Failure to Investigate Allegations of Abuse and Neglect
Summary
The facility failed to thoroughly investigate and document allegations of abuse and neglect involving two residents. One resident alleged that a CNA made inappropriate sexual advances, while another resident reported that a CNA caused an injury during care. Despite these serious allegations, the facility did not conduct thorough investigations or report the incidents to the appropriate authorities in a timely manner. The first resident, who had a history of making false allegations, claimed that a CNA wanted to engage in inappropriate behavior. The facility's records did not show any investigation into this allegation, and the CNA continued to work at the facility until terminated for unrelated reasons. The second resident reported hearing a pop during care, which was later diagnosed as a chronic fracture. The facility did not suspend the CNA involved or report the incident as required, despite the resident's repeated claims of injury. Interviews with staff revealed a lack of consistent reporting and investigation procedures. Some staff members were unaware of the allegations, while others did not report them due to the residents' histories or perceived lack of intent. The facility's failure to act on these allegations placed residents at risk of further abuse and neglect, as the necessary protective measures were not implemented.
Removal Plan
- Resident #1 was discharged from the facility.
- An Allegation of Abuse was reported to HHSC for Resident #1.
- The Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
- The Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
- Resident #2 was interviewed regarding abuse and neglect with no reports and/or allegations of being abused and/or neglected.
- Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted.
- An allegation of abuse was reported to HHSC for Resident #2.
- The Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The Administrator and/or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified.
- Head to toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment with no concerns identified.
- The Administrator and/or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted.
- The DON/designee reviewed the resident progress notes to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified.
- The DON/Designee reviewed incident/accidents to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified.
- The Administrator and/or Designee reviewed resident grievances to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified.
- The Regional President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation.
- The Administrator/DON and/or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift.
- The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required.
- The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation.
- To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head to toe assessments were completed and provided.
- The Administrator will monitor to ensure new resident incidents are reviewed daily to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided.
- Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation.
- The facility has the Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/concerns will be reported to the Administrator/Abuse Coordinator immediately.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Investigate Possible Resident-to-Resident Sexual Abuse: Two residents with severe cognitive impairment were repeatedly found unclothed together, but the facility did not assess either resident’s capacity to consent or complete a formal abuse investigation. The record also showed bruising and a report of bloody vaginal discharge for one resident, and staff, including the DON, stated no assessments or investigations were completed and the encounters were assumed to be consensual based on the residents’ behavior.
A CNA reported that another CNA forcibly grabbed a resident, pushed the resident into a wheelchair, blocked the resident with a table, and used profanities toward the resident. The RN supervisor and DON did not initiate an immediate abuse investigation, did not complete a resident assessment or incident documentation, did not notify the provider, and did not remove the accused CNA from access to the resident. The resident had dementia with moderately impaired cognition and a care plan noting potential for abuse related to resistance of care, verbal aggression, and physical aggression.
Failure to investigate and document an allegation of neglect: an RN received a Nursing Student’s report that a CNA was not providing cares and residents were left soaking wet and unchanged, and the complaint/grievance form was texted to the former ADM, DON, and SSD. The facility did not make its initial report to the SA until weeks later, the original grievance form could not be located, and no written investigation record was produced even though policy required prompt interviews of residents and staff and a written record.
Incomplete Investigation of Alleged Abuse: The facility did not have evidence that an allegation that a resident was pinched by staff was thoroughly investigated. The resident had moderate cognitive impairment and bruising to the L forearm. The provider investigation report lacked an identified perpetrator, documentation of who was contacted, and witness statements. The ADM and DON interviewed the resident and completed safe surveys, but no written staff statements were available and the investigation documentation was incomplete.
A facility failed to timely investigate allegations that nurses were taking insulin from one resident and giving it to another when insulin syringes were reportedly unavailable. Residents and LPNs described sharing insulin pens and vials between residents, and one resident reported missing insulin on at least one occasion. The DON was notified of the concern but initially only checked supply availability rather than interviewing residents or staff about whether insulin had been borrowed or misused.
A resident with stroke-related deficits, impaired cognition, and extensive care needs reported that an LPN inserted his finger into her anus during bowel care and continued despite her crying and asking him to stop. The family also reported the procedure was painful and distressing. The facility’s response was incomplete: the DON was not aware of an earlier progress note about the family’s complaint, no immediate rectal assessment was done, the initial body audit did not include the peri-rectal area, and resident interviews were delayed and limited to only a small sample of residents.
Failure to Investigate Possible Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to investigate potential resident-to-resident sexual abuse involving two residents with significant cognitive impairment, R58 and R61. R58’s annual MDS identified severe cognitive impairment, and diagnoses included Alzheimer’s disease, neurocognitive disorder with Lewy bodies, and dementia; R61’s quarterly MDS also identified severe cognitive impairment, with diagnoses including Alzheimer’s disease and dementia with psychotic disturbance. Both residents were identified in care plans as vulnerable adults, and staff were directed to report and investigate any allegations or suspected abuse, neglect, or exploitation. The record documented repeated incidents in which the residents were found together in bed unclothed or undressed, including on 10/3/25, 11/19/25, and 5/7/26. The record failed to show that the facility assessed either resident’s capacity to consent to sexual activity after any of the incidents, and the facility did not complete a formal abuse investigation to determine whether the encounters were consensual. The record also documented bruising on R58’s forearms, right anterior thigh, and inner thigh, as well as a report of bloody vaginal discharge, but there was no evidence these findings were investigated in relation to the known sexual activity. RN-A stated she did not know whether assessments or investigations had been completed, LPN-A stated she documented the 5/7/26 incident but did not complete assessments or investigations, and the DON stated no assessments had been conducted to evaluate injury or capacity to consent and that the facility did not complete a formal investigation because staff believed the encounters were consensual.
Failure to Investigate Abuse Allegation and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident and failed to implement immediate protective actions after a CNA reported observing another CNA forcibly grab the resident, push the resident into a wheelchair, and use a dining room table as a barrier to keep the resident from getting out of the wheelchair. The reporting CNA also stated they heard repeated profanities directed at the resident. The resident had diagnoses including dementia, depression, and anemia, and the admission MDS documented moderately impaired cognition. The resident’s psychosocial care plan identified a potential for abuse related to resistance of care, verbal aggression, and physical aggression. After the allegation was reported to an LPN and an RN supervisor, the RN supervisor did not initiate an immediate investigation at the time of discovery. The resident was not assessed for physical injury or psychosocial harm, no incident report or abuse investigation was documented, and the medical provider was not notified. The resident’s representative was not contacted until later, and there was no documented psychiatric consultation. The staff member accused of abuse was not removed from access to the resident or other residents, and the resident continued to be assigned to that staff member on subsequent shifts. Statements obtained from staff reflected conflicting accounts of the interaction in the dining/dayroom area of the locked memory care unit. One CNA reported seeing the resident being pushed and blocked in by a table, while the accused CNA stated the resident was yelling, cursing, and being redirected, and denied pinning the resident against a wall or blocking the resident with a table. The RN supervisor acknowledged that no accident and incident report, investigative summary, body assessment, resident assessment, or abuse investigation was completed on the day the allegation was reported, and that the accused CNA remained on the unit. The DON and administrator also stated the allegation was not reported as abuse because it was not believed abuse had occurred.
Failure to Investigate and Document Allegation of Neglect
Penalty
Summary
The facility failed to ensure an allegation of neglect was thoroughly investigated and documented after a Nursing Student reported that a CNA had not provided cares to residents on her unit. The allegation was first made to an RN, who described neglect as delayed care, staff isolation of residents, not giving medications, or not implementing interventions. The RN stated she notified the former Administrator, instructed the Nursing Student to complete a complaint/grievance form, took a picture of it, and texted it to the former Administrator. The RN also stated she later spoke with him by phone and relayed what had been reported, but she did not receive any status updates on the outcome of the investigation. The facility’s records showed the allegation was initially made on March 27, 2026, but the facility did not make its initial report of neglect to the State Agency until April 17, 2026, about 21 days later, and then initiated an investigation. Review of the State Agency complaint portal found no other self-report or 5-day investigation report for the alleged timeframe. The SSD stated that suspected neglect is reported to her as the abuse coordinator, that the grievance form was completed and sent by text to her, the DON, and the former Administrator, but she was unable to locate the specific form in the binder and said she was not assigned to investigate because the former Administrator said he would conduct the investigation. The DON acknowledged receiving the texted grievance form stating that residents were soaking wet all day and remained unchanged. She recalled speaking with the former Administrator and said he assumed responsibility for follow-up, but when asked to produce the original complaint/grievance form, it was missing. The former Administrator denied being notified of the allegation and denied receiving the texted form, though he acknowledged he was the abuse coordinator and expected to be available while traveling. A senior corporate clinical leader stated the former Administrator said he investigated by speaking with residents and staff, but no documentation of that investigation was provided. The facility policy required suspected neglect to be investigated as soon as practicable by interviewing residents and staff and maintaining a written record of the investigation.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to have evidence that an allegation of abuse involving a resident’s report that a staff member pinched her was thoroughly investigated. Resident #4 was an older female admitted to the facility with a diagnosis of cerebral infarction and a BIMS score of 08, indicating moderate cognitive impairment. Her care plan noted two bruises to the left forearm and included interventions related to monitoring and documenting bruising and skin condition. According to the provider investigation report, on 05/15/2026 Resident #4 told the ADON that she believed a staff member had pinched her during care. The report did not identify an alleged perpetrator, did not document who was contacted about the allegation, and did not include witness statements. The report reflected that safe surveys were completed and abuse and neglect in-services were provided, but it did not contain documentation showing a complete investigative process. During interviews, the ADM stated he interviewed Resident #4, who could not recall a specific date or time of the incident, could not describe the staff member, and could not identify the color of the staff member’s scrubs. The ADM stated he instructed the DON to call staff who worked the relevant night shifts, start in-services, and conduct safe surveys. The DON stated she called staff who worked those shifts and that no staff knew anything about the bruises, but no written statements were available. The DON also stated she believed the bruises may have been caused by the lid of the bedside commode, and staff reported that Resident #4 often transferred herself to the commode despite requiring one-person assistance. The facility policy stated that all reports of abuse, including injuries of unknown origin, are to be thoroughly investigated and that findings of all investigations are to be documented and reported.
Failure to Timely Investigate Insulin Misappropriation Allegations
Penalty
Summary
The facility failed to timely investigate allegations that nurses were taking and using insulin from one resident for another when insulin syringes were reportedly unavailable. The deficiency involved residents who were receiving insulin, including residents with diabetes, and the report identified four residents as affected by the misappropriation concern. Resident #32 was cognitively intact and on both basal and sliding-scale insulin; Resident #15 had severe cognitive impairment and was on insulin; Resident #12 was cognitively intact and on insulin; and Resident #16 reported missing insulin one day and receiving insulin from another resident on other days when syringes were unavailable. Resident and staff interviews described that for about a week the facility was out of insulin syringes, and nurses responded by borrowing insulin pens or vials from other residents and administering them to residents who needed insulin. Resident #32 stated she heard nurses discussing sharing insulin needles and was told by an LPN that they were sharing insulin pens between residents because the facility was out of syringes. LPNs stated they took insulin from other residents and gave it to others, with one LPN saying she had no choice and another acknowledging she knew it was wrong. One LPN stated she likely took Resident #32's insulin or gave her someone else's insulin, and another stated she took Resident #12's insulin vial and gave it to Resident #15 or vice versa. The DON was notified by the Ombudsman that there was concern about insulin syringes not being available, but she stated she only checked whether syringes were currently in the building and did not interview residents or nurses at that time to determine whether insulin had been missed or borrowed from other residents. The SRI later documented an allegation of misappropriation involving staff taking insulin from one resident and giving it to another without consent. The facility policy required residents to be free from misappropriation and required a thorough investigation of alleged violations, but the report states the facility did not timely investigate the allegations.
Failure to Thoroughly Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse and failed to protect residents during the investigation for a resident who reported sexual abuse during bowel care. The resident had a recent stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder with mixed anxiety and depressed mood, moderately impaired cognition, and required extensive assistance with personal care, transfers, toileting, and dressing. She used a manual wheelchair and was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. Her care plan identified her as at risk for abuse and/or neglect and directed staff to keep her safe and follow the facility vulnerable adult policy. The allegation arose after the resident received treatment for constipation that included a rectal suppository and manual stool removal. Progress notes documented that the resident’s daughter complained the procedure was painful and that the family was dissatisfied with the nurse who performed it. The resident later stated that the nurse inserted his finger into her anus, kept circling it, and continued despite her crying and asking him to stop. She reported that he smiled at her while she was being hurt and later described feeling embarrassed, vulnerable, and fearful that he might return and retaliate. The facility’s report to the State Agency identified the allegation as sexual abuse and stated the most recent occurrence was in the resident bathroom. The investigation documented interviews with the alleged perpetrator, two NAs, and six residents out of 60, but the record also showed gaps in the response. The DON stated she was not aware of the incident until the family voiced concerns on 5/18/26 and that she was not aware of the 5/17/26 progress note describing the family’s complaint until later. The DON also stated no physical exam was completed at the time of the allegation, the resident’s rectal area was not assessed in the initial body audit, and resident interviews were not started until 5/22/26. The DON and administrator stated that all residents who could be interviewed should have been interviewed, and that residents unable to speak for themselves should have been checked for signs of distress, but this was not done at the time of the allegation.
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