Health inspection·December 16, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident's family and responsible party when there was a change in resident condition for 1 of 6 (Resident #1) reviewed for reporting. Residents Affected - Few The facility failed to inform Resident #1's family when CNA A reported the ADM on 11/07/2024 that Resident # 2 allegedly had spoken to Resident # 1 very disrespectfully and nasty. This failure could place residents at risk of their responsible party not being involved in ensuring safety. Findings included: A record review of Resident #1's face sheet dated 12/16/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was vascular dementia (memory loss in those at higher risk of stroke due to obesity or diabetes), and legal blindness (vision loss). A record review of Resident #1's Quarterly MDS assessment, dated 09/26/2024, reflected the resident had a BIMS score of 6, which indicated severe cognitive impairment. A record review of Resident #1's facility investigation report dated 11/08/2024, reflected Resident # 1's RP notified the community that she was told by CNA A that Resident #2 told Resident #1 to suck his dick. A record review of Resident #1's progress note dated 11/07/2024 did not reflect documentation of call made to family. A record review of Resident #2's face sheet dated 12/16/2025, reflected a [AGE] year-old male who was admitted on [DATE]. Resident #2's diagnosis was hypertension (high blood pressure), and congestive heart failure (heart does not pump blood as well as it should). A record review of Resident #2's Quarterly MDS assessment, dated 09/09/2024, reflected the resident had a BIMS score of 15, which indicated cognitively intact. A record review of Resident #2's progress notes dated 11/25/2024, reflected Resident # 2 passed away. During an interview with Resident #1's RP on 12/16/2024 at 1:30pm, stated that she was not made aware Page 1 of 4 675857 675857 12/16/2024 William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident # 1 was being investigated at the facility for alleged abuse. The RP stated no one at the facility contacted her to let her know and when she was made aware to her on 11/8/2024 by CNA A that a report had been made. During an interview with DON on 12/16/2024 at 12/16/2024 at 5:18pm, the DON stated he was not made aware of the allegations until 11-8-2024 when Resident # 1 came to the facility to inquire about the allegations. The DON stated the RP did not want to talk to him she wanted to speak with the ADM. The DON stated it was expected to contact the family member when there was suspected abuse. The DON stated the charge nurses are responsible to make the family member aware of and if family was not contacted that would indicate no knowledge of the alleged allegations. During an interview with the ADM on 12/16/2024 at 6:24 pm, stated that when CNA A reported the alleged allegation to him on 11/07/2024 he should had contacted the family member immediately starring his investigation. The ADM stated CNA A reported the alleged allegations directly to him. The ADM stated the charge nurses was responsible for contacting family members to make the family aware. The ADM stated it was expected for the family to be contacted for the resident's safety. Review of facility's policy titled Identifying and Reporting Changes in Condition, Notifications of Changes, and Abnormal findings undated reflected Nurses should ensure that all changes in condition are promptly reported to the family/representative/responsible party/legal representative. 675857 Page 2 of 4 675857 12/16/2024 William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation is made to the State Survey Agency for 2 of 6 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) an allegation of verbal sexual abuse between Resident # 1 and Resident # 2 when it was reported to the ADM on 11-07-2024. This failure could place residents at risk for further abuse. Findings included: A record review of Resident #1's face sheet dated 12/16/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was vascular dementia (memory loss in those at higher risk of stroke due to obesity or diabetes), and legal blindness (vision loss). A record review of Resident #1's Quarterly MDS assessment, dated 09/26/2024, reflected the resident had a BIMS score of 6, which indicated severe cognitive impairment. A record review of Resident #2's face sheet dated 12/16/2025, reflected a [AGE] year-old male who was admitted on [DATE]. Resident #2's diagnosis was hypertension (high blood pressure), and congestive heart failure (heart does not pump blood as well as it should). A record review of Resident #2's Quarterly MDS assessment, dated 09/09/2024, reflected the resident had a BIMS score of 15, which indicated cognitively intact. A record review of Resident #2's progress notes dated 11/25/2024, reflected Resident # 2 passed away. A record review of Resident #1's facility investigation report dated 11/08/2024, reflected Resident # 1's RP notified the community that she was told by CNA A that Resident #2 told Resident #1 to suck his dick. A record review of the facility's provider investigator report dated 11/18/2024 reflected the facility did not report the alleged verbal sexual abuse allegations within 24 hours to the State Survey Agency (HHSC). During an interview with Resident #1's RP on 12/16/2024 at 1:30pm, stated that she was told by CNA A that Resident # 1 had been talked to belligerently by Resident # 2. Resident # 1's RP stated the CNA A allegedly stated Resident # 2 told Resident #1 to suck his dick. Resident #1's RP stated she was not notified by the facility that Resident # 1 was allegedly verbally abused or that it was being investigated. Resident #1's RP stated that she did not know anything about the investigation until she went to the facility on [DATE] after being told that Resident # 1 was being investigated for alleged abuse. Resident # 1's RP stated the ADM advised her that and investigation had been started. 675857 Page 3 of 4 675857 12/16/2024 William R Courtney Texas State Veterans Home 1424 Martin Luther King Jr LN Temple, TX 76504

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident # 1's RP stated she should had been contacted if there were alleged allegations with Resident # 1 and even if there were no findings. During an interview with CNA A on 12/16/2024 at 2:44pm, stated that she was no longer employed with the facility. CNA A stated she reported to the ADM on 11/07/2024 that Resident # 2 had talked to Resident # 1 disrespectfully. CNA A stated when Resident # 1's family member called to the facility on [DATE] she thought they were calling about the report of verbal abuse and the family member had not been made aware of. CNA A stated Resident #1's RP came up to the facility and that's when she was told of the alleged verbal abuse by the ADM. During an interview with Resident #1 on 12/16/2024 at 2:58 pm, stated that he did not have any issues with Resident # 2. Resident #1 stated he had not been talked ugly to or sexually by Resident #2. During an interview with the ADM on 12/16/2024 at 6:24 pm, stated that when CNA A reported the alleged allegation to him on 11/07/2024 he immediately started investigating. The ADM stated he interviewed both Resident # 1 and Resident # 2 and both denied the allegations. The ADM stated was he did not report to the state as alleged abuse until 11-18-2024 when he had a meeting with Resident # 1's RP. The ADM stated the report should have been made to HHSC on 11-07-2024 when it was reported to him. The ADM stated it was expected to report alleged abuse to HHSC within 24 hours to prevent further abuse. A record review of the facility's Abuse Guidance: Preventing, Identifying, and Reporting policy, dated January 2024, reflected Report alleged or suspicions of abuse to HHSC by email reporting or via TULIP reporting within the designated time frames in accordance with HHSC's PL 19-17 (replaces PL 17-18). Are reported immediately, but not later than two hours after the allegation is made, if the events that causes the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. State authorities should be notified of report of abuse described above which alleges that a resident has been a victim of any act or attempted act of abuse or neglect. 675857 Page 4 of 4