Alfredo Gonzalez Texas State Veterans Home

In the surveyor’s words

From the most serious findings on record at Alfredo Gonzalez Texas State Veterans Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 17, 2023

  Based on observation, interview, and record review, the facility failed to provide adequate supervision for four Residents (Resident #76, Resident #93 ) of eight residents whose records were reviewed for elopement and supervision. 1.The facility failed to ensure Resident #76, and Resident #93 received adequate supervision. Resident #76 eloped from the facility memory unit on 10/22/2022 & 12/19/22. Resident #93 eloped on 1/30/23. The non-compliance was identified as Past Non Compliance. The Immediate Jeopardy (IJ) began on 12/18/22 and ended on 2/13/23. The facility corrected the non-compliance before the survey began. […]

• Immediate jeopardy, isolatedF600Feb 27, 2026

  Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to put interventions in place to protect Resident #2 from abuse after a reported resident to resident physical altercation with Resident #1 on 02/07/26. On 02/08/26 a 2nd altercation between Resident #1 and Resident #2 occurred which resulted in Resident #2 being found on the floor with bilateral skin tears to arms and right knee and stated Resident #1 had pulled him down to the floor on 02/08/26. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 02/07/26 and ended on 02/08/26. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF607Feb 27, 2026

  Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to protect Resident #2 from abuse after a reported resident to resident physical altercation with Resident #1 on 02/07/26. On 02/08/26 a 2nd altercation between Resident #1 and Resident #2 occurred which resulted in Resident #2 being found on the floor with bilateral skin tears to arms and right knee and stated Resident #1 had pulled him down to the floor on 02/08/26. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 02/07/26 and ended on 02/08/26. […]

• Actual harm, isolatedF689Jun 12, 2021

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for three of ten residents (Resident#127, Resident #128, and Resident #112) reviewed for accidents and supervision, 1)NA B provided incontinent care to Resident #127 alone. Resident #127 was a two person assist and fell from the bed while care was being provided by NA B and he sustained a laceration to the forehead which required 10 sutures and a three day hospitalization . 2)CNA C provided Resident#128 incontinent care alone. Resident #128 was a two person assist during incontinent care. 3)NA D provided Resident#112 incontinent care alone. […]

• No harm, potential for more than minimal, patternF684Feb 27, 2026

  Based on interviews, and record reviews 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. 1.The facility failed to follow their skin and wound prevention and management policy and did not have a licensed nurse complete and document a skin assessment at least weekly for Resident #3. This failure could put residents at risk of having skin breakdowns that could go unidentified and untreated. The findings included: 1. […]