F0609

D

Failure to Report Allegation of Neglect to State Agency

Plano, Texas Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to report an allegation of neglect and abuse to the State Agency within the required timeframe. On 11/28/2025, law enforcement responded to the facility at 8:55 AM for a complaint of elder abuse after a resident reported that staff had not changed his brief in over five hours. The facility’s own abuse policy required that any person with reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state, and/or adult protective services, and that the administrator or designee must report qualifying incidents to HHSC within specified timeframes. Despite this, the allegation made on 11/28/2025 that the resident’s brief had not been changed in five hours was not reported to the State Agency.

The resident involved was an adult male with a BIMS score of 15, indicating intact cognition, and diagnoses including congestive heart failure, Type II diabetes, hyperlipidemia, major depressive disorder, and hypertension. He used a manual wheelchair and required one-person assistance for transfers, turning, positioning, dressing, and toileting, and had frequent bowel incontinence requiring staff assistance with incontinent care. During an observation and interview on 1/20/2026, the resident stated he had called the police because it took five hours before someone came to change his brief. He reported that he was changed before breakfast, later used his call light for help changing his brief, and that although someone entered his room to bring his meal, they did not change him at that time.

Interviews with staff confirmed that the allegation was known to facility leadership but not reported as required. The DON stated he was present when law enforcement responded, spoke directly with the officer about the abuse allegation, and then informed the administrator, whom he identified as the abuse coordinator responsible for reporting allegations to HHSC. The DON denied that the resident went five hours without care and stated the resident was changed before and after breakfast. CNA A, who worked both shifts that day, reported that the resident required assistance for bowel movements and could not clean himself, and stated that neither he nor other residents had to wait five hours to be changed. LVN B reported the resident was changed before breakfast around 8:00 AM and that residents are checked before each meal, denying the resident was left unattended for five hours. The current administrator, who assumed the role after the incident, stated that the event would have been a reportable allegation and acknowledged that such allegations must be reported to HHSC.