Clyde W Cosper Texas State Veterans Home

In the surveyor’s words

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

• Immediate jeopardy, patternF686Feb 7, 2025

  Based on observation, interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 6 Residents (Resident #74) reviewed for pressure injuries. 1. The facility failed to provide care to prevent pressure ulcer or injury development for Resident #74. Resident #74 broke his right ankle and a soft splint was applied on 07/13/24. The facility failed to obtain a clarification order from the doctor related to Resident #74's splnt care. Resident #74 developed 4 unstageable deep tissue injuries to his right foot and possible osteomyelitis. An IJ was identified on 02/05/25. […]

• Immediate jeopardy, isolatedF689Feb 7, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 5 residents (Resident #134) reviewed for supervision. The facility failed to ensure Resident #134 received adequate supervision to prevent exiting the facility without facility knowledge on 01/25/2025, when Resident #134 was found outside sitting on the curb of the facility's parking lot with her wheelchair tipped over. The facility failed to ensure adequate interventions were placed for Resident #134 after exit seeking attempts on 11/18/2024 and 01/25/2025. […]

• Immediate jeopardy, isolatedF600Dec 8, 2023

  Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 5/14/2023.CNA A had a history of a physical abuse allegation in December 2022 towards Resident #2. The facility failed to implement measures to protect residents from further abuse. The facility failed to train staff on how to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. […]

• Immediate jeopardy, isolatedF607Dec 8, 2023

  Based on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to follow facility policy of each resident having the right to be free from abuse, corporal punishment, and involuntary seclusion by not protecting Resident #1 from physical abuse by a staff member. The facility failed to implement their policy by providing training to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. […]

• No harm, potential for more than minimal, widespreadF880Jan 25, 2024

  45879 46892 47006 Based on observations, interviews, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident's #30 and #299) reviewed for infection control practices related to droplet precautions and 4 of 11 facility staff members (MA C, LVN A, LVN F, and Speech Therapist D) reviewed for infection control practices related to medication pass and droplet precautions. […]