Clyde W Cosper Texas State Veterans Home
CLYDE W COSPER TEXAS STATE VETERANS HOME in BONHAM, TX — inspection on April 29, 2026.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to ensure CNA Z called Resident #76 by his preferred name while providing care on 04/28/26.
This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.Findings included:
Record review of Resident #76's face sheet dated 04/28/26 indicated he was [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included adjustment disorder with mixed anxiety and depressed mood (stress-related condition when individual copes with life changes) , and vascular dementia (progressive decline in thinking caused by conditions that reduce blood flow to the brain).
Record review of Resident #76's significant change MDS dated [DATE] indicated usually made himself understood and usually understood others.
The MDS also indicated he had a BIMS score of 03 which meant he had severe cognitive loss.
Record review of Resident #76's care plan dated 11/25/25 indicated he was a male resident and preferred to be called [name] with interventions to respect resident wishes.
During an observation and interview on 04/28/26 at 8:55 AM Resident#76 was lying in bed when CNA Z and CNA AA were attempting to provide care for Resident #76. CNA Z called Resident #76 by his last name and he told the two CNAs loudly that they could call him Dickhead, Asshole, or anything else but he did not want them calling him by his last name. Resident #76 said his name was [name] and that was what he wanted to be called. CNA Z called him by his last name again and Resident #76 immediately corrected her and said Dickhead.
During an interview on 04/28/2026 at 10:05 AM CNA AA said she had been on floor as CNA for 12-14 days. CNA AA said she always called Resident #76 by his last name, but he has gotten mad, but that's his name. CNA AA said no nurse has ever said anything about him being called anything but his last name. CNA AA said if he wanted to be called something different, she would have called him that because that was his right. CNA AA said CNA Z was her trainer and she had never told her that.
During an interview on 04/28/2026 at 10:20 AM CNA Z said no other nurse had said Resident #76 did not like to be called by his last name, but he always responded when they called him by his last name.
CNA Z said she had always called Resident #76 by his last name but on 04/28/26 Resident #76 was not his normal self. CNA Z said for Resident #76's dignity and respect all staff should have been calling Resident #76 by his first name instead of his last name.
During an interview on 04/29/2026 at 3:17 PM LVN W said she was not aware that Resident #76 preferred to be called by his first name and LVN W said she typically called all residents by their last names out of respect. LVN W said it was Resident #76's right to be called by his first name if he wanted to be called by his first name and what all staff should have been calling him by his first name. LVN W said it was the charge nurse's responsibility to know resident preferences and to notify CNAs.
During an interview on 04/29/26 at 4:05 PM the DON said he expected the CNAs to call residents as the resident prefers.
The DON said the preference should have been in Resident #76's care plan for triggers.
The DON said it was Resident #76's right to be called what he preferred and avoid all triggers.
During an interview on 04/29/26 at 4:10 PM the Administrator said he expected the residents to be called by their preferred names.
The Administrator said the nursing staff and the leadership staff (the ADON, DON, and Administrator) were responsible for ensuring the residents were called by their preferred names.
The Administrator said the failure placed a risk for triggers and upsetting the residents.
Record review of the undated facility policy Resident Rights indicated:Purpose: The purpose of this policy is to affirm and protect the fundamental rights of all patients/residents receiving care at [Facility Name], in accordance with federal and state regulations.Dignity and Respect: The right to be treated with consideration, respect, and recognition of individuality.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
During an observation and
and had mold.
She said they cleaned the shower stalls every Sunday, but they did not clean them on Sunday, 04/26/2026, because they did not have enough staff.
Housekeeper O said the shower stalls should be clean to prevent cross contamination, so the residents did not get sick, and because mold could affect the residents breathing.
During an observation and interview with the Housekeeping Supervisor and Housekeeper P on 04/29/2026 at 2:49 PM, the Housekeeping Supervisor said the shower stalls in the A-Hall shower room needed to be scrubbed.
She said they looked dirty and had pink grime on them.
The Housekeeping Supervisor said they had a tile and grout cleaner to clean the shower stalls.
She said the shower stalls in the C-Hall shower room looked dirty and needed to be scrubbed.
The Housekeeping Supervisor said she was not sure if the black grime on the shower stalls was mold.
She said she was responsible for making sure the showers were cleaned by the housekeepers.
The Housekeeping Supervisor said she checked on Mondays to ensure the shower rooms were deep cleaned on Sunday, but lately she had not been monitoring.
The Housekeeping Supervisor said the residents should not have to get clean in a dirty shower and the dirty showers could cause cross contamination.
She said the showers should be clean to prevent the residents from getting sick.
Housekeeper P said the A-hall and C-hall shower stalls could be cleaner. He said the last time he scrubbed the shower stalls was 2-3 weeks ago.
Housekeeper P said the showers needed to be clean to prevent the residents from getting sick
During an interview on 04/29/2026 at 3:56 PM, the Administrator said he expected for the shower rooms to remain clean and hygienic.
The Administrator said he and the housekeeping staff were responsible for ensuring the shower rooms were clean.
The Administrator said he rounded daily and had not noticed the shower rooms were not clean.
The Administrator said it was important for the shower rooms to be clean to ensure a clean and sanitary environment and so the residents did not get sick.
Record review of the facility's policy titled, Resident Rights, dated October 2022, indicated, Safe environment.
The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
received or performed any of the treatments, procedures, or programs within the assessment period.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
with federal guidelines.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
stated nurses and aides were responsible for ensuring the floor mats were in place.
The DON stated
04/29/26 at 4:17 p.m., the Administrator stated he expected Resident #28 to have both floor mats on
mats were in place.
The Administrator stated unit managers, DON and himself were responsible for monitoring by spot checks.
The Administrator stated it was important to ensure safety measures were in place to ensure his safety.
Record review of the facility's Clinical Services: Care Plans and Case Management, revised on 06/2019 reflected . to develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident.1. An interdisciplinary team develops and maintains a comprehensive care plan for each resident. 2.
The comprehensive care plan has been designed to: identify care needs that includes resident's strengths, history, and preferences.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
During an interview on 04/29/26 at 11:31 a.m., ADON T stated he was responsible for the ambassador rounds for Resident #28. ADON T stated rounds should be done every day but there were some days he did not have time to complete. ADON T stated his last round was done on 04/27/26 and he did not look at the filter. ADON T stated it was important to ensure filters were cleaned to prevent an infection and ensure proper airflow.
During an interview on 04/29/26 at 2:20 p.m., Unit Manager S stated she just started the management position on Monday (04/27/26) but she expected the filters to be cleaned/changed by the nurse on Wednesday nights.
Unit Manager S stated she would be monitoring and overseeing by random rounds.
Unit Manager S stated it was important to ensure filters were cleaned to prevent a respiratory infection.
During an interview on 04/29/26 at 3:15 p.m., the DON stated the nurse on Wednesday night was responsible for cleaning/changing the filter.
The DON stated he monitored by random spot checks and ambassador rounds.
The DON stated there had not been any issues in the past.
The DON stated it was important to cleaned/change the oxygen filter to prevent the possibility of infection.
During an interview on 04/29/26 at 4:17 p.m., the Administrator stated he expected the filters to be cleaned/changed on Wednesday nights by the charge nurse.
The Administrator stated the unit managers, DON and himself were responsible for monitoring and overseeing by random spot checks and daily ambassador rounds.
The Administrator stated it was important to clean/change the oxygen filter to prevent Resident #28 from getting sick.
Record review of the facility's Oxygen Administration, revised on 09/02/25 reflected . to administer oxygen to the resident with insufficient oxygen saturation.5 (b). clean the filters daily with soap and water.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
During an interview on 04/29/2026 at 3:47 PM, the Administrator said he expected expired medications to be disposed of so they were not administered to the residents.
The Administrator said the unit managers and the nurses were responsible for ensuring expired medications were discarded.
The Administrator said not discarding expired medications could result in an adverse effect to the resident or the medication being ineffective.
During an interview on 04/29/2026 at 4:18 PM, the DON said the nurses should be checking medication when administering them and should ensure no expired medications were on the medication cart and in the refrigerators.
The DON said he did not know there had been studies to show what effects expired medications could have on the residents, so it was unknown what effect expired medications could have.
Record review of the facility's undated policy titled, Storage of Medications, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's, provider pharmacy recommendations, or those of the supplier to maintain their integrity.
Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
recommendations, or those of the supplier to maintain their integrity.
The provider pharmacy
Medications are kept in these containers and stored in a controlled environment.
This storage may
containers.
Transfer of medications from one container to another is done only by the pharmacy personnel.
Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .
Record review of the facility's undated policy titled, Medication Labels, indicated, Medications are labeled in accordance with facility requirements and state and federal laws.
Only the dispensing pharmacy can modify or change prescription labels.
Labels are permanently affixed to the outside of the prescription container.
Each prescription medication label includes: 1.
Resident's name 2.
Specific directions for use, including route of administration a.
Due to the complexity and length/length/number of instructions, some medications may be labeled use as directed and refer the person administering the medication to the medication administration record for instruction details. If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order—check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. 2.
When such a label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. 3.
The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
ordered.
The DON said failure to monitor ordered labs for Resident #12 could cause his wounds to
compliance.
The DON said it was important to ensure labs were drawn as ordered by the physician to
at 3:58 p.m., the Administrator said he expected labs to be drawn as ordered. He said the nurses were responsible for filling out the lab slip and the lab company was supposed to draw the lab ordered. He said nurse management was responsible for ensuring labs were drawn as ordered.
The Administrator said it was important for labs to be drawn as ordered by the physician for the welfare of the resident's health.
Record review of the facility's policy titled Laboratory Services, revised 09/02/25, indicated .Purpose: laboratory services will be performed as ordered by the physician.Policy Explanation and Compliance Guidelines: 1.
Laboratory services will be ordered by the physician. 2.
Laboratory services will be completed on the date specified by the physician or on the next scheduled lab day, if a specific date is not identified.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
assure that foods are served as listed on the menu.
Each meal tray will be checked for: c.
Proper
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
Record review of the Therapeutic Deits policy, dated 2023, revealed diets will be offered as ordered
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
ensuring the kitchen was cleaned and the skillets were in good condition.
The Administrator said the
Record review of the facility's undated policy titled Cleaning and Sanitation of Dining and Food
and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.
Record review of the U.S.
Food and Drug Administration Food Code 2022, indicated, Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
During an interview on 04/29/26 at 4:17 p.m., the Administrator stated he was informed today (04/29/26) by the DOR Resident #67 was not on rehab services.
The Administrator stated he expected the DOR to contact Resident #67's family to confirm whether they approved of the copay.
The Administrator stated therapy services were brought up for Resident #67 after each fall during morning meetings.
The Administrator stated the DOR stated she would consult with the family to get approval for him to start therapy, but he did not follow up to ensure the family was contacted.
The Administrator stated it was important for residents to receive therapy to maintain the highest level of independence.
Record review of the facility's policy Rehabilitation Services-Texas, dated 08/2021, reflected .Therapy services will be available to assist residents with maintaining their maximum level of independence and enhance quality of life.
Therapy may be beneficial for ambulation, activities of daily living (ADLs), positioning, joint range of motion, etc.
The community will have therapy services, in the form of physical therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST), available to residents who meet criteria and may benefit from services. 1.
Residents will be screened upon admission and as needed to determine if therapy services may be of benefit.3.
Residents and/or the resident representative will be involved in the therapy plan.
675873 04/29/2026
Clyde W Cosper Texas State Veterans Home 1300 Seven Oaks Rd Bonham, TX 75418
and applying clean gloves after cleaning the soiled resident * Removing gloves, washing hands, and
supplies and linen.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.