F0600

G

Failure to Protect Residents From Call Light Tampering and Verbal Abuse

Athens, Texas Survey Completed on 02-13-2026

Penalty

Fine: $138,600

Summary

The deficiency involves the facility’s failure to protect several residents from abuse and neglect by ensuring access to functioning call lights and freedom from verbal abuse. Multiple residents with significant physical and cognitive impairments were care planned to have call lights within reach and to use them to request assistance, yet staff allegedly removed or disabled this means of communication. One male resident with severe cognitive impairment, cervical spinal cord injury, Parkinson’s disease, dementia, neurogenic bowel, and bladder dysfunction was dependent on staff for most ADLs and incontinent of bowel and bladder. His care plan required that his call light be kept within reach and that he be encouraged to use it. A grievance reported that a CNA had been switching out this resident’s working call light with a dummy call light that did not function, particularly on evening and weekend shifts. The Administrator later found this resident’s call light tangled in his wheelchair and unplugged from the wall, and the HR Director and another CNA each separately reported previously finding two call lights on his side of the room, with one plugged in and the other coiled on the floor or in the resident’s hand but not plugged in.

Two additional female residents with dementia, fall risk, incontinence, and varying levels of assistance needs were also implicated in the dummy call light allegations. One resident with intact cognition, diabetes, dysphagia, and a history of falls was care planned to have her call light within reach and to use it for assistance. A grievance stated that a night-shift CNA had placed this resident’s working call light out of reach and provided another call light that was not plugged in as a dummy. An LVN reported that a day-shift aide relayed this resident’s statement that the night aide had done this and that the aide had done the same to two other residents. Another resident with dementia, a displaced femur fracture, major depressive disorder, repeated falls, and total incontinence was care planned both for falls and for redirection to use the call light instead of calling out loudly. A grievance reported concern that a CNA had possibly been switching this resident’s call light with a dummy one that did not work, believed to occur on evening and weekend shifts. The Social Worker stated she was told that an aide was moving the good light out of reach and using an extra one for three residents.

The facility also failed to protect a cognitively intact male resident from verbal abuse by staff. This resident, who shared a room with the dependent male resident described above, reported that when he instructed a CNA to get his roommate up immediately, the CNA delayed and he began using profanity toward her. He stated that the CNA responded by telling him to “shut the [F-word] up and mind your business,” and he reported feeling offended by her cursing. A nurse reported overhearing the resident yelling and using profanity but did not hear the CNA yell or curse. This same resident also reported that the CNA had been moving his roommate’s call light out of reach and plugging in a fake call light, and he stated that he had been returning the working call light to his roommate for at least a month. Facility leadership, including the DON and Administrator, acknowledged being informed of allegations that two CNAs were involved in using extra or dummy call lights and that such conduct could constitute neglect or seclusion, but the residents continued to experience delayed responses to call lights and ongoing concerns about call light access and staff behavior.

Family and staff interviews further described the pattern of inaction and inconsistent response to the abuse and neglect allegations. The family member of the dependent male resident reported that she had been told by several people that two CNAs were taking residents’ call lights away and giving them non-functioning call lights, and she described finding her family member without water and with saturated sheets on multiple visits. She reported the call light issue to the DON, who later left a voicemail stating that both implicated CNAs were being taken off the schedule, but the family member subsequently observed one of the CNAs working on the unit and caring for the same resident. In recorded conversations, the DON admitted she “dropped the ball,” acknowledged that the family had reported specific rooms and staff names, and stated that she believed the situation could be neglect or seclusion because the dependent resident’s means of communication had been taken away. The Administrator acknowledged receiving grievances about fake call lights, being told the names of the two CNAs, and understanding that the allegations could constitute neglect or seclusion, yet also stated that the aides were not immediately suspended and that the issue was not reported to the state agency. These actions and inactions resulted in residents not being consistently provided with functioning, accessible call lights and one resident being subjected to alleged verbal abuse by a CNA.

Additional staff accounts corroborated the presence of extra call lights and concerns about delayed responses. The HR Director described finding two call lights on the dependent male resident’s side of the room in late December, with one plugged in and draped between the bed and bedside table and another coiled on the floor and not plugged in, which she took to the ADON without notifying the Administrator. A CNA who routinely cared for this resident reported finding an extra, unplugged call light in his hand while the working call light was plugged in and draped over his bedside drawers; she believed the extra light had been given because the resident used his call light frequently and staff did not want him to call. Another resident reported that his roommate became upset and hollered when he did not have his call light and that he himself would return the call light to his roommate when it had been moved. The DON and Administrator each stated that the allegations of dummy call lights and the identified staff should have been treated as potential neglect or seclusion and reported, but acknowledged that this did not occur and that one of the implicated CNAs continued to work on the affected hall after the allegations were known.