Watkins-Logan-Garrison Texas State Veteran's Home

In the surveyor’s words

From the most serious findings on record at Watkins-Logan-Garrison Texas State Veteran's Home, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 31, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident environment remained free of accident hazards as possible and the resident received adequate supervision to prevent accidents for 1 of 6 residents reviewed for accidents. (Resident #2) The facility failed to put interventions in place to prevent accidents regarding Resident #2 that had a history of self-injurious behaviors. Resident #2 tried to harm himself by placing a call light cord around his neck twice on [DATE]. […]

• Immediate jeopardy, patternF740Aug 31, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident received necessary behavioral health care services to maintain the highest practicable mental and psychosocial wellbeing for 1 of 6 residents reviewed for behavioral services. (Resident #2) The facility failed to: Ensure psychological services were provided as ordered by the physician Intervene and provide safety measures on [DATE] when Resident #2 tried to kill himself. He wrapped a call light cord around his neck twice and threw himself from the wheelchair. Ensure they initiated the facility policy on Suicide Precautions. […]

• Immediate jeopardy, isolatedF689May 8, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF692Apr 6, 2022

  Based on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance unless the resident's clinical condition demonstrated that this was not possible, or the resident's preferences indicated otherwise for 1 of 5 Residents (Resident #1) reviewed for nutritional status. The facility did not develop and implement interventions to address Resident #1's decrease in appetite and intake and actual weight loss. The facility did not develop and implement interventions to address Resident #1's increased need for assistance with eating. […]

• Immediate jeopardy, isolatedF758Apr 6, 2022

  Based on interview and record review the facility failed to ensure residents who have not used [CONDITION(S)] drugs are not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed (Resident #1) The facility failed to implement non-pharmacological interventions before placing Resident #1 on [CONDITION(S)] medications when he began experiencing adjustment difficulties and exhibiting behaviors The facility failed to monitor, identify and act upon adverse consequences of [CONDITION(S)] medication when Resident #1 experienced unplanned weight loss, decline in ADL functions, dehydration, sedation, lethargy and mental changes. […]