F0610

D

Failure to Thoroughly Investigate Resident’s Verbal Abuse Allegation

Fort Worth, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by Resident #1. Resident #1 was an adult male with intact cognitive skills for daily decision-making, with diagnoses including stroke, seizures, and non-Alzheimer’s dementia, and a PASARR-positive status related to intellectual disability. During a PASARR meeting on 12/02/25, he reported that during a Fall Festival on 10/15/25, the Administrator and Activity Director told him to “shut up,” “mind your business,” and “don’t say anything” after he complained that the festival was not just for residents. He stated that the Activity Director was joking but that the Administrator “meant it” and took it “to a whole new level.” He had not reported the allegation before that meeting.

When Resident #1 voiced the allegation during the PASARR meeting, the MDS Nurse left the meeting and brought the Administrator into the room, explaining she believed the accused had the right to face their accuser. The Administrator, who was the alleged perpetrator and also the Abuse Coordinator, entered the meeting and directly engaged with Resident #1 about his allegation. Resident #1 reported that when he tried to speak, the Administrator repeatedly put her hand up to stop him from talking, and that she argued with him about what she had said. The ECC Service Coordinator, who was also present, stated that the Administrator negated the resident’s claim, said he was fabricating the allegation in retaliation, and argued back and forth with him. The Activity Director was not present at this meeting and was not confronted by the resident.

The subsequent facility investigation, led by the DON with assistance from Corporate Staff, did not include an interview with Resident #1 and did not include a safe survey with him, despite his being the alleged victim. The DON acknowledged she did not interview the resident and instead relied on statements from the MDS Nurse and Administrator, as well as denials from the Administrator and Activity Director. She also did not interview other individuals who were present at the PASARR meeting, such as the Therapy Director or ECC Service Coordinator. Corporate Staff later stated he was unaware that the resident had not been interviewed and that other meeting participants had not been interviewed, and he acknowledged that failure to complete a thorough investigation could result in missed information. The facility’s abuse/neglect policy stated that all investigations of abuse would be investigated, but the investigation report for this allegation did not reflect that Resident #1 was interviewed or given a safe survey, and the DON stated she did not identify any issues with her investigation.

The Administrator stated that facility staff were supposed to contact the DON or Corporate Staff if she was named as the alleged perpetrator, but in this case she personally went into the PASARR meeting and spoke with the resident about his allegation. The MDS Nurse later recognized that having a resident face the alleged perpetrator could cause fear of retaliation and make it feel unsafe to report concerns. Corporate Staff stated that the MDS Nurse should have notified the DON instead of bringing in the Administrator. Despite these circumstances, the investigation concluded the allegation was unfounded, without direct resident interview or comprehensive witness interviews, resulting in a failure to have evidence that the alleged violation was thoroughly investigated as required by facility policy.

The DON characterized Resident #1 as a “fabricator of instances and stories” and stated he was care planned for this behavior, and she reported that both the Administrator and Activity Director denied the allegation. The Administrator reported that the resident had made multiple calls to the state in the past and was upset about not being allowed to sell items out of his room. However, these characterizations and prior behaviors were not balanced by a documented, direct interview with the resident about the specific allegation, nor by interviews with all individuals present at the PASARR meeting. The Provider Investigation Report did not document a resident interview or safe survey, and the DON admitted she was “probably supposed to interview the resident” but did not know what the policy required without reading it. As a result, the facility lacked documentation that it had thoroughly investigated the verbal abuse allegation in accordance with its abuse/neglect policy.