F0600

E

Failure to Prevent Abuse and Neglect and to Investigate Allegations Involving Two Residents

Mount Pleasant, Texas Survey Completed on 02-23-2026

Penalty

Fine: $17,220

Summary

The deficiency involves the facility’s failure to protect residents from abuse and neglect, including failure to provide timely incontinent care and repositioning, failure to protect a resident from verbal abuse by a CNA, and an allegation of physical abuse by the ADON. One cognitively intact female resident with dementia, anxiety, depression, diabetes mellitus, and atrial fibrillation was care planned as needing staff assistance for ADLs, including one-person assistance for bathing, two-person assistance with a mechanical lift for transfers, and staff supervision for toileting, bed mobility, dressing, and eating. She was also care planned for bladder incontinence and impaired mobility, with interventions including application of barrier cream after incontinent episodes. A later care plan entry documented a potential psychosocial well-being problem related to an allegation of verbal abuse. Video evidence from one date showed this resident lying in bed on her back, not turned, repositioned, or provided incontinent care from 1:56 PM until 7:55 PM. On another date, a time-lapse video from 5:45 AM to 11:45 AM showed no staff entering the room to check, change, or reposition her for six hours.

In interviews, the resident’s family member reported calling the facility and requesting incontinent care because no staff had checked on the resident since before 6 AM when night shift staff last checked her. A nursing assistant assigned to the resident on one of the dates stated she had not been in the room to provide care because she had not had time and acknowledged she was new and found it difficult to care for all assigned residents, adding that residents should be checked every two hours and that not doing so could be considered neglect. Another CNA who cared for the resident on the earlier date recalled arriving around mid-afternoon, possibly entering the room only to provide fresh ice and asking the resident if she needed changing, then not changing her until about 8 PM after a family call, and could not recall changing her at any other time that shift. This CNA stated she should have made rounds on every resident every two hours to check and clean them and acknowledged that failing to do so placed the resident at risk for neglect. The DON and Administrator both stated their expectation that CNAs check residents at least every two hours and recognized that extended periods without checks placed residents at risk for neglect.

The same cognitively intact resident was also subjected to degrading verbal interactions by a CNA during incontinent care, captured on video with audio. The video showed the resident lying in bed on her back when the CNA entered, snatched gloves from the wall box, and responded condescendingly when the resident said she needed to be changed, telling her there was a line and that there were no “first privileges.” When the resident commented that the CNA did not like her job, the CNA replied hatefully that she liked her job but not when people could not wait in line, and further stated that the resident thought she was privileged and kept hitting her call light. The resident remarked that someone must have “peed in [the CNA’s] cheerios,” and the CNA responded that she had been doing this too long to “deal for people like this” and that she would not hold her tongue for anyone. While providing care, the CNA continued to interject instructions in a rude manner, pointing and telling the resident to roll. The resident later told surveyors that a staff member had talked mean to her when she asked to be changed, that the staff member must have had a bad day, and that she did not want that staff member back in her room.

The resident’s family member reported bringing the video of the verbal interaction to the ADON and asking her to watch it, and requested that the CNA not be allowed back in the resident’s room because of how she talked to and treated the resident. The family member stated the ADON declined to watch the video, said she did not need to see it and would retrain the aide, and then walked away to move tables in the dining hall, leaving the family member standing there. In her interview, the ADON acknowledged declining to watch the video when it was offered, stating that the family member told her the CNA had provided all care perfectly but needed to talk to the resident when providing care. She said she did not retrain the CNA, did not initiate any reporting or investigation because she believed everything was done correctly, and told the CNA only to do the required care and get out of the resident’s room. The ADON stated she did not consider it important to talk to residents while providing care and said she did not receive a request from the family to keep the CNA out of the room. She also stated that if allegations of abuse were not reported and investigated properly, residents were placed at risk of abuse.

A second resident, an elderly female with senile degeneration of the brain, dementia, and atherosclerotic heart disease, had a quarterly MDS showing she was usually understood and usually understood others, but with a BIMS score of 5 indicating severely impaired cognition and disorganized thinking. She required supervision or touching assistance with eating and was dependent on staff for toileting and transfers, and was incontinent of bowel and bladder. Her care plan documented an ADL self-care performance deficit related to impaired mobility, cognition, weakness, and reliance on staff for ADL assistance. An anonymous staff person reported that about three months prior, this resident was in the dining room hollering “Help! Help!” when the ADON walked by; the resident reached out to grab the ADON to stop her, and the ADON hit the resident on the hand and told her to leave her alone and not touch her. The anonymous reporter stated they then went to assist the resident, that another staff member also witnessed the incident, and that they were tired of injustices residents experienced. They reported that the ADON often refused to assist residents and that they had reported this to the DON, who did nothing, which was why they had not reported the hand-hitting incident earlier.

The anonymous reporter further stated that many employees had witnessed the ADON’s mistreatment of residents and reported it to the DON but would not report it further due to fear of being fired. Another staff member named as a witness denied seeing the ADON abuse or mistreat residents and denied seeing the ADON hit this resident. The Administrator reported that the ADON was suspended related to the allegation of hitting this resident. When interviewed, the resident, who was confused, stated she did not remember any staff hitting or mistreating her and said everyone treated her well, but her confusion was evident when she answered her ringing cell phone by picking up her drink and saying hello. The DON stated that abuse should be reported immediately to the abuse coordinator and that if staff would not report to her, they should go to the Administrator, and that failure to report abuse and neglect immediately placed residents at risk of not being protected from abuse. The Administrator stated she expected staff to follow the abuse and neglect policy and report abuse and neglect immediately, that she was not aware of any abuse allegations involving this resident, and that abuse not being reported placed residents at risk of further abuse.

The facility’s undated Abuse and Neglect policy stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, and that residents should not be subjected to abuse by anyone, including facility staff, other residents, consultants, volunteers, staff of other agencies, family members, friends, or others. The policy defined abuse to include deprivation of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being, and specified that instances of abuse cause physical harm, pain, or mental anguish, including verbal, sexual, physical, and mental abuse. Physical abuse was defined to include hitting, and mental abuse to include humiliation and harassment. Neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy required that all reports or suspicions of abuse, neglect, or potentially criminal behavior be investigated per facility protocol, reviewed by the Administrator and/or Abuse Preventionist within 24 hours, and reported to state authorities within specified time frames. It also required any employee with reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation to make an immediate verbal report to the Abuse Preventionist or designee and to the Administrator, with mandated reporting to state and/or adult protective services.