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F0600
G

Failure to Prevent Resident Abuse and Neglect

Glen Rose, Texas Survey Completed on 05-11-2025

Penalty

Fine: $14,015
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from abuse and neglect. In one incident, a male resident with multiple cognitive and behavioral diagnoses, including delusional disorder, dementia, and impulse disorder, was subjected to verbal abuse by a hospitality aide (HA). The aide yelled at the resident, used profane and derogatory language, and refused to provide care after the resident expressed discomfort due to being wet. The incident was witnessed by other staff, and the aide admitted to using inappropriate language, citing personal stress as a trigger. The resident did not recall the event and showed no signs of distress or injury upon assessment. In a separate incident, a female resident with severe cognitive impairment, dementia, and major depressive disorder was physically abused by her spouse during a visit. The spouse slapped the resident on the cheek after she spit water on him, resulting in visible redness. The event was witnessed by staff, who immediately intervened and separated the resident from her spouse. The resident did not display emotional distress or behavioral changes following the incident, and her family and staff reported no prior history of aggression from the spouse. Both incidents were confirmed through interviews with staff, the residents' family members, and review of medical records and facility policies. The facility's failure to prevent these instances of verbal and physical abuse constituted noncompliance with regulations designed to protect residents from abuse, neglect, and exploitation.

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