F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to review and revise the person-centered care plan to reflect
the current condition for 1 of 15 (Resident #1) residents reviewed for care plan revisions.The facility failed to
revise Resident #1's care plan to reflect interventions for physical aggression r/t anger due to dementia on
02//15/2026.This failure could place residents at risk of not receiving appropriate interventions to meet their
current needs. Findings included:Record review of Resident #1's admission record, dated 02/23/2026,
revealed an [AGE] year-old male was admitted on [DATE]. Resident #1 had diagnoses which included:
vascular dementia (progressive decline in thinking and memory skills caused by reduced blood flow to the
brain), Alzheimer's disease (memory loss, cognitive decline, and behavioral changes due to brain cell
death), and major depressive disorders (sad).Record review of Resident #1's Quarterly MDS assessment,
dated 02/18/2026, revealed the resident had a BIMS score that was blank, which indicated Resident #1
was unable to complete the interview. Resident #1's behavioral symptoms on the Quarterly MDS revealed
presence of physical aggression.Record review of Resident #1's care plan, dated 02/22/2026, revealed
Resident #1was care planned on 05/10/2024 for cognitive function/dementia or impaired thought process r/t
dementia with interventions to keep my routine consistent and try to provide consistent caregivers as much
as possible in order to decrease confusion.Record review of Resident #1's care plan, dated 02/22/2026,
revealed Resident #1 was care planned on 02/07/2026 and did not include interventions for physical
aggression r/t anger due to dementia on 02/15/2026.During an interview on 02/22/2026 at 11:15 p.m., the
DON stated it was expected for the care plans to reflect the current intervention for the behavior on
02/15/2026. The DON stated the MDS Coordinator was responsible for updating the care plans. The DON
stated without the intervention updated it would not show what was put in place for Resident #1.During an
interview on 02/22/2026 at 2:04 p.m., the MDS Coordinator stated she was responsible for updating the
care plan interventions for 02/15/2026. The MDS Coordinator stated it was expected for her to update the
care plan with the interventions of 1 to 1 so staff would know how to assist the residents. The MDS
Coordinator stated he failed to update the most recent intervention date of 02/15/2026 for Resident
#1.During an interview on 02/23/2026 at 4:11 p.m., Resident #1 stated he was safe but could not recall any
incidents with any other residents that he may had.During an interview on 02/23/2026 at 4:20 p.m., the
ADM stated it was expected for the MDS Coordinator to have updated Resident #1 behavior interventions
on the care plan 02/15/2026. The ADM stated the MDS Coordinator was responsible for making sure the
intervention was updated on 02/15/2026 to ensure Resident #1's individual needs would be met.Record
review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001, revised
March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives
and timetables to meet the resident's physical, psychosocial and functional needs is developed and
implemented for each resident. Identifying problem areas
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675857
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675857
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
William R Courtney Texas State Veterans Home
1424 Martin Luther King Jr LN
Temple, TX 76504
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
and their causes and developing interventions that are targeted and meaningful to the resident, are the
endpoint of an interdisciplinary process.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675857
If continuation sheet
Page 2 of 2