F0600

H

Failure to Protect a Resident From Ongoing Verbal and Emotional Abuse by an LVN

Weimar, Texas Survey Completed on 03-30-2026

Penalty

Fine: $15,920

Summary

The deficiency involves the facility’s failure to protect a resident from verbal and emotional abuse and intimidation by an LVN over an extended period. The resident was an older female with COPD, paraplegia, muscle weakness, major depressive disorder, nicotine dependence, insomnia, dementia without behavioral disturbance, psychotic/anxiety/mood disturbance, and wheelchair dependence. Her care plan reflected depression and impaired cognitive function due to dementia, and her most recent MDS showed a BIMS score of 14, indicating intact cognition. The care plan identified her as a smoker but did not include any documentation of abuse allegations.

On one documented occasion, a progress note dated 11/10/2025 at 9:00 p.m. reflected that LVN B witnessed an argument in which LVN A told the resident, "You need to get off of my hall and go back down to your room right now," and, "I am not your nurse, and I want you off of my hall and don't comeback down here." The resident reported to LVN B that LVN A had "popped her in the mouth," and LVN B completed a head‑to‑toe assessment and notified the physician. The allegation was reported to the ADM/abuse coordinator and to the State Survey Agency, and the facility’s investigation and a prior state survey found the physical abuse allegation unsubstantiated; however, the verbal interaction and the resident’s report of being struck were documented. The interim DON later stated that this interaction was not considered sufficient evidence to substantiate abuse.

Multiple interviews described a pattern of ongoing intimidating and exclusionary behavior by LVN A toward the resident from the time LVN A began working at the facility until her termination. The resident stated that when LVN A was on shift, she had to avoid the nurse’s station because LVN A would stop her, grab her electric wheelchair controller, and turn her around, and that LVN A refused to take her out for smoke breaks. The resident reported that her cigarettes were moved from the 300‑hall nurse’s station because LVN A did not want them there, and that she had to take a longer route to therapy to avoid passing the nurse’s station when LVN A was present. She described initially feeling bad and sad while watching LVN A and other residents smoke without her and said she adjusted by avoiding contact, communication, and proximity to LVN A.

Staff interviews corroborated that LVN A spoke rudely to the resident, denied her smoke breaks, and restricted her from going near the nurse’s station when LVN A was on shift. The HS stated that LVN A intimidated the resident by making rude comments, telling her she was not allowed near the nurse’s station, and refusing to take her out to smoke, requiring other staff to come off the floor to do so. The HS also reported that the resident would travel the long way around the facility to avoid LVN A and that the resident’s cigarettes were moved from the nurse’s station to the memory care nurse’s station after LVN A objected to them being there. The DON acknowledged having to counsel LVN A about her attitude and unprofessional interactions and stated she had redirected LVN A after LVN A told the resident she could not drive her motor wheelchair around the nurse’s station because LVN A did not want the resident around her following the earlier abuse allegation. Despite these observations and reports, the facility did not update the resident’s care plan to reflect the abuse allegations or the ongoing intimidation and did not recognize or substantiate the pattern of verbal and emotional abuse and intimidation toward the resident.