F0609

J

Failure to Immediately Report and Remove Staff After Alleged Abuse Incident

Ralls, Texas Survey Completed on 01-14-2026

Penalty

Fine: $25,480

Summary

The deficiency involves the facility’s failure to ensure that an allegation of abuse was reported immediately, as required by policy and federal regulations, and that involved staff were removed from contact with the resident pending investigation. A cognitively impaired female resident with Alzheimer’s disease, schizoaffective disorder, paranoid schizophrenia, intermittent explosive disorder, and other psychiatric and neurologic diagnoses alleged that staff verbally and physically abused her. She reported that while she was watching television in the dining room, night-shift staff turned off the television and told her she had to go to bed, then dumped her out of her wheelchair, placed a blanket over her head, grabbed her feet, and dragged her down the hall to her room. A subsequent skin assessment documented bruising to her lower forearm, and she was not on blood thinners at the time of the incident.

The incident occurred during a night shift when an LVN and two CNAs were the only staff on duty. According to the DON and ADM, these three staff members were captured on video dragging the resident down the hall on a blanket and were determined to have verbally and physically abused her and violated her resident rights by forcing her to go to bed and turning off the lights. Despite this, none of the three staff reported the incident to the Administrator or other facility leadership at the time it occurred or at any point during the following shifts. They continued to work their full night shift immediately after the incident and returned for subsequent night shifts, continuing to provide care to the same resident without reporting the event.

The resident did not report the abuse on the day following the incident and remained in her room, later stating that she told staff to leave her alone. Two days after the incident, she reported to the ADON and other CNAs that staff had dragged her to her room and turned off the television. The ADON, who had been trained on abuse, neglect, and resident rights, stated that based on facility policy she expected staff to report any abuse immediately and acknowledged that staff did not follow the abuse, neglect, and exploitation policy requiring immediate reporting to the Administrator or designee. Interviews with the LVN involved revealed that she believed she had not done anything wrong, did not recognize dragging the resident on a sheet as abuse, and did not report the incident. The facility’s written policies clearly defined abuse, required immediate reporting of suspected abuse by any staff member, and prohibited actions such as unreasonable confinement and willful infliction of injury or mental anguish, but these requirements were not followed by the involved staff, resulting in the failure to immediately report the alleged abuse and to protect the resident from further contact with the alleged perpetrators.

The noncompliance was identified as Past Noncompliance (PNC) with Immediate Jeopardy that began on 12/19/25 and ended on 01/07/26. The Immediate Jeopardy related to the failure to report the alleged abuse immediately and to remove the involved staff from resident care while the incident remained unreported and uninvestigated.