F0610

K

Failure to Protect Residents During Call-Light Neglect and Verbal Abuse Allegations

Athens, Texas Survey Completed on 02-13-2026

Penalty

Fine: $138,600

Summary

The deficiency involves the facility’s failure to take appropriate steps to prevent further potential abuse or neglect and to implement corrective action while investigations into alleged neglect and verbal abuse were in progress. Multiple grievances were filed on 02/02/26 by a CNA reporting that another CNA had been switching out working call lights with non-functioning "dummy" call lights or placing call lights out of reach for several residents. These grievances identified concerns that one CNA was switching out call lights for three residents during evening/weekend shifts, and that another CNA had given a resident a dummy call light that was not plugged in. The grievances were assigned to the Administrator/DON, but no meetings were held with the complainant or residents, and the facility’s documented follow-up consisted of maintenance checking call lights and noting they were working, with the grievances then marked as resolved.

Resident #1, who had severe cognitive impairment, cervical spinal cord injury, Parkinson’s disease, dementia, neurogenic bowel, and neuromuscular bladder dysfunction, was care planned to have his call light within reach and to use it to request assistance. A grievance reported that his call light was being switched with a dummy one that did not work. An internal document dated 02/05/26 shows the Administrator learned on 02/02/26 of grievances about a fake call light and that staff had heard of dummy call lights but were unsure who was responsible. The Administrator interviewed Resident #1 and his roommate, who reported delays in call light response and identified a CNA as unplugging call lights. The Administrator later found Resident #1’s call light tangled in his wheelchair and pulled from the wall. Other staff, including the HR Director and another CNA, reported previously finding two call lights on Resident #1’s side of the room, with one plugged in and one coiled on the floor or in the resident’s hand, and turned the extra light in to nursing/HR without further action being taken at that time.

Resident #3, who had intact cognition and a history of falls, was also care planned to have her call light within reach and to use it for assistance. A grievance reported that a night-shift CNA had put her call light out of reach and placed another, unplugged call light in her room as a dummy light, and that the same CNA had done this to two other residents. Resident #4, who had dementia, repeated falls, and was care planned to have her call light within reach and to be redirected to use it instead of calling out, was similarly named in a grievance alleging her call light was possibly being switched with a dummy one during shifts worked by the same CNA. Despite these specific allegations and identification of involved staff, the Administrator and DON did not immediately suspend the named CNAs when they became aware of the allegations on or about 02/02/26–02/03/26, and one CNA continued to work on the affected hall and care for the involved residents.

The facility also failed to prevent verbal abuse of Resident #2 after an allegation of neglect involving call lights had already been reported. Resident #2, who had intact cognition and was the roommate of Resident #1, reported that a CNA moved Resident #1’s call light out of reach and that he had repeatedly reported this to the ADON, Administrator, and HR Director. He later reported an incident in which, after he demanded that the CNA get his roommate up, he used profanity toward the CNA and the CNA responded by telling him to "shut the [F-word] up" and to mind his business. The facility’s Provider Investigation Report documented Resident #2’s account that he was offended by the CNA’s language. Although the DON left a voicemail for Resident #1’s family member stating that one CNA was off the schedule and the other would be suspended as of that day, video and time records show that the CNA identified in both the call light allegations and the verbal abuse allegation continued to work that day and was not suspended until later that evening for the verbal abuse incident. The DON later acknowledged to the family member that she "dropped the ball" and that the identified CNAs should have been suspended when the allegations were known, and the Administrator acknowledged that the allegations could constitute neglect or seclusion and that the two aides should have been suspended immediately but were not.