag was usually placed in a privacy bag and that it had likely been forgotten, noting it was a dignity issue because others could see the urine.
Opened Resident Mail: Two cognitively intact residents did not receive unopened correspondence. One resident received VA mail that had been opened and taped shut, and staff and family still had the envelope. For another resident, staff opened and sorted cards and letters from the public, said some were inappropriate, and did not ask the resident whether he wanted the mail opened or read to him. Staff acknowledged residents have the right to receive mail unopened, and facility records showed no care plan focus related to mail privacy.
A resident’s MDS was incorrectly coded to show dialysis in Section O, item J1 even though the resident stated he had never received dialysis at the facility or before admission. The resident had a BIMS of 15, and his care plan contained no dialysis-related focus areas, goals, or interventions. The MDS RN said the entry was likely a data entry error, and the ADM, DON, Clinical VP, and MDS Director all identified the MDS RN as responsible for accurate coding with oversight from leadership.
Failure to consistently provide ordered nutritional supplements and reconcile intake documentation led to significant weight loss for a resident with severe cognitive impairment and multiple chronic conditions. Staff observed the resident struggling to eat at times, yet meal tickets, ADL records, and MAR documentation did not match: the resident was served the wrong supplement flavor, ordered Magic Cups were missed, and supplement refusals were not reported to the MD or RD. The RD had ordered health shakes BID, Magic Cups with meals, and an appetite stimulant, but staff documentation showed inconsistent delivery and inaccurate meal consumption records.
Failure to Use Required PPE During Foley Catheter Care: A CNA provided incontinent and urinary catheter care to a resident with a Foley catheter without wearing a gown despite EBP signage and PPE being available. The resident had severe cognitive impairment, was dependent for ADLs, and had active orders for EBP. Staff interviews showed inconsistent understanding of EBP requirements for residents with indwelling urinary catheters, with some staff stating only gloves were needed or that EBP applied only with active infection.
A resident with cognitive impairment and multiple medical conditions was able to exit the facility unsupervised due to an unlocked back door and lack of staff presence at the entrance, despite being identified as an elopement risk in the care plan. The resident was found outside, disoriented, and later required hospital treatment for a subdural hematoma.
A resident with multiple medical conditions, including paraplegia and a suprapubic catheter, was left in a saturated brief and bed linens due to a CNA's failure to perform necessary catheter care. The resident's care plan required regular checks to prevent skin breakdown, but the CNA did not follow these orders, resulting in the resident being found in a state of neglect. A subsequent skin assessment showed areas of blanchable redness, although no skin breakdown was noted.
The facility failed to properly store Hydrocodone-Acet 325mg, a controlled substance, by placing it with non-controlled discontinued medications in a medication room bin. RN D initially made the error, which was later corrected by RN E, who retrieved the medication and placed it under ADON G's door. The medication was eventually given to the Pharmacy Nurse. The facility's policy requires controlled medications to be stored in locked, permanently affixed compartments, which was not followed in this instance.
Missed Daily Glucometer QC Checks
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs by not completing required daily QC checks on glucometers for 3 of 4 medication carts reviewed: Hall 400, Hall 500, and Hall 600. Record review showed missing glucometer control log entries across multiple months from December 2025 through July 2026 for these carts, while the Hall 800 medication cart had available logs that were completed. The facility’s policy directed staff to follow the manufacturer’s directions and recommendations for glucometer use and cleaning, and the manufacturer’s guidelines for the Assure Platinum glucometers used on all 4 carts stated that QC checks should be completed every 24 hours. The missing Hall 400 log entries included numerous dates in December 2025, January through July 2026, with repeated gaps across the review period. Hall 500 logs were also missing entries on multiple dates in January, February, April, May, June, and July 2026. Hall 600 logs were missing entries in December 2025 and February through July 2026, including several consecutive dates in March 2026. These omissions were identified during record review of the glucometer control logs for the medication carts. During interviews, LVN F, LVN E, RN P, RN R, the ADON, Unit Manager RN M, and Unit Manager LVN N all stated that glucometers should be checked every night shift and that the checks were to be completed by the nurse. Staff also stated that preceptors training new employees were responsible for teaching the QC process, and unit managers or the RN house supervisor were expected to ensure the checks were completed. Staff further stated that failure to complete the checks could result in inaccurate blood sugar readings and incorrect insulin dosing.
Outdated Daily Menu Posted on Locked Unit
Penalty
Summary
The facility failed to ensure current daily menus were posted in the locked unit dining area. During observations on 07/28/26 and 07/29/26, the posted menu continued to display Saturday, July 25, 2026, including a lunch item of ham, instead of the current day's menu. The menu remained unchanged for 4 consecutive days in the locked unit dining area. During interviews, CNA D stated the menu did not reflect the correct day and should have displayed Wednesday's menu, and that residents would not know what meals were being served if menus were not updated daily. LVN E, the charge nurse for the locked unit, confirmed the menu remained on Saturday's menu and stated residents had become frustrated because they expected ham as posted and could become fixated on the menu and upset when the meal served did not match. The DM and ADM both acknowledged dietary staff were responsible for updating menus daily, and the ADM stated residents relied on the posted menu and expected to receive the meal listed. Record review showed the facility's menu planning policy required current menus to be posted during the appropriate time period.
Food Items Stored Without Required Labels or Dates
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service standards for 1 of 1 kitchen reviewed. During observation of the prep area, pantry, freezer, and refrigerator, surveyors found multiple food items that were not labeled or dated, including creamers, bread, a white substance in a clear bin, snacks, chips, cereal, marshmallows, cream of wheat, grits, oats, meat patties, shrimp, frozen biscuits, a cake, ice creams, cobbler, an undetermined box of items, uncovered eggs, milk, covered cups of liquid, and health shakes. The observations showed that food items were being stored in a manner that did not include required labeling and dating. Staff interviews confirmed that labeling and dating food was expected practice in the kitchen. Kitchen staff stated they had been trained to label and date food when delivered and to label and date leftover food, and that everyone working in the kitchen was responsible for doing so. The DM also stated it was everyone's responsibility to label and date all food in the kitchen. Facility policies titled General Food Preparation and Handling and Food Storage stated that leftovers must be dated, labeled, covered, cooled, and stored in a refrigerator, and that dry storage, refrigerated foods, and frozen foods must be labeled and dated.
Uncovered catheter bag visible during meal service
Penalty
Summary
The facility failed to treat a resident with respect and dignity when his indwelling catheter bag was left uncovered and visible in the dining room during the noon meal. Resident #52 was a male resident with diagnoses including hemiplegia, obstructive and reflux uropathy, and benign prostatic hyperplasia. His annual MDS showed a BIMS of 4, indicating severe cognitive impairment, and he was dependent on staff for toileting hygiene and required an indwelling catheter. His care plan identified the indwelling catheter related to obstructive uropathy, and his active orders included Foley catheter care with perineal wipes and/or soap and water each shift and as needed. During observation, Resident #52 was seated in a Geri-chair in the dining room with approximately 40 residents and 7 staff present, and his catheter bag was hanging from under the chair in view of the dining room with a small amount of amber urine visible in the bag. Eleven residents seated at nearby tables could observe the uncovered catheter bag while eating. When CNA G was asked to assess the resident, she stated the catheter bag was usually in a privacy bag and that staff must have forgotten to cover it, adding that it was a dignity issue because other people could see the urine in the bag. A later observation showed the catheter bag hanging from the side of the resident’s bed without a privacy bag, though it was not visible from the hallway or room.
Opened Resident Mail
Penalty
Summary
The facility failed to allow two residents to receive unopened mail at the facility. For Resident #35, record review showed a male resident with diagnoses including COPD, hypertension, age-related physical debility, and cognitive communication deficit, while his annual MDS assessment showed a BIMS score of 15, indicating he was cognitively intact. His care plan contained no focus or intervention related to his ability to receive mail in the facility. Resident #108 was also cognitively intact, with a BIMS score of 14, and had diagnoses including Type 2 diabetes, Parkinsonism, and PTSD; his care plan likewise contained no focus or intervention related to receiving mail in the facility. Resident #108 stated he received a piece of mail from the VA that had been opened and taped shut, and his family member had the opened envelope. The envelope was observed and appeared to have been opened with a letter opener and then taped. The REC stated that she and the security guard handled mail, that she sorted mail when it was received, and that mail addressed to residents was opened and then sent to the corporate office or to family members. She also stated that residents have the right to receive mail unopened and that she did not understand why Resident #108’s mail was opened. For Resident #35, staff stated that cards and letters from the public were opened and sorted because some were considered inappropriate, and that staff did not speak with Resident #35 before opening them. AA R stated the resident was not asked whether he wanted the cards opened in front of him or filtered, and acknowledged that residents have the right to open their own mail. Resident #35 stated he received cards that were opened. The AD stated staff had a meeting and said the cards must be read to him, while the ADM stated the resident should have made the decision about whether to read the cards and that one card was filtered out. The FM stated the facility had permission to do everything they did and that the facility read a bad card and the FM told the facility not to read it to him.
Inaccurate MDS Coding for Dialysis Status
Penalty
Summary
The facility failed to ensure that Resident #4’s MDS assessment accurately reflected his status when Section O, item J1 was coded to indicate that he received dialysis while a resident in the facility during the 14-day look-back period. Record review of the resident’s admission information showed he was a male admitted with diagnoses including rheumatoid arthritis, depression, and atrial fibrillation. His quarterly MDS assessment dated 06/11/2026 showed a BIMS score of 15, indicating he was cognitively intact. Review of the resident’s comprehensive care plan dated 07/25/2026 showed no focus areas, goals, or interventions related to dialysis. During observation and interview on 07/28/2026, the resident was sitting in his wheelchair, appeared clean and well groomed, and stated he had never received dialysis while residing at the facility or prior to admission. The MDS RN later stated the assessment was incorrectly documented as dialysis and said the error was likely a data entry mistake because the resident was not receiving dialysis care. During interviews, the ADM, DON, Clinical VP, and MDS Director all stated that the MDS RN was responsible for ensuring assessments were accurate, with oversight from the MDS Director and DON. The MDS Director stated the MDS assessment is the foundation of the RAI process and that inaccurate information could affect the care plan. The facility’s RAI Manual stated that O0110J1 is used to code peritoneal or renal dialysis received at the nursing home or another facility, and may be coded if the resident performs his own dialysis.
Failure to Consistently Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident with significant weight loss by not consistently providing ordered supplements and by not accurately matching meal ticket preferences with what was served. Resident #13 was admitted with multiple chronic conditions, including dementia, cerebral infarction, atrial fibrillation, stage 4 kidney disease, anemia in chronic kidney disease, generalized muscle weakness, and cognitive communication deficit. His quarterly MDS showed a BIMS score of 6, indicating severely impaired cognition, and his care plan identified weight loss interventions, including monthly weight monitoring and offering snacks if he ate less than 50% of meals. During dining observation, the resident was seen struggling to eat meatloaf and unable to get food onto his fork, though he could eat bread without difficulty and appeared frustrated. Record review showed progressive weight loss over 1, 3, and 6 months. The RD had seen him monthly and recommended supplemental health shakes BID with meals, Magic Cups with meals, and an appetite stimulant, and the physician ordered those interventions. However, during meal observations, staff served a chocolate supplement when the meal ticket showed a strawberry preference, did not offer the strawberry shake, and failed to provide the ordered Magic Cup. At another meal observation, staff again failed to provide either the health shake or the Magic Cup as printed on the meal ticket. Documentation also showed inconsistencies between the ADL meal consumption records and the MAR, with ADL records indicating the resident ate 51% or more of meals while the MAR showed that supplements were sometimes refused and sometimes received. Staff interviews revealed that refusals were not reported to the physician or RD, despite policy requiring reporting and documentation of adverse side effects or medication/supplement refusals. The unit manager stated she was unaware the resident was not receiving the supplements and said she would have reported it if she had known.
Failure to Use Required PPE During Foley Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed. During an observation, a CNA provided incontinent and urinary catheter care to a resident with an indwelling Foley catheter without applying a gown, even though Enhanced Barrier Precautions signage was posted on the door and PPE was available outside the room. The resident had severe cognitive impairment with a BIMS score of 4 and was dependent on staff for toileting, bathing, dressing, and eating. Record review showed the resident had diagnoses including hemiplegia, hemiparesis following cerebral infarction, dysphagia, hypothyroidism, iron-deficiency anemia, hyperlipemia, depression, and generalized muscle weakness. The resident’s care plan identified extensive staff assistance needs and indicated Enhanced Barrier Precautions requiring a gown and gloves during high-contact resident care. The medical record also showed active physician orders for Enhanced Barrier Precautions due to the presence of a Foley catheter. Interviews with multiple CNAs and nursing staff showed inconsistent understanding of when Enhanced Barrier Precautions were required for residents with indwelling urinary catheters. Some staff stated that all residents with Foley catheters should be on EBP with gown and gloves, while others stated only gloves were needed or that EBP was not needed unless there was an active infection. The SDC stated she trained staff on hand hygiene, glove use, and wiping front to back, and stated that not all residents needed EBP unless they had an active infection.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Hazards
Penalty
Summary
A deficiency occurred when a resident with a complex medical history, including sequelae of intracerebral hemorrhage, hypertension, diabetes, and cognitive impairment, was able to elope from the facility. The resident had a care plan that identified him as an elopement risk due to a history of attempts to leave the facility unattended. Interventions listed included distraction, structured activities, reorientation strategies, and the use of a wander guard. However, on the day of the incident, the resident was able to leave the facility premises without staff knowledge. Staff interviews and record reviews revealed that the resident was last seen by an LVN, who noted the resident was searching for someone and then ambulated away. Later, the resident's spouse contacted the facility after receiving a call from the resident, who was outside and disoriented. Facility staff initiated a search and found the resident approximately 500 feet from the building, sitting on the ground. The resident was assessed and found to have no physical injuries at that time, but was noted to be more confused than usual. The resident was sent to the hospital for further evaluation due to an elevated INR and was subsequently treated for a subdural hematoma. Observations of the facility environment revealed that the back door between two halls was always kept unlocked, and the patio area had no gate, allowing direct access to the parking lot and surrounding areas. The lack of physical barriers and the absence of staff at the front entrance after the concierge left contributed to the resident's ability to exit the building unnoticed. The facility's elopement evaluation for the resident did not identify him as an elopement risk, despite his care plan indicating otherwise, and the unsecured environment allowed the incident to occur.
Removal Plan
- Resident was assisted to re-enter the facility and assessed per RN with no injury noted.
- The MD and responsible party were notified with new orders for resident to be sent to the ER due to deviation from baseline mental status.
- One-on-one initiated pending ER transfer, wander guard placement prior to ER transfer.
- Resident returned from hospital and discharged home with wife.
- The resident's care plan was updated to include personalized interventions and potential triggers for exit seeking behavior by the DON and/or Social Worker.
- All available staff were trained on elopement procedures and all other staff will be trained before their next scheduled shift on elopement procedures and managing exit seeking behaviors by the DON and/or designee.
- Social Worker was educated by DON on resident specific care plan interventions and identify triggers related to exit seeking behaviors.
- An Elopement Drill was conducted on each shift by DON and/or designee.
- Elopement Risk book reviewed and updated by Social Worker/Designee. This book contains identification information on residents at risk for wandering. Picture of resident as well as face sheet are included. Book is available to all staff with copy at receptionist desk and on each nursing unit.
- All available staff were trained on the elopement book by DON/Designee. All other staff were trained before their next scheduled shift on the elopement book.
- All doors with the wander guard system were checked to ensure proper function by facility maintenance staff. All door wander guards were functioning properly.
- Elopement risk was completed on all residents by DON/Designee. Any resident identified with elopement risk had interventions added. These include but are not limited to Wander Guard, Secure Unit, frequent checks, and the Care Plan updated. These updates reflect resident specific interventions. Residents with any risk had interventions implemented.
- Security Staff job opening posted on hiring platforms for nighttime rounding, monitoring interior and exterior of facility examining doors to ensure they are functioning, secured and untampered.
- All Security job openings were filled, and orientation completed. All rounding sheets reviewed with no concerns, elopements, or significant findings.
- Elopement policy was reviewed with no updates required by the Regional Clinical Consultant.
Failure to Provide Catheter Care Leads to Resident Neglect
Penalty
Summary
The facility failed to provide appropriate treatment and care to a resident in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. The deficiency involved a resident with multiple medical conditions, including multiple sclerosis, anxiety disorder, benign prostatic hyperplasia, and paraplegia, who required a suprapubic catheter. On a specific date, a CNA did not perform the necessary catheter care, resulting in the resident being left in a saturated brief and bed linens due to a leaking catheter. The resident's clinical records indicated that he was cognitively intact and required two-person assistance for all activities. The care plan specified the need for regular checks and catheter care to prevent skin breakdown. However, the CNA failed to check on the resident during her rounds, leading to the resident being found in a state of neglect. The Director of Nursing confirmed that the CNA did not follow the care orders, and the resident was left unattended for an extended period. Interviews and observations revealed that the resident was found with a large urine stain on the bed sheet, and a subsequent skin assessment showed multiple areas of blanchable redness, although no skin breakdown was noted. The facility's investigation confirmed the CNA's failure to provide the required care, and the CNA was suspended pending the investigation. The incident highlighted a lapse in adhering to the facility's policies on resident rights and catheter care.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure that drugs were stored and labeled in accordance with currently accepted professional principles, specifically in one of the two medication rooms. The issue involved the improper storage of Hydrocodone-Acet 325mg, a controlled substance, which was placed with non-controlled discontinued medications in a black plastic bin in the medication room. This bin had a slit and a hole on the lid and was secured with a combination lock, but it was not appropriate for storing controlled substances. The error was initially made by RN D, who, after being informed by a hospice nurse that medications needed to be disposed of immediately upon a resident's expiration, placed the hydrocodone in the bin. Upon realizing the mistake, RN D contacted RN E, who retrieved the medication from the bin and placed it under ADON G's door until it could be handed over to the Pharmacy Nurse. The medication remained in ADON G's office until the following day when it was finally given to the Pharmacy Nurse. Interviews with various staff members, including LVNs, the ADON, and the DON, revealed a lack of adherence to the facility's protocol for disposing of narcotics, which required that such medications remain in the medication cart until collected by the Pharmacy Nurse and DON for proper disposal. The facility's policy mandates that Schedule II-V controlled medications be stored in separately locked, permanently affixed compartments, with access to controlled medications being separate from non-controlled ones. The failure to follow these protocols could lead to drug diversion, potentially resulting in residents not receiving their medications as ordered. The report highlights the importance of maintaining secure storage and proper labeling of medications to prevent unauthorized access and ensure resident safety.
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 98 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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 Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Amarillo Rehabilitation And Nursing Ce | 0.6 mi | ★★★★★ | 16 | 1 |
| Amarillo Medical Lodge | 1 mi | ★★★★★ | 4 | 0 |
| Windflower Health Center | 1.1 mi | ★★★★★ | 11 | 0 |
| Heritage Convalescent Center | 1.1 mi | ★★★★★ | 8 | 0 |
| Amarillo Center For Skilled Care | 1.4 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ussery Roan 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 October 2026) and official state health department websites.