F0607

E

Failure to Implement Abuse Reporting and Investigation Policies for Two Residents

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

Penalty

Fine: $17,220

Summary

The deficiency involves the facility’s failure to implement its written abuse and neglect policies in response to specific allegations involving two residents. For one resident with dementia, anxiety, depression, diabetes, and atrial fibrillation, who was cognitively intact with a BIMS score of 15 and required staff assistance for ADLs and incontinence care, a video dated 12/15/25 showed a CNA entering the resident’s room, abruptly taking gloves, and responding condescendingly and hatefully when the resident stated she needed to be changed. The CNA told the resident there was a “line” and “no first privileges,” stated she did not like when people could not wait, and made repeated comments implying the resident felt “privileged,” while continuing care in a rude and demeaning manner. The resident’s family later brought this video to the ADON and reported concerns about how the CNA talked to and treated the resident, and requested that the CNA not be allowed back in the resident’s room.

The ADON declined to watch the video when it was offered by the family and did not report the allegation to the abuse coordinator or initiate an investigation as required by the facility’s abuse and neglect policy. The ADON stated that the family told her the CNA had provided all care correctly but did not talk to the resident during care, and therefore she believed there was nothing to report or investigate. She also stated she did not retrain the CNA, and that she told the CNA to perform the required care and leave the room without conversing with the resident. The ADON indicated she did not watch the video because the family frequently brought videos and she did not consider this an actual complaint. The DON similarly reported that, based on what the ADON told her at the time, she believed the family’s concern was only that the CNA did not talk to the resident during care and therefore did not see a need to view the video or treat it as an abuse allegation at that time.

A second deficiency involved a separate incident reported by an anonymous staff member concerning another resident with severe cognitive impairment (BIMS score of 5), dementia, senile brain degeneration, and dependence on staff for toileting and transfers. About three months prior to the interview, this resident was in the dining room calling out “Help! Help!” when the ADON walked by. According to the anonymous staff member, the resident reached out to grab the ADON to stop her, and the ADON hit the resident’s hand and told her, “Leave me alone don’t touch me.” The anonymous staff member then went to assist the resident. The staff member reported that another employee also witnessed the incident and that many employees had observed the ADON’s mistreatment of residents and reported concerns to the DON, but they did not report this specific incident further due to fear of being fired and a belief that prior reports to the DON had not resulted in action. The Administrator later stated she was not aware of any abuse allegations involving this resident until the anonymous report was made. The facility’s written policy required all employees to immediately report any suspected abuse, neglect, exploitation, or mistreatment to the Abuse Preventionist or designee and the administrator, and to ensure all such reports were promptly investigated, but this did not occur in either case.