Health inspection·July 11, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 2 of 8 residents (Resident #2 and Resident #3) reviewed for abuse and neglect. The facility did not ensure it protected residents from abuse when Resident #1 threw lukewarm coffee, yelled, and cussed at Resident #2 and Resident #3 on 07/07/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #1's admission Record, dated 06/08/25, reflected a [AGE] year-old man admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities) and anxiety disorder (feeling apprehensive, uneasy, or nervous about something). Record review of Resident #1's quarterly MDS assessment, dated 04/22/25, reflected Resident #1 had not exhibited wandering behavior and had a BIMS score of 13/15, indicating intact cognition. Resident #1 did not have physical behavioral symptoms directed toward others. Record review of Resident #1's care plan, undated, reflected At risk for psycho-social issues: emotional distress or behaviors r/t: dementia w/agitation dx, exposure to war. 7/5/25 Resident to staff and resident to resident physical aggression, yelled/cursed out loud, pushed LVN and threw warm/cool coffee at staff and two residents. With interventions 7/5/25- Increased monitoring when in common areas and around other residents. And 7/5/25- Senior Psych Med Intervention., Administer Medications as ordered., Calm and re-assure resident/patient is safe, Keep environment calm, quiet and avoid loud noises as much as possible., Redirect/educate/intervene as needed., Refer to Mental Health Providers as indicated. Referred to [Psych Services]., Refer to social service as indicated., and Separate away from other resident as needed. Record review of Resident #2's admission Record, dated 06/08/25, reflected an [AGE] year-old male admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities), Alzheimer's disease (most common form of dementia), anxiety (feeling apprehensive, uneasy, or nervous about something), and depressive episodes. Record review of Resident #2's admission MDS assessment, dated 06/30/25, reflected Resident #2 had not exhibited wandering behavior and had a BIMS score of 10/15, indicating moderate impaired cognition. Record review of Resident #2's care plan, undated, reflected Psycho-social/Behavioral Risk: Depressive Episodes, Hx of Childhood Abuse. Loneliness at times., dated 06/26/25 with interventions RISK-BEHAVIORS MONITORING-Calm and re-assure resident/patient is safe. Record review of Resident #3's admission Record, dated 06/10/25, reflected an [AGE] year-old female admitted [DATE] with diagnoses to include major depressive disorder and cognitive Page 1 of 6 675863 675863 07/11/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few communication deficit. Record review of Resident #3's quarterly MDS assessment, dated 05/15/25, reflected Resident #3 had a BIMS score of 6/15, indicating severe impaired cognition. Record review of Resident #3's care plan, undated, reflected I have mood/behavior problems-feels tired, trouble concentrating on things, sad mood/depressed. Record review of Resident #1's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected During breakfast [Resident #1] was sitting next to [Resident #3] and [Resident #2]. [Resident #3] was talking with [Resident #2] when [Resident #1] became upset and started yelling and cussing at [Resident #2]. Staff attempted to redirected, [Resident #1] then stood up, continuing to yell/cuss. Stating no one in here cares if I'm yelling. I can do what I want, what are you going to do about it. [Resident #1] then pushed [LVN A], and threw lukewarm/cool coffee across staff, [Resident #3] and [Resident #2]. Able to redirect resident to bedroom at this time, while [Resident #1] continued yelling down hallway. [Resident #1] states He is the one that started it by talking to my lady. [Resident #1] assessed. No injuries noted. [Psych] notified and [medications prescribed]. Continue to monitor behaviors. PCP/RN Supervisor/Administrator/DON notified. [Resident #1] consented to medication at this time. Record review of Resident #2's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #2] was sitting at a table with [Resident #3] and [Resident #1]. [Resident #1] became upset and started yelling/cussing at [Resident #2]. Staff attempted to redirect [Resident #1]. [Resident #2] stayed seated, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #2]/[Resident #3]/staff. [Resident #2] was redirected to bedroom at this time. Resident #2 was assessed. No injuries noted r/t coffee. [Resident #2] was calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders. Record review of Resident #3's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #3] was sitting at table with [Resident #1] and [Resident #2]. [Resident #1] became upset with [Resident #2] and started yelling/cussing. Staff attempted to redirect [Resident #1]. [Resident #3] stayed seated in wheelchair, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #3]/[Resident #2]/staff. [Resident #3] was redirected to bedroom at this time. [Resident #3 assessed. No injuries noted r/t coffee. [Resident #3] calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders at this time. RP notified. Interview on 07/10/25 at 10:24 AM, LVN A revealed Resident #3 was a little confused. She revealed Resident #2 was talking to Resident #3 and Resident #2 said to Resident #3: you're talking to Resident #2 now. LVN A revealed Resident #1 was yelling at Resident #2, while Resident #2 and Resident #3 remained quiet. LVN A revealed she moved Resident #2 and Resident #3 away from Resident #1 and told Resident #1 to not yell because he was scaring the residents. She revealed Resident #1 got coffee and while LVN A stood in between Resident #1 and Resident #2 and Resident #3, LVN A revealed Resident #1 pushed her and threw his coffee (the coffee was cool) on Resident #2 and Resident #3. LVN A revealed they had to get their clothes changed. LVN A revealed Resident #1 denied the incident and he always said nothing is his fault. LVN A revealed she interviewed Resident #3 and Resident #3 seemed unaffected because she was still wanting to sit with Resident #1 at mealtimes. LVN A further revealed Resident #1 did not typically behave this way with other residents. Interview on 07/10/25 at 11AM, Resident #1 revealed he liked to try to get along with all the residents, but he felt he made it known with his demeanor for others to not mess with him or he thought so. He revealed sometimes he did yell at others but not unless someone messed with him. He revealed he did not intentionally throw coffee on someone. He revealed he held his cup of coffee and then a staff member grabbed him, which spilled the coffee out of his cup and onto the individuals. Interview on 07/10/25 at 01:35 PM, Resident #2 revealed there was a 675863 Page 2 of 6 675863 07/11/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident walking around and kissing every girl. He was unable to identify the resident's name. Resident #2 revealed he stopped this resident and then this resident threw coffee on him. He revealed he did not like this and said, how would you like it if someone threw coffee on you? He revealed it was hot coffee (clarified that he felt it was hot to him), but he was okay physically. He revealed he had not seen this resident since this incident but if he saw him, he would get upset. He revealed he did not tell the staff about his feelings. Interview on 07/10/25 at 02:01 PM, Resident #3 revealed she did not recall this incident on 07/05/25, however, she felt safe with Resident #1. Interview on 07/10/25 at 02:22 PM, the DON revealed Resident #1 never had any physical interaction with other residents. She revealed he would have more verbal interactions. Interview on 07/10/25 at 02:50 PM, Social Worker B revealed she interviewed Resident #2 and Resident #3, and they were fine after the 07/05/25 incident. She revealed she interviewed them on the Monday she came back to work (2 days after the incident occurred), because the incident occurred on a Saturday. She revealed Resident #2 did not have a problem with Resident #1 and Resident #3 liked spending time with Resident #1. Interview on 07/10/25 at 03:30 PM, Social Worker C (who was Resident #2's new Social Worker as he moved to the secured unit) revealed she interviewed Resident #2 today and he had to be reminded about the incident on 07/05/25 and that he didn't seem affected by the incident as he said he felt okay after that incident. Interview on 07/11/25 at 11:50 AM, the DON revealed LVN A did not grab Resident #1 during 07/05/25 incident, and the DON revealed she would not allow a staff member grab any resident (as was stated by Resident #1 in his interview) and staff were trained to not grab any resident. Interview 07/11/25 at 11:52 AM, the Psych Doctor revealed Resident #1 did get agitated and had a short fuse (meaning he was quick to react). He revealed Resident #1 had no aggressive behaviors around others and his aggression happened with cause. He revealed he was aware of all incidents involving Resident #1's behaviors so he had been working on improving Resident #1's behaviors and was not just relying on medications. Interview on 07/11/25 at 4:11PM. the ADM revealed she did not think this incident on 07/05/25 was abuse otherwise she would have reported it. She revealed this incident was not reportable per the Long-Term Care Provider Letter. She revealed Resident #1 threw his coffee out of frustration and did not aim it towards any one. Record review of facility policy titled, Abuse Guidance: Preventing, Identifying, and Reporting, revised January 2024, reflected, If anyone harms or threatens to harm a resident/patient, neglect their care, takes their property, or violates their dignity, the resident, has the right to file a complaint. Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitor, etc. to promptly report any incident of suspected neglect or resident abuse. Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies. 675863 Page 3 of 6 675863 07/11/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

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 interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 2 of 8 residents (Resident #2 and Resident #3) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident that occurred on 07/05/2025 in which Resident #1 threw lukewarm coffee, yelled, and cussed at Resident #2 and Resident #3. This incident has still not been reported in TULIP. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included:Record review of Resident #1's admission Record, dated 06/08/25, reflected a [AGE] year-old man admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities) and anxiety disorder (feeling apprehensive, uneasy, or nervous about something). Record review of Resident #1's quarterly MDS assessment, dated 04/22/25, reflected Resident #1 had not exhibited wandering behavior and had a BIMS score of 13/15, indicating intact cognition. Resident #1 did not have physical behavioral symptoms directed toward others. Record review of Resident #1's care plan, undated, reflected At risk for psycho-social issues: emotional distress or behaviors r/t: dementia w/agitation dx, exposure to war. 7/5/25 Resident to staff and resident to resident physical aggression, yelled/cursed out loud, pushed LVN and threw warm/cool coffee at staff and two residents. With interventions 7/5/25- Increased monitoring when in common areas and around other residents. And 7/5/25- Senior Psych Med Intervention., Administer Medications as ordered., Calm and re-assure resident/patient is safe, Keep environment calm, quiet and avoid loud noises as much as possible., Redirect/educate/intervene as needed., Refer to Mental Health Providers as indicated. Referred to [Psych Services]., Refer to social service as indicated., and Separate away from other resident as needed. Record review of Resident #2's admission Record, dated 06/08/25, reflected an [AGE] year-old male admitted [DATE] with diagnoses to include dementia (loss of cognitive functioning-such as thinking, remembering, and reasoning-to the extent that it interferes with a person's daily life and activities), Alzheimer's disease (most common form of dementia), anxiety (feeling apprehensive, uneasy, or nervous about something), and depressive episodes. Record review of Resident #2's admission MDS assessment, dated 06/30/25, reflected Resident #2 had not exhibited wandering behavior and had a BIMS score of 10/15, indicating moderate impaired cognition. Record review of Resident #2's care plan, undated, reflected Psycho-social/Behavioral Risk: Depressive Episodes, Hx of Childhood Abuse. Loneliness at times., dated 06/26/25 with interventions RISK-BEHAVIORS MONITORING-Calm and re-assure resident/patient is safe. Record review of Resident #3's admission Record, dated 06/10/25, reflected an [AGE] year-old female admitted [DATE] with diagnoses to include major depressive disorder and cognitive communication deficit. Record review of Resident #3's quarterly MDS assessment, dated 05/15/25, reflected Resident #3 had a BIMS score of 6/15, indicating severe impaired cognition. Record review of Resident #3's care plan, undated, reflected I have mood/behavior problems-feels tired, trouble concentrating on things, sad mood/depressed. Record review of Resident #1's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected During breakfast [Resident #1] was sitting next to [Resident #3] and [Resident #2]. [Resident #3] was talking with [Resident #2] when [Resident #1] became upset and started yelling and cussing at [Resident #2]. Staff attempted to redirected, [Resident #1] then stood up, continuing to yell/cuss. Stating no one in here cares if I'm yelling. I can do what I want, what are you going to do about it. [Resident #1] then pushed [LVN A], and 675863 Page 4 of 6 675863 07/11/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few threw lukewarm/cool coffee across staff, [Resident #3] and [Resident #2]. Able to redirect resident to bedroom at this time, while [Resident #1] continued yelling down hallway. [Resident #1] states He is the one that started it by talking to my lady. [Resident #1] assessed. No injuries noted. [Psych] notified and [medications prescribed]. Continue to monitor behaviors. PCP/RN Supervisor/Administrator/DON notified. [Resident #1] consented to medication at this time. Record review of Resident #2's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #2] was sitting at a table with [Resident #3] and [Resident #1]. [Resident #1] became upset and started yelling/cussing at [Resident #2]. Staff attempted to redirect [Resident #1]. [Resident #2] stayed seated, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #2]/[Resident #3]/staff. [Resident #2] was redirected to bedroom at this time. Resident #2 was assessed. No injuries noted r/t coffee. [Resident #2] was calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders. Record review of Resident #3's Nursing Progress Note, dated 07/05/25 at 08:05 AM and authored by LVN A, reflected, During breakfast [Resident #3] was sitting at table with [Resident #1] and [Resident #2]. [Resident #1] became upset with [Resident #2] and started yelling/cussing. Staff attempted to redirect [Resident #1]. [Resident #3] stayed seated in wheelchair, while [Resident #1] continued yelling/cursing, then threw luke warm/cool coffee on [Resident #3]/[Resident #2]/staff. [Resident #3] was redirected to bedroom at this time. [Resident #3 assessed. No injuries noted r/t coffee. [Resident #3] calm and sitting at bedside. PCP/RN Supervisor/Administrator/DON notified. No new orders at this time. RP notified. Interview on 07/10/25 at 10:24 AM, LVN A revealed Resident #3 was a little confused. She revealed Resident #2 was talking to Resident #3 and Resident #2 said to Resident #3: you're talking to Resident #2 now. LVN A revealed Resident #1 was yelling at Resident #2, while Resident #2 and Resident #3 remained quiet. LVN A revealed she moved Resident #2 and Resident #3 away from Resident #1 and told Resident #1 to not yell because he was scaring the residents. She revealed Resident #1 got coffee and while LVN A stood in between Resident #1 and Resident #2 and Resident #3, LVN A revealed Resident #1 pushed her and threw his coffee (the coffee was cool) on Resident #2 and Resident #3. LVN A revealed they had to get their clothes changed. LVN A revealed Resident #1 denied the incident and he always said nothing is his fault. LVN A revealed she interviewed Resident #3 and Resident #3 seemed unaffected because she was still wanting to sit with Resident #1 at mealtimes. LVN A further revealed Resident #1 did not typically behave this way with other residents. Interview on 07/10/25 at 11AM, Resident #1 revealed he liked to try to get along with all the residents, but he felt he made it known with his demeanor for others to not mess with him or he thought so. He revealed sometimes he did yell at others but not unless someone messed with him. He revealed he did not intentionally throw coffee on someone. He revealed he held his cup of coffee and then a staff member grabbed him, which spilled the coffee out of his cup and onto the individuals. Interview on 07/10/25 at 01:35 PM, Resident #2 revealed there was a resident walking around and kissing every girl. He was unable to identify the resident's name. Resident #2 revealed he stopped this resident and then this resident threw coffee on him. He revealed he did not like this and said, how would you like it if someone threw coffee on you? He revealed it was hot coffee (clarified that he felt it was hot to him), but he was okay physically. He revealed he had not seen this resident since this incident but if he saw him, he would get upset. He revealed he did not tell the staff about his feelings. Interview on 07/10/25 at 02:01 PM, Resident #3 revealed she did not recall this incident on 07/05/25, however, she felt safe with Resident #1. Interview on 07/10/25 at 02:22 PM, the DON revealed Resident #1 never had any physical interaction with other residents. She revealed he would have more verbal interactions. Interview on 07/10/25 at 02:50 PM, 675863 Page 5 of 6 675863 07/11/2025 Frank M Tejeda Texas State Veterans Home 200 Veterans Dr Floresville, TX 78114

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Social Worker B revealed she interviewed Resident #2 and Resident #3, and they were fine after the 07/05/25 incident. She revealed she interviewed them on the Monday she came back to work (2 days after the incident occurred), because the incident occurred on a Saturday. She revealed Resident #2 did not have a problem with Resident #1 and Resident #3 liked spending time with Resident #1. Interview on 07/10/25 at 03:30 PM, Social Worker C (who was Resident #2's new Social Worker as he moved to the secured unit) revealed she interviewed Resident #2 today and he had to be reminded about the incident on 07/05/25 and that he didn't seem affected by the incident as he said he felt okay after that incident. Interview on 07/11/25 at 11:50 AM, the DON revealed LVN A did not grab Resident #1 during 07/05/25 incident, and the DON revealed she would not allow a staff member grab any resident (as was stated by Resident #1 in his interview) and staff were trained to not grab any resident. Interview 07/11/25 at 11:52 AM, the Psych Doctor revealed Resident #1 did get agitated and had a short fuse (meaning he was quick to react). He revealed Resident #1 had no aggressive behaviors around others and his aggression happened with cause. He revealed he was aware of all incidents involving Resident #1's behaviors so he had been working on improving Resident #1's behaviors and was not just relying on medications. Interview on 07/11/25 at 4:11PM. the ADM revealed she did not think this incident on 07/05/25 was abuse otherwise she would have reported it. She revealed this incident was not reportable per the Long-Term Care Provider Letter. She revealed Resident #1 threw his coffee out of frustration and did not aim it towards any one. Record review of TULIP did not reflect a facility reported incident that corresponded to the allegations in the incident described above. Record review of facility policy titled, Abuse Guidance: Preventing, Identifying, and Reporting, revised January 2024, reflected, If anyone harms or threatens to harm a resident/patient, neglect their care, takes their property, or violates their dignity, the resident, has the right to file a complaint. Identification- It is the responsibility of our team members, consultants, attending physicians, family members, visitor, etc. to promptly report any incident of suspected neglect or resident abuse. Reporting/Response- All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies. 675863 Page 6 of 6