CNA A was providing incontinence care to Resident #11 on March 28 when the resident became combative, according to federal inspection records. The 89-year-old man had Lewy body dementia and a documented history of becoming "combative with care at times," requiring two staff members for assistance.
CNA A worked alone.
"I went to turn him and put on his brief he did not want to me to change him he kept getting out of the bed," CNA A told inspectors. The resident "grabbed her scrub top, ripped her top, and pulled her hair."
She never called for help. "I usually could get them to calm down on my own," she said.
By the next morning, nursing notes documented skin tears to the resident's right forearm, left hand, and left fourth finger, plus bruising and swelling to both hands. An X-ray of his right hand showed no acute fractures, but the resident's left hand continued swelling.
The Director of Nursing learned about the incident March 29 but treated it "more like an injury of unknown origin than abuse and neglect," she told inspectors. The facility's own policy required reporting suspicious injuries when the source wasn't observed and couldn't be explained by the resident.
This case met those criteria exactly.
On April 2, hospice staff ordered another X-ray due to worsening swelling in the resident's left hand. Results showed possible fracture to the distal radius that couldn't be ruled out. Only then did the facility report to the state on April 2 — five days after the incident.
"Because of the new finding of a possible fracture they reported it to the state," the DON explained.
CNA A continued working with the same resident during those five days, though she "mostly work on woman's side now." She began working at the facility in March 2024, just weeks before the incident.
The resident required a splint for his left hand and antibiotics for cellulitis. Medical notes described him as "aggressive/combative with care last week, caused some skin tears to left-hand."
Federal inspectors found the facility failed to protect residents from abuse and failed to report suspected abuse in a timely manner. Texas regulations require nursing homes to report abuse incidents "immediately, but not later than two hours after the incident occurs or is suspected."
The immediate jeopardy finding triggered emergency corrective actions on June 5. The facility terminated CNA A's contract that day and conducted head-to-toe assessments of all residents to check for signs of abuse.
"CNA A contract terminated on 6/5/2024," facility records show.
Emergency staff training began immediately. The Administrator provided education on identifying types of abuse, residents' rights to be free from abuse, and protocols for handling combative residents with dementia.
Forty-two of 43 staff members completed the training by June 6. Physical therapist assistant J described learning that "the expected protocol when providing services to a combative resident was to walk away and come back with help."
The facility's policy required staff to have two people assist Resident #11 "at all times." His care plan specifically stated interventions should include having "two CNAs assisting him at all time" and instructing staff to "please tell residents what you are going to do before you begin."
CNA A acknowledged she should have followed protocol. "She stated she should have called for help to have a witness for the resident's safety and her safety," inspection records show.
The Administrator admitted gaps in reporting procedures. In future cases where "a resident cannot tell them what happened, and they did not see what happened, and there was an injury, they should report it," she told inspectors.
Beyond the abuse case, inspectors found widespread care problems throughout the 46-bed facility.
LVN C falsified medication administration records, marking that she had monitored a resident's wounds when she hadn't actually examined them. During one observation, she discovered a bandaged wound on a resident that she was unaware existed, despite documenting wound monitoring for two consecutive days.
"LVN C stated she had marked the MAR for to monitor the residents skin conditions on 6/3/24 and 6/4/24 but had not looked at the resident," inspectors wrote.
The same nurse improperly administered insulin into a resident's deltoid muscle instead of subcutaneous tissue as ordered. She also contaminated her hands during wound care by touching a paper towel dispenser after washing.
Medication storage presented additional hazards. The facility's medication cart contained loose unidentified pills, debris, a dirty pill cutter covered in white powder, and a medication bottle missing its expiration date label.
Kitchen safety violations included expired food, a malfunctioning freezer operating at 52 degrees with thawed food inside, and an ice maker with "dark brown and black sludge" that hadn't been properly cleaned. The maintenance supervisor admitted he never disassembled the ice maker for thorough cleaning in his four years at the facility.
Care planning failures affected multiple residents. Two residents had no code status documented in their care plans despite active DNR and full code orders. Another resident received antipsychotic medications without proper psychiatric diagnoses or updated consent forms.
The facility struggled with basic care coordination. Oxygen tubing for one resident was dated April 15 but hadn't been changed weekly as ordered. Staff documented completing oxygen equipment changes that never occurred.
PASARR screening violations left a resident with depression, PTSD, and anorexia without proper mental health evaluations. The MDS nurse incorrectly determined the resident was "negative for PASARR so they did not need to indicate yes for mental illness on the assessment."
Physical plant problems included 20 of 46 resident rooms failing to meet minimum size requirements of 80 square feet per resident. Some double-occupancy rooms housed residents in spaces too small for adequate daily living activities.
The facility's dishwasher operated below manufacturer specifications, reaching only 112 degrees for washing instead of the required 120 degrees. Kitchen staff had been recording false temperatures of 120 degrees on daily logs while the equipment failed to sanitize properly.
Inspectors found the facility's infection control program inadequate after observing improper hand hygiene during wound care. The vent hood hadn't been inspected since February despite requiring quarterly service.
Pleasanton North Nursing and Rehabilitation must maintain intensive monitoring until it demonstrates sustained compliance. The Administrator committed to daily resident assessments for signs of abuse, staff competency interviews every shift, and monthly quality assurance reviews.
The facility faces ongoing federal oversight after inspectors identified immediate jeopardy to resident health and safety. Corporate resources provided additional education to administrators about suspending staff immediately when abuse allegations arise.
For Resident #11, the consequences extended beyond physical injuries. His wife now spends more time at the facility monitoring his care, watching for signs that the aggressive behaviors documented in his medical record might again lead to harm during the most basic daily activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pleasanton North Nursing and Rehabilitation from 2024-06-07 including all violations, facility responses, and corrective action plans.
Additional Resources
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