Watkins-Logan-Garrison Texas State Veteran's Home

Inspectors wroteBased on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 3 residents reviewed for misappropriation of resident property. (Resident #2) The facility failed to prevent ECA A from accepting checks from Resident #2 after making him believe she was in a financial bind and would be thrown out of her home. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's care plan included interventions for aggressive behavior. This failure could place residents at an increased risk of not having individualized, person-centered care plans developed and maintained to address their identified needs, goals, and interventions necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 7 residents (Resident #1 and Resident #2) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was being supervised during one-to-one supervision, resulting in a resident-to-resident altercation with Resident #2. This failure could place residents at an increased risk of avoidable accidents, abuse, and resident-to-resident altercations due to the failure to consistently implement interventions.

Inspectors wroteBased on, interview, and record review, the facility failed to ensure resident received adequate supervision and assistance devices to prevent accidents for 1 of 20 resident reviewed for accidents. (Resident #68) The facility did not provide adequate supervision on 05/29/2025 at 7:45AM while transporting Resident #68 in the facility van by the transportation coordinator which resulted in Resident #68 who obtained a fall in the facility van and was sent to the hospital. This failure could place residents at risk for serious injury and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident # 72) reviewed for pharmacy services. RN A administered a medication prepared by LVN B nurse without verifying the physician's order for the medication and ensuring the medication was the right dose. This failure could place residents at risk for receiving the wrong medication or the wrong dose of a medication resulting in a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed orally, of their rights, for 7 of 11 residents interviewed during a group meeting. (Resident #s #16, #18, #29, #33, #47, #72, and #75). Residents #16, #18, #29, #33, #47, #72, and #75 were not provided on going communication of their rights orally, during their stay in the facility. This failure could place the residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received mail for 11 of 11 residents reviewed for rights to forms of communication. (Resident #s #16, #18, #29, #33, #47, #57, #72, #75, #86, #89 and #91). The facility did not deliver mail to Residents #16, #18, #29, #33, #47, #57, #72, #75, #86, #89 and #91, on Saturdays. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life. During interview, residents #16, #18, #33, #47, #57, #72, #75, #86 and #91 said mail is delivered on Saturday but the Saturday mail is not delivered until Monday. Resident #72 said he delivered the mail, Monday through Friday. He said the mail is provided to him and he delivered the mail to each house that had mail. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 20 resident reviewed for accidents. (Resident #1 and Resident #2) The facility failed to provide adequate supervision which resulted in Resident #1 spilling hot coffee on himself and obtained 2nd degree burn to right thigh that measured 27cm x 20cm x 0.1cm; 540cm of surface area. The facility did not provide adequate supervision while transporting Resident #2 in the facility van which resulted in Resident #2 obtained wedge compression fracture mid thoracic spine. An IJ was identified on 05/06/24. The IJ template was provided to the facility on [DATE] at 5:56pm. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 20 residents (Resident #2) reviewed for clinical records in that. -RN Supervisor G changed contents entered on Resident #2's risk management (incident report). This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident 's health.

Inspectors wroteBased on interview and record review the facility failed to promptly notify the ordering physician or NP of laboratory results that fell outside the clinical ranges in accordance with facility policies and procedures for notification for 1 of 4 residents reviewed for labs. The facility received lab results for Resident #1's labs on 12/14/23 which indicated his potassium was low. The requesting physician and the NP were not notified. This failure could place residents at risk of delayed treatment/intervention and decline in health. Findings Included: Record review of Resident #1's face sheet dated 1/4/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, high blood pressure, dementia, and mixed high cholesterol. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement a baseline care plan which includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 resident (Resident #300) reviewed for baseline care plans. The facility did not develop a baseline care plan for Resident #300. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 resident (Resident #300) reviewed for care plans in that: Residents #300 care plans did not implement a person-centered individualized care plan in that: a. Resident #300 diagnosis of Acute Kidney Disease was not addressed in the care plan. b. Resident #300 received pain medications with pain not addressed in the care plan. c. Resident #300's diagnosis of Urinary Tract Infection was not addressed in the care plan. d. Resident #300's care plan did not address the use of Foley Catheter. e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team failed to review and revise all residents' care plans after each comprehensive and quarterly review assessments for one (Resident #300) of four residents reviewed for comprehensive care plans. The facility failed to revise Resident #300's care plan to reflect the Foley Catheter. This deficient practice could place the residents at risk of not receiving the care and services required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 4 residents reviewed for gastrostomy tubes (Resident # 59) received proper tube care during administration of medications. The facility failed to follow their policy for administering medications via gastrostomy tube and used an unauthorized instrument to de-clog a feeding tube. This failure could place the resident at risk for not receiving his medication dose as ordered and at risk for a punctured gastrostomy tube and possible leakage of medications, formula, and/or water into the abdominal cavity.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 2 medication carts (B-House Nurse medication cart) and 1 of 10 medication storage rooms (Resident #84's room) reviewed for labeling and storage. The facility failed to remove expired Lorazepam 0.5 mg tablets with an expiration date 02/27/23 from the nurse medication cart in B-House and expired Valsartan 80 mg tablets with an expiration date 11/10/22 from Resident #84's locked medication storage cabinet in her room. This deficient practice could place residents at risk for receiving outdated medications and could result in residents not receiving the intended therapeutic effects of their medications causing a health decline.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions in an effort to discontinue these drugs for 1 of 6 (Resident #58) reviewed for unnecessary medications. The facility failed to ensure Resident #58 received a gradual dose reduction of his anti-anxiety medication. This failure could place residents at risk for receiving unnecessary psychotropic medications and an increased risk for adverse effects from psychotropic medications.