William R Courtney Texas State Veterans Home

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jan 12, 2024

  44317 Based 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. […]

• Immediate jeopardy, isolatedF600Jul 23, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF607Jul 23, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF609Jul 23, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Mar 22, 2025

  Based 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. […]