Tuskegee Airmen Texas State Veterans Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 1, 2026

  Based on observations, interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accident and hazards. The facility failed to ensure Resident #1 received adequate supervision to prevent the resident from eloping from the facility through an ancillary door on the service hallway on 03/21/26 at approximately 3:30 PM. An Immediate Jeopardy (IJ) situation was identified on 03/31/26. While the IJ was removed on 04/01/26 the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate effectiveness of their corrective systems. […]

• Immediate jeopardy, isolatedF600Dec 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #2) reviewed for abuse.The facility failed to ensure Resident #2 had the right to be free from abuse on 11/27/25, while on the memory care unit, Resident #1 punched Resident #2 in the face causing him to fall against the wall and then to the ground resulting in facial bleeding and a fractured hip. The noncompliance was identified as a past non-compliance. The Immediate Jeopardy (IJ) began on 11/27/25 and ended on 12/02/25 the facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of harm and/or severe injury. […]

• Immediate jeopardy, isolatedF689Dec 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #2) reviewed for supervision. The facility failed to provide adequate supervision to prevent a physical altercation when Resident #1, who was sitting at the dining room table eating and talking with LVN A, got up from the table. LVN A asked him where he was going and to have a seat, Resident #1 stated, I will be right back with you. […]

• No harm, potential for more than minimal, isolatedF908Jul 23, 2026

  Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 Residents (Resident #1) reviewed for essential equipment. The facility failed to ensure Resident #1's WanderGuard device (wander management bracelet) was functioning on all sensors of the four exit doors on the Delta pod. This failure could place residents at risk for elopement and injury. Findings included:Record review of Resident #1's Quarterly MDS, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF605Jul 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #3) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #3 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN. Resident #3 was ordered PRN Lorazepam (a benzodiazepine medication used primarily to treat anxiety disorders and sever agitation) on 06/03/26 without a stop date. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. […]