Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at William R Courtney Texas State Veterans Home during CMS and state inspections, most recent first.
Failure to immediately notify an RP of a resident’s change in condition. A resident with a UTI and intact cognition was placed on contact isolation for E. coli in her urine, but the RP was not informed of the infection or isolation status. Nursing documentation and interviews showed the family learned of the change only after coming to the facility, and the DON confirmed the charge nurse was responsible for immediate notification.
A resident with dementia and documented physical aggression had an MDS assessment indicating behavioral symptoms, but the comprehensive care plan was not revised to include interventions for physical aggression related to anger. Despite facility expectations and policy requiring current, person-centered interventions, the MDS Coordinator did not update the care plan with one-to-one behavioral interventions after the aggressive episode, leaving the care plan without documentation of the measures in place to address the resident’s behavior.
A resident with dementia, multiple chronic conditions, and severe cognitive impairment had physician orders for scheduled lorazepam 0.5 mg twice daily and PRN lorazepam 1 mg. Over several days, nurses signed the MAR for the 0.5 mg scheduled dose while signing out and administering 1 mg tablets on the narcotic count sheet, and multiple LVNs later admitted giving full 1 mg doses instead of the ordered 0.5 mg without wasting or documenting any waste. The DON and pharmacy nurse initially believed nurses were halving 1 mg tablets and failing to document waste, but staff interviews and records showed the ordered dose was not followed and controlled substance documentation was inaccurate, contrary to facility policies for medication administration and controlled substance reconciliation. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and a lack of clear protocols, which left residents vulnerable to mistreatment and delayed detection of incidents.
Two residents with cognitive impairments were involved in a physical altercation after one entered the other's room uninvited, leading to an assault. Staff intervened and assessed both residents, but did not immediately report the incident to the administrator or to state authorities as required by policy. Interviews revealed confusion among staff about the reporting process and the identity of the abuse coordinator, resulting in a failure to follow established abuse reporting procedures.
A resident with Alzheimer's and dementia eloped from an LTC facility after removing his wander guard device, which staff failed to notice was missing for a month. The resident left through the front door without being observed and checked into a hotel, where he later fell and injured himself. The facility did not consistently check the functionality and placement of wander guard devices, leading to a significant lapse in safety and care.
A resident with Alzheimer's and dementia eloped from a facility due to inadequate documentation and inconsistent staff observations. The resident, at high risk for elopement, left without notifying staff, and conflicting reports about the last sighting were noted. The facility's records were incomplete and inaccurate, contributing to the delayed realization of the resident's absence.
A resident with dementia and a history of elopement left the facility and was found at a hotel. Despite being located, the facility failed to conduct a thorough assessment of the resident's condition, as required by their policies. The resident later reported a fall at the hotel, which was not documented or assessed by the facility staff.
A facility failed to inform a resident's family of a change in condition involving alleged verbal abuse. The resident, with severe cognitive impairment, was spoken to disrespectfully by another resident. The incident was reported to the ADM, but the family was not informed as required by facility policy, potentially risking resident safety.
A facility failed to report an allegation of verbal sexual abuse between two residents to the State Survey Agency within the required 24-hour timeframe. The incident was reported to the ADM by a CNA, but the report to HHSC was delayed by 11 days. The involved residents, one with severe cognitive impairment and legal blindness, and the other cognitively intact, both denied the allegations. The delay in reporting could place residents at risk for further abuse.
Failure to Notify RP of Contact Isolation for E. coli
Penalty
Summary
The facility failed to immediately notify Resident #1’s responsible party when she was placed on contact isolation precautions for E. coli in her urine. Resident #1 was a [AGE]-year-old female admitted with a history of urinary tract infection, and her quarterly MDS reflected BIMS 15 with intact cognition and total incontinence of bladder and bowel. A nursing note documented that she remained on antibiotic therapy for a UTI and was on contact isolation for E. coli, with isolation precautions in place and staff reminders for handwashing and PPE use. A nursing progress note stated that the family came in upset because they had not been notified that Resident #1 had been placed on enhanced barrier precautions related to E. coli in her urine. During interviews, Resident #1 stated that her RP was not notified when she was put on isolation after her roommate moved out, and the RP stated she learned of the infection and isolation only when she came to the facility and spoke with Resident #1. The DON stated the facility policy required immediate notification of the Medical Director, nurse practitioner, and RP for a change in condition, and that the charge nurse was responsible for notifying the RP about the E. coli and contact isolation status.
Failure to Update Care Plan for Resident’s Physical Aggression Related to Dementia
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a person-centered care plan to reflect a resident’s current condition and behavioral needs. A male resident with vascular dementia, Alzheimer’s disease, and major depressive disorder was admitted on 02/23/2026. His Quarterly MDS assessment dated 02/18/2026 showed he was unable to complete the BIMS interview and documented the presence of physical aggression. The resident’s care plan, originally initiated in 2024 for cognitive impairment related to dementia, included interventions such as maintaining a consistent routine and caregivers to decrease confusion. However, the care plan dated 02/22/2026 did not include interventions addressing physical aggression related to anger due to dementia that occurred on 02/15/2026. Interviews with facility staff confirmed that the care plan was expected to reflect current interventions for the behavior noted on 02/15/2026 and that the MDS Coordinator was responsible for updating the care plan. The DON stated that without the updated interventions, the care plan would not show what had been put in place for the resident. The MDS Coordinator acknowledged responsibility for updating the care plan with one-to-one interventions so staff would know how to assist the resident and admitted failing to update the most recent intervention date of 02/15/2026. The Administrator also stated it was expected that the MDS Coordinator would have updated the resident’s behavior interventions on the care plan to ensure the resident’s individual needs would be met. The facility’s policy on comprehensive person-centered care plans requires development and implementation of care plans with measurable objectives and targeted interventions based on identified problem areas and their causes.
Failure to Administer and Document Lorazepam per Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services, including accurate acquiring and administering of medications, for one resident who had physician orders for both scheduled and PRN lorazepam. The resident was an elderly male with vascular dementia, Alzheimer’s disease, type 2 diabetes, atrial fibrillation, chronic kidney disease, and a history of repeated falls, and had a BIMS score indicating severe cognitive impairment. His care plan included pain medication therapy with monitoring and documentation of side effects and effectiveness each shift. Physician orders in the EMR included a scheduled lorazepam 0.5 mg tablet to be given every morning and at bedtime for anxiety/agitation related to dementia, and a separate PRN order for lorazepam (Ativan) 1 mg every 4 hours as needed for anxiety. Review of the December MAR showed that the scheduled 0.5 mg lorazepam doses were signed as given on multiple mornings and bedtimes, while the narcotic count sheet documented that 1 mg lorazepam tablets were signed out and administered at corresponding times. Multiple LVNs who worked those medication passes stated in interviews that they administered 1 mg lorazepam tablets instead of the ordered 0.5 mg dose, did not waste any portion of the 1 mg tablets, and did not follow the physician’s order for the 0.5 mg scheduled dose. One LVN stated the 0.5 mg tablet was not available, so the 1 mg tablet was given and documented under the 0.5 mg order in the MAR. Another LVN acknowledged signing the MAR for 0.5 mg while actually giving 1 mg and not correcting the documentation. The DON initially characterized the issue as a documentation error and stated that nurses were halving 1 mg tablets and wasting the remainder, but this was contradicted by the LVNs, who denied wasting and confirmed giving full 1 mg doses. The pharmacy nurse reported that nurses told her they were using the 1 mg PRN tablets and administering half, but also acknowledged that they had not documented any wasting on the narcotic count sheet and she did not verify whether a witness was present for any waste. The medical director stated she was aware of narcotic medication errors and nurses wasting medications and expressed concern that the resident may have received more than the scheduled lorazepam dose. The ADM and DON both stated expectations that staff follow physician orders, administer medications as ordered, and document administration and any waste correctly, and noted that incorrect MAR documentation and narcotic records create uncertainty about whether the resident actually received medications as ordered. Facility policies required medications to be administered as prescribed, documented accurately in the MAR, and controlled substances to be reconciled with appropriate records of dispensing, waste, and inventory. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, could result in worsening or exacerbation of chronic medical conditions, and hospitalization.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Failure to Timely Report Resident-to-Resident Altercation and Suspected Abuse
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, and did not establish effective policies and procedures to investigate allegations of abuse for two residents. On the date of the incident, a resident with severe cognitive impairment and a history of aggression when his space was invaded, physically assaulted another resident who had moderate cognitive impairment and a history of wandering and behavioral symptoms. The altercation occurred when the wandering resident entered the other's room uninvited, resulting in the latter punching the former and knocking him to the ground. Staff intervened to separate the residents and conducted immediate assessments, but did not identify injuries at that time. Despite the altercation, facility staff did not report the incident to the administrator immediately after it occurred, as required by facility policy. The administrator, who also served as the abuse coordinator, was not made aware of the incident until much later and only learned of it through the survey process. Interviews revealed that staff were unclear about the reporting process and the identity of the abuse coordinator, with several staff members indicating they would report incidents up the chain of command rather than directly to the administrator as required. The facility's abuse policy required immediate reporting of suspected abuse, including resident-to-resident altercations, to the administrator/abuse coordinator and to state authorities, but this was not followed. Additionally, the facility failed to report the alleged abuse to Health and Human Services as mandated. Review of the Texas Unified Licensure Information Portal showed no self-report for the incident. The lack of timely reporting and failure to follow established procedures resulted in the identification of Immediate Jeopardy by surveyors. The deficiency was attributed to the breakdown in communication and lack of adherence to the facility's abuse reporting policy, as well as insufficient staff knowledge regarding the correct reporting process.
Removal Plan
- All residents were assessed by the nurse to ensure physical and emotional well-being.
- Administrator, Social Worker, Director of Nursing, or Designee will conduct team member and resident interviews to identify any concerns. If any are identified, nursing and social service will assess, notify the physician, local authorities, and the IDT, and will review the plan of care as indicated.
- Vice President of Operations conducted re-education to the Director of Nursing and Administrator regarding Abuse and Neglect, Identifying and Preventing, ensuring identified risk is on the plan of care and appropriate monitoring and supportive interventions are in place and an investigation is conducted.
- Vice President of Operations conducted a re-education of Abuse and Neglect reporting guideline to the Director of Nursing Services and Administrator.
- The Director of Nursing Services conducted education to the Assistant Director of Nursing Services, Memory Care Director, and Health Information Coordinator on Abuse and Neglect reporting guidelines and regarding Abuse and Neglect, Identifying and Preventing, ensuring identified risk is on the plan of care and appropriate monitoring and supportive interventions are in place and an investigation is conducted.
- Director of Nursing, Assistant Director of Nursing, Health Information Coordinator, and Memory Care Director conducted re-education to the team members regarding Abuse and Neglect, Identifying and Preventing, ensuring identified risk is on the plan of care and appropriate monitoring and supportive interventions are in place.
- Director of Nursing, Administrator, or Designee provided education to all team members regarding the process for monitoring, observing, and reporting all concerns involving resident to resident altercations or signs/symptoms of abuse, neglect, or exploitation by anyone, including family, visitors, or staff, immediately to their immediate supervisor and administrator/abuse coordinator to protect the safety and well-being of all residents and to ensure appropriate interventions are in place and the care plan/Kardex are adhered to as per facility’s expected practices.
- Director of Nursing or Designee to conduct re-education for all team members on Abuse and Neglect and reporting of Abuse and Neglect to all new team members and when using agency staff.
- Ad Hoc QAPI held with Administrator, Director of Nursing, and Medical Director to review abuse and neglect policy, reporting abuse and neglect, and review the plan of removal.
- Director of Nursing, Administrator, Social Worker, or Designee will conduct random daily rounds on various shifts to validate the safety and well-being of residents by conducting safe surveys.
- Director of Nursing or Designee will utilize an audit monitoring tool to review progress notes, changes in conditions, risk management reports, and the nursing 24 hr report during the morning clinical meeting to validate appropriate follow up and necessary interventions are in place. The Administrator will provide oversight by monitoring and validating this task to confirm completions. The regional nurse assigned to the community will review this system during her visits to validate completion.
- Findings will be reported to the QAPI committee during monthly meeting. The QAPI committee will determine compliance or identify a need for additional training.
Resident Elopement Due to Inadequate Supervision and Device Monitoring
Penalty
Summary
The facility failed to ensure that a resident's wander guard bracelet was secured, leading to the resident's elopement. The resident, who had a history of Alzheimer's disease, dementia, and was at high risk for elopement, was able to remove his wander guard device and leave the facility without staff noticing. The resident's care plan indicated he was exit-seeking and at risk for elopement, yet the staff did not notice his absence until approximately 11 hours after he left. Interviews and record reviews revealed that the resident had removed his wander guard device a month prior, and staff failed to notice its absence. The resident left the facility through the front door without being observed by staff, who were reportedly on a break. The resident managed to travel to a hotel, where he checked in and later fell in the shower, sustaining a minor injury. The facility's staff did not conduct regular checks on the resident's wander guard device, which was supposed to be checked every shift for functionality and placement. The facility's investigation into the incident was found to be lacking, as there were no immediate interventions to check the functionality and placement of other residents' wander guard devices. Staff interviews indicated a lack of consistent understanding and execution of protocols for checking wander guard devices and monitoring residents at risk of elopement. The facility's failure to secure the resident's wander guard and adequately supervise him resulted in a significant lapse in safety and care.
Inadequate Documentation Leads to Resident Elopement
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was at high risk for elopement. The resident, diagnosed with Alzheimer's disease and dementia, was admitted with a history of exit-seeking behavior and required supervision for various activities of daily living. Despite these needs, the facility's documentation was incomplete and inconsistent, with significant gaps in the resident's progress notes from February 21 to March 15. This lack of documentation contributed to the staff's inability to accurately track the resident's whereabouts, ultimately leading to the resident's elopement. On March 15, the resident left the facility without notifying the staff, and there were conflicting reports about when the resident was last seen. Staff members provided varying accounts of their last observations, with some claiming to have seen the resident in the afternoon, while others reported seeing the resident in the evening. However, the resident checked into a hotel in the early afternoon, contradicting the staff's statements. The facility's records, including the Medication Administration Record (MAR) and Point of Care (POC) documentation, contained inaccuracies and discrepancies, further complicating the situation. The facility's investigation revealed that the staff failed to document the resident's care and observations accurately and timely. The lack of proper documentation and communication among staff members led to a delayed response in realizing the resident was missing. The facility's failure to maintain organized and accessible medical records placed the resident at risk and hindered the staff's ability to provide appropriate care and supervision.
Failure to Assess Resident Post-Elopement
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This deficiency was identified in the case of a resident who eloped from the facility and was later found at a hotel. The resident, who had a history of Alzheimer's disease, dementia, depression, and unsteadiness on feet, was at risk for elopement and falls. Despite these risks, the facility did not conduct a thorough assessment of the resident's condition after he was located, which could have led to untreated changes in his condition. The resident was last seen in his room on the evening of one day and was reported missing later that night. The facility initiated a search and notified the police and the resident's family. The resident was found the next day at a hotel, where he expressed his intention not to return to the facility. Although the facility's Memory Care Director conducted a visual assessment, there was no documentation of a comprehensive head-to-toe assessment in the resident's electronic health records. The resident later reported falling in the hotel shower, which was not known to the facility staff at the time. Interviews with facility staff revealed that they were aware of the importance of assessing residents after an elopement to identify any changes in condition or injuries. However, the facility's policies on elopement response and exit-seeking management were not followed, as they required a thorough evaluation of the resident's physical condition and psychosocial well-being after being located. The lack of a documented assessment and the failure to adhere to the facility's policies contributed to the deficiency in providing appropriate care to the resident.
Failure to Inform Family of Resident's Condition Change
Penalty
Summary
The facility failed to inform a resident's family and responsible party of a change in the resident's condition, specifically regarding an alleged incident of verbal abuse. A resident with severe cognitive impairment and legal blindness was allegedly spoken to disrespectfully by another resident. The incident was reported by a CNA to the ADM, but the family was not informed until the following day by the CNA, rather than by the facility staff as required. Interviews with the DON and ADM revealed that the facility's protocol was not followed, as the charge nurses were responsible for notifying the family of any suspected abuse. The facility's policy mandates that changes in condition be promptly reported to the family or responsible party, which did not occur in this case. The failure to notify the family could potentially place residents at risk by not involving their responsible parties in ensuring their safety.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report allegations of verbal sexual abuse between two residents to the State Survey Agency within the required 24-hour timeframe. The incident was initially reported to the Administrator (ADM) by a Certified Nursing Assistant (CNA) on November 7, 2024, but the ADM did not report it to the Health and Human Services Commission (HHSC) until November 18, 2024. The facility's policy mandates that such allegations be reported immediately, but no later than 24 hours if they do not involve serious bodily injury. The delay in reporting was acknowledged by the ADM during an interview, who stated that the report should have been made on the day the allegation was reported to him. The incident involved a male resident with severe cognitive impairment and legal blindness, who was allegedly verbally abused by another male resident who was cognitively intact. The alleged verbal abuse was reported by the resident's Responsible Party (RP) after being informed by the CNA. However, the RP was not notified by the facility about the investigation until she visited the facility. Interviews with the involved residents revealed that both denied the allegations. The facility's failure to report the incident in a timely manner could place residents at risk for further abuse, as noted in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 86 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Temple
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellington Rehabilitation And Healthcare | 1.3 mi | ★★★★★ | 2 | 1 |
| Baylor Scott & White Continuing Care Hospital Skil | 1.4 mi | ★★★★★ | 1 | 0 |
| Avir At Weston | 1.7 mi | ★★★★★ | 3 | 0 |
| Cornerstone Gardens Llp | 1.8 mi | ★★★★★ | 0 | 0 |
| Avir At Temple East | 2 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.