F0609

D

Failure to Timely Report Resident-to-Resident Abuse Allegation

San Antonio, Texas Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that an alleged incident of resident-to-resident abuse was reported to the appropriate authorities immediately, but no later than two hours after the allegation was made, as required by regulation and facility policy. Resident #2, who had dementia with agitation, moderate cognitive impairment (BIMS 8/15), anxiety, and a care plan noting behavior problems related to throwing items at other people, threw an empty plastic cup at his roommate, Resident #3, during care on 1/6/26 at 5:45 PM. The incident occurred when Resident #3 attempted to open the privacy curtain while staff were providing care to Resident #2, after having opened the curtain a couple of times before and making comments about Resident #2's mother. The cup struck Resident #3 and caused a small skin tear over his left eyebrow, which was treated in-house, and Resident #3 was subsequently moved to another room.

The Provider Investigation Report showed that the Administrator (ADM) did not report this resident-to-resident altercation to the state survey agency until 1/7/26 at 11:04 AM, more than two hours after the allegation and outside the timeframe required for alleged abuse. The facility’s Abuse Prevention and Prohibition Program policy required that allegations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency and other appropriate entities. During interview, the ADM acknowledged reporting the incident within 24 hours and stated she believed the two-hour requirement applied only when serious bodily injury occurred, characterizing the two-hour reporting requirement as a technicality. This failure to follow the regulatory and policy requirement for timely reporting of alleged abuse constituted the cited deficiency.