F0600

E

Failure to Protect Residents From Verbal and Physical Abuse by an LVN

San Antonio, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The facility failed to protect three residents from abuse by LVN B, in violation of its abuse, neglect, and exploitation policy. One resident, an older female with anxiety disorder, hypertensive heart disease, and major depressive disorder, had a BIMS score of 13 indicating no cognitive impairment and was care planned for depression, anxiety, and fall precautions. She reported that LVN B was not nice, acted like a bully, and that the situation involving her money "went too far," stating it was none of the nurse’s business what she did with her money. Staff interviews indicated that LVN B questioned this resident about giving $200 to another resident and continued to antagonize her about the money.

Another resident, a 66-year-old male with end stage renal disease, type 2 diabetes, and anxiety disorder, had a BIMS score of 15 indicating he was cognitively intact and was care planned for dialysis and right below-knee amputation. He reported that he and LVN B were "going back and forth" verbally, and that she hit him, pushed his wheelchair, and pushed him in the chest in front of other workers, after which he hit her back. Multiple staff interviews (MA C and CNA D) described that this resident and another were playing chess and listening to the television when LVN B repeatedly told him to turn the television down, unplugged the television when he did not comply to her satisfaction, told him to go back to his room, blocked his access to the nurses’ station and the posted Administrator’s phone number by using a medication cart, and grabbed his arm/wrist and held it against his chest. CNA D stated the resident said it hurt and sounded like he was about to cry while asking if she was going to let him go.

A third resident, an older male with type 2 diabetes, COPD, schizophrenia, and anxiety disorder, had a BIMS score of 5 indicating severe cognitive impairment but was able to be interviewed and recall the incident with LVN B. He stated he was angry about what the nurse did, described her as very disrespectful with a bad attitude, and said he had signed himself out and wanted to listen to his radio on the porch, but she would not enter the code to allow him to go outside. The Administrator reported that another staff member (MA E) recorded an incident in which LVN B told this resident he could not go outside on the front porch to listen to music after he had signed himself out, and that during the exchange the resident told LVN B to shut up and she told him to shut up, further telling him he needed to go back upstairs, that he did not live on that unit, and that he should go upstairs to "disrespect" the nurses there. These events, as reported by residents and staff, demonstrate that the facility did not ensure residents’ right to be free from verbal and physical abuse by staff.