William R Courtney Texas State Veterans Home

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident #1) out of 11 residents reviewed for abuse and neglect in that:CNA B observed CNA A tapping Resident # 1's mouth, several times, during care, while she was when she went to ask CNA A if she needed assistance with getting Resident #1 to bed on 05/21/2026. This failure could place residents at risk of physical and mental or emotional harm, fear, and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure DA H wore a hair net when standing over the food prep table and portioning salads on plates. The facility failed to ensure DA H washed her hands between food preparation tasks. The facility failed to ensure the [NAME] used proper hand sanitation between puree preparation. The facility failed to and LVN A used proper hand sanitation during food plate distribution for the lunch meal. The facility failed to ensure CNA C and LVN B used proper hand sanitation during food plate distribution for breakfast meal. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the first quarter (October 1, 2025, to December 31, 2025). The facility failed to submit complete PBJ staffing information to CMS for October 1, 2025, to December 31, 2025. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of the CASPER3 PBJ report reflected the facility failed to submit data for the FY quarter 1 (October 1, 2025- December 31, 2025). No other quarter was triggered. An interview was conducted on 05/21/2026 at 3:35PM with the DON, who reported that she was not aware that quarter 1 PBJ was not submitted. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received and were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 residents (Residents # 51 # 65 and #135) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Residents #51, #65 and #135. The facility failed to provide palatable food served at an appetizing temperature and taste for 3 test trays provided to the survey team. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 3 residents (Resident # 68) reviewed for PASARR Level I screenings. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #68. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder and bipolar disorder was present upon admission. The facility did not complete a 1012 form to update Resident #68 PASARR Level 1 with the diagnosis. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteAbbreviations: Based on interview and record review, the facility failed to immediately notify the resident's representative when the resident experienced a change in condition for 1 of 3 residents (Resident #1) reviewed for a change of condition. The facility failed to notify Resident #1's Responsible Party (RP) when she was put on contact isolation precautions for E coli. This failure could place residents at risk delayed coordination when they experience a change in condition.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 15 (Resident #1) residents reviewed for care plan revisions. The facility failed to revise Resident #1's care plan to reflect interventions for physical aggression r/t anger due to dementia on 02//15/2026. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services, in that:The facility failed to administer Resident #1's Lorazepam medication according to physicians' orders on 12/16/2025, 12/17/2025, and 12/18/2025 resulting in Resident #1 getting double the amount of his scheduled medication. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 (Residents #1 and #2) of 12 residents reviewed for resident to resident altercations. The facility failed to prevent Resident #2 from being abused when Resident #1 punched him and knocked him on the floor, resulting in pain. Staff failed to notify the ADM, who was the abuse coordinator of the incident. This failure resulted in an IJ being identified on 07/22/25. The IJ template was provided to the facility on [DATE] at 6:05 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2). 1. The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations for two out of eight residents (Resident #1 and Resident #2) 1. The facility staff did not report Resident #1 and Resident #2's resident-to-resident altercation to the administrator immediately after the incident on 05/27/25. 2. The facility failed to report to Health and Human Services alleged abuse that occurred in the facility's secured unit on 05/27/25 involving Resident #1 and Resident #2. This failure resulted in the identification of Immediate Jeopardy (IJ) on 07/02/25 at 5:00pm. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 of 2 medication carts (Med Cart #1) reviewed for medication storage in that: The facility failed to prevent Med Cart #1 from being unattended and unlocked against the wall across from the nurses' station on the 300/400 Hall on 6/24/2025. This failure could allow residents, visitors, staff, and unauthorized individuals unsupervised access to prescription and over-the-counter medications. Findings Include: Observation on 6/24/2025 at 4:10 am revealed, Med Cart #1 sitting against the wall across from the nurses' station on the 300/400 Hall was unsupervised and unlocked. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for elopement. 1. The facility failed to ensure Resident #1's wander guard bracelet was secured on his wrist so he could not remove it before he eloped from the facility on 03/15/25. 2. The facility failed to ensure staff noticed Resident #1 was missing until approximately 11 hours after he left the faciity on [DATE]. An IJ was identified on 03/21/25. The IJ template was provided to the facility on [DATE] at 4:57 p.m. While the IJ was removed on 03/22/25, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 12 residents reviewed for elopement. The facility failed to ensure staff's statements were accurately documented when they last observed and checked on Resident #1 before he eloped on 03/15/25. This failure could place residents at risk of not being checked on, eloping, falls, and changes in condition.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 12 residents reviewed for elopement. The facility failed to ensure staff assessed Resident #1 after finding him at a hotel on 03/16/25 after he eloped from the facility on 03/15/25. This failure could place residents at risk of changes in condition not being treated.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 6 residents (Resident #3 Resident #14) reviewed for comprehensive care plans. The facility failed to ensure Resident #3's comprehensive care plan was updated to reflect Resident #3's refusal of physician order for daily weights. The facility failed to ensure Resident #14's care plan was updated to reflect the resident's recent falls on 02/15/2025. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Residents #3 and #100) of nine residents reviewed for quality of care. The facility failed weigh Residents #3 and #100 daily according to physician orders. This failure could place residents at risk of not receiving necessary medical care and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 1 of 3 residents (Resident #120) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN-D provided wound care for Resident #120 without wearing a gown. This deficient practice could place residents at-risk for spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident's family and responsible party when there was a change in resident condition for 1 of 6 (Resident #1) reviewed for reporting. The facility failed to inform Resident #1's family when CNA A reported the ADM on 11/07/2024 that Resident # 2 allegedly had spoken to Resident # 1 very disrespectfully and nasty. This failure could place residents at risk of their responsible party not being involved in ensuring safety.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation is made to the State Survey Agency for 2 of 6 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) an allegation of verbal sexual abuse between Resident # 1 and Resident # 2 when it was reported to the ADM on 11-07-2024. This failure could place residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 9 (Resident #11, Resident #51, Resident #54, Resident #62, Resident #77, Residents #105, Resident #116, Resident #135, and Resident #137) out of 148 residents reviewed for infection control. The facility failed to: 1. Isolate a resident with confirmed scabies (Resident #105) and five other residents (Residents #11, #51, #54, #62, #116, and #137) presented with rashes. On 01/10/24 at7:20 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 (Residents #44, 77, and 127) of 36 residents' rooms observed for respiratory care. 1. The facility failed to ensure Resident #44's nasal tubing for his oxygen machine was changed out weekly, the flow rate on the oxygen machine was at levels according to his Med Dir's orders, and the distilled water used to fill the cylinder on the oxygen machine was not expired. 2. The facility failed to ensure Resident #127's nasal tubing for his oxygen machine was labeled, dated, and changed out weekly and the cylinder was filled with distilled water when the oxygen machine was in use. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date for three (3 ) of four (4) medications carts reviewed. 1. LVN A failed to sign out narcotic after administering medication to Resident # 97 from Medication Cart #1 . 2. LVN I failed to administer medication to Resident # 37 after popping the medication and had expired medications on the 500 hall medication cart. 3. LVN J, LVN L, and CMA K failed to lock the medication carts (MCU cart-#1, 300 hall nurses #2, CMA cart #3). 4. The 300-hall nurse's cart had undated insulin pen for Resident # 108 and LVN J failed to sign the narcotics bookfor Medication cart . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's medical record included documentation that indicated the resident received education on the influenza immunization for 3 of 5 residents (Resident #39, Resident #44, and Resident #77) residents reviewed for immunizations. 1. The facility failed to ensure Resident #39's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 2. The facility failed to ensure Resident #44's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident. 3. The facility failed to ensure Resident #77's medical record contained evidence of education on the influenza immunization when the vaccine was administered to the resident. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 6 (Resident #23, 39, 78, 92, 96, and 113) of 36 residents' rooms observed for a clean environment. 1. The facility failed to ensure Resident #23 and 78's bedroom had no foul odors and restroom floor and toilet were clean. 2. The facility failed to ensure Resident #39's restroom floor was clean. 3. The facility failed to ensure Resident #92's bedroom floor and bed sheets were clean. 4. The facility failed to ensure Resident #96's bedroom floor, bed sheets, restroom floor, and toilet were clean. 5. The facility failed to ensure Resident #113's bedroom floor, bedsheets, privacy curtains, restroom floor, and sink were clean. These deficient practices could place residents at risk of infections and a decreased quality of life.

Inspectors wroteBased on interviews and record review the facility failed to have an assessment that accurately reflected the status for 1 of 2 Residents (Resident #149) reviewed for assessment accuracy. Resident #149's discharge MDS dated [DATE] reflected he was discharged to Short Term General Hospital (acute hospital), while he was discharged home with family. This failure affected 1 resident and placed him at risk of not receiving the proper care and services due to inaccurate records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 16 and Resident # 135) reviewed for quality of life. 1. The facility failed to ensure Resident #16's nails were cleaned. 2. The facility failed to ensure Resident #135's nails were cleaned and he was shaved. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing data was posted as required for 1 of 3 days (0/1/09/24) reviewed for nursing services and postings. The facility failed to post the required staffing information for 01/09/24. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.