F0609

D

Failure to Timely Report and Act on Allegation of Staff-to-Resident Abuse

Schulenburg, Texas Survey Completed on 02-20-2026

Penalty

Fine: $19,121

Summary

The deficiency involves the facility’s failure to immediately report an allegation of abuse and to protect a resident from further potential abuse after the allegation was made. A male resident in his early fifties with bipolar disorder (current hypomanic episode), thrombotic microangiopathy, and systemic lupus erythematosus was care planned as dependent on staff to meet his emotional, intellectual, physical, and social needs and had a quarterly MDS indicating moderate cognitive issues. On the morning of 02/07/2026, a medication technician (MT) texted the Administrator stating she would be writing a grievance on an LVN due to an incident at breakfast. In the text, the MT reported that the LVN argued with the resident about going to his room, told him she could not wait until he was off parole so she could show him what a nurse was about, and that the resident reported the LVN had tapped him on the back of the head in the dining room. The Administrator acknowledged the text and told the MT she would take care of it but did not come to the facility that day.

Interviews with staff and the resident confirmed the allegation and described the events in more detail. The MT stated she heard the LVN tell the resident she was tired of him going back and forth and heard the resident tell the LVN she had whole conversations by herself, after which the LVN responded that she could not wait until his parole release so she could show him what a nurse was about. The MT reported that the resident told her the LVN popped him in the back of the head and that he was scared to ask the LVN for anything for the rest of the day. A CNA reported seeing the LVN touch the back of the resident’s head, causing his head to go forward, and confirmed that the resident told her the LVN had pushed his head; she stated it was never okay to touch a resident in that manner and that the LVN did not apologize or excuse herself. Another CNA also reported seeing the LVN push the resident’s head forward and stated that, although it was not a full-force push, staff should not play with residents by pushing their heads. Both CNAs indicated they had been trained in abuse and neglect, knew the Administrator was the abuse and neglect coordinator, and understood that abuse and neglect should be reported immediately.

The resident reported that the LVN was “very opened mouthed,” told him she was tired of giving him his 2:00 PM pill, and in the dining room told him to sit right or he would fall back, get blood all over the floor, and she would have to pick it up, then hit the back of his head. He stated the contact did not hurt but made him feel like she could take over him, made him feel stupid, and humiliated him in front of others. He reported that he avoided the LVN afterward, felt uncomfortable and worried she might be verbally inappropriate again, and did not feel comfortable asking her for his PRN pain medications even though he was in pain, describing that he felt he had to beg for his pills. The ADON, who learned of the incident on 02/09/2026, assessed the resident and found no visible discoloration or skin injury; during that assessment, the resident confirmed that the LVN had pushed the back of his head and reported that over the weekend he did not feel safe and was afraid to ask the LVN for PRN medication. The DON and ADON both stated that the LVN continued to work for two days after the allegation was reported to the Administrator and that this could have put residents at risk of abuse and neglect.

The Administrator acknowledged that she received the report of the allegation of abuse and neglect on 02/07/2026 and did not report it to the State Agency (HHS) until 02/09/2026. She stated it was an error on her part, that she initially believed it was a personal issue between the MT and the LVN, and that she wanted to investigate before reporting. The ADON, RDO, and RNC all stated that allegations of abuse and neglect were to be reported immediately to HHS, that staff alleged to have committed abuse should be suspended pending investigation, and that the facility’s abuse and neglect policies were not implemented in this case. The RDO and RNC emphasized that personal relationships between staff could not be considered when an allegation involved resident abuse or neglect and that the Administrator did not follow facility and state guidelines for reporting and protecting residents. The noncompliance was identified as past noncompliance at the Immediate Jeopardy level, beginning on 02/07/2026 and ending on 02/11/2026, and the failure was described as one that could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.