Clyde W Cosper Veterans Home: Oxygen Filter Failure - TX
Inspectors visiting Clyde W Cosper Texas State Veterans Home on April 28 and 29, 2026 found the condition of Resident 28's oxygen concentrator filter and then spent two days asking staff who was responsible for it. The answers formed a circle that led nowhere.
The facility's own oxygen administration policy, revised as recently as September 2025, required filters to be cleaned daily with soap and water. Wednesday night nurses were assigned the task. The filter inspectors found was not the product of a single missed Wednesday. It was thick and grey and fuzzy, the kind of buildup that accumulates when cleaning is skipped repeatedly.
LVN R looked at the filter during an interview on April 28 and said, simply, "it's dirty." LVN R said clean filters mattered because a dirty one could cause a respiratory infection and restrict airflow. LVN Q, the nurse assigned to Wednesday April 22, the most recent Wednesday before inspectors arrived, did not answer a phone call that afternoon.
The assistant director of nursing, identified in the report as ADON T, told inspectors he was personally responsible for ambassador rounds on Resident 28's unit. He said those rounds were supposed to happen every day. He said there were some days he didn't have time to complete them. His last round, he said, was April 27, the day before inspectors arrived. He did not look at the filter.
The unit manager, who started her management position on Monday April 27, said she expected the Wednesday night nurse to handle filter cleaning and that she planned to monitor through random rounds going forward. She had been on the job two days.
The director of nursing told inspectors he monitored through random spot checks and ambassador rounds, the same system ADON T described. The DON said there had not been any issues in the past. He did not explain how he would have known.
The administrator said he expected the charge nurse to clean the filter on Wednesday nights. He said unit managers, the DON, and he himself were all responsible for monitoring through random spot checks and daily ambassador rounds. The same rounds that ADON T acknowledged he sometimes skipped. The same rounds that had not caught a filter so dirty that a nurse looked at it and immediately called it dirty.
Six people, from bedside nurse to administrator, described a monitoring system built on the assumption that someone else was checking. Nobody was.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects where things stood when inspectors walked in, not where they were headed. A dirty oxygen concentrator filter reduces the efficiency of oxygen delivery and creates conditions for respiratory infection in a patient already dependent on supplemental oxygen. The facility's own nurses said so, one after another, in the same interviews where they acknowledged the filter hadn't been cleaned.
Resident 28 is a veteran living in a state-run home specifically built to care for people who served. The oxygen concentrator is not optional equipment. The filter is not a minor maintenance item. The facility wrote a policy requiring daily cleaning, assigned the task to specific staff on a specific night, and built a supervisory structure, ambassador rounds, spot checks, a chain of management oversight, that apparently produced no one who looked at the filter until a federal inspector did.
The administrator told inspectors it was important to clean the oxygen filter to prevent Resident 28 from getting sick.
He was right about that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clyde W Cosper Texas State Veterans Home from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CLYDE W COSPER TEXAS STATE VETERANS HOME in BONHAM, TX was cited for violations during a health inspection on April 29, 2026.
The answers formed a circle that led nowhere.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.