The resident, identified in inspection records as Resident #1, made multiple statements about sexual assault to nursing staff over several months. She told workers that people in the facility were "transforming" into her rapist and that she was being sexually assaulted by someone with a specific name.
Rather than investigate, the Director of Nursing instructed staff to simply document the allegations as evidence of the resident's psychiatric condition.
Federal inspectors found the facility violated requirements to immediately report suspected abuse when they investigated a complaint in October 2024. The inspection revealed a pattern of staff members receiving rape allegations from the resident but treating them as symptoms rather than potential crimes.
Licensed Vocational Nurse A told inspectors that Resident #1 would say people were transforming into her rapist, referring to an unknown male by name. The nurse said she reported this to the Director of Nursing, who told her to document everything "in order to record Resident #1's delusions as Resident #1 had a history of delusion."
The LVN acknowledged she should have called the Administrator to report the allegation immediately. "She revealed if there was an allegation of abuse or neglect, she would report to ADM immediately," inspectors noted. "She revealed she should have called the Administrator to report this allegation."
Multiple staff members received similar reports from the resident. Certified Nursing Assistant B said Resident #1 "would always mention she was raped" and had schizophrenia. The CNA said she would report these allegations to her nurse, who would then report to the Director of Nursing.
Another nursing assistant, CNA C, told inspectors the resident "would say she was being raped in the facility." This assistant also reported the allegations up the chain to the Director of Nursing, who "would speak with Resident #1."
Licensed Vocational Nurse D described the resident's statements in more detail, saying Resident #1 would claim "her roommate would change gender and become her rapist." This nurse also reported the allegations to the Director of Nursing as "behaviors and delusions."
LVN E told inspectors that Resident #1 "did make allegations of abuse" but said the resident "had this issue prior." This nurse said she reported the allegations to both the Director of Nursing and the Administrator immediately.
When inspectors interviewed facility leadership, both the Director of Nursing and current Administrator acknowledged they were aware of the rape allegations. They told inspectors they considered the reports unsubstantiated because of the resident's psychiatric diagnoses, which included schizophrenia, personality disorder, and bipolar disorder.
The Director of Nursing explained their reasoning to inspectors: "The allegations were unsubstantiated because Resident #1 would make claims like her roommate transformed into her rapist, so they switched Resident #1's room and then she was fine."
The facility's solution was to move the resident to a different room. After the room change, managers said the resident stopped making the allegations.
The Director of Nursing told inspectors that Resident #1 would also claim the named individual "was a rapist from another facility." The DON said there was no one with that name working at The Heights of Atascosa.
Crucially, facility leadership admitted they never reported the allegations to state authorities. The Director of Nursing told inspectors "this was not reported to state because it was a part of delusions and there were no concerns Resident #1 was being raped in the facility."
The DON revealed this wasn't the first time the resident had made such allegations. She said Resident #1 had made similar reports at another facility where the DON previously worked, and those allegations also went unreported.
The current Administrator, who was not working at the facility when the resident lived there, told inspectors she spoke with the Director of Nursing about the situation. She said the facility had conducted an internal investigation and concluded the allegations were hallucinations.
"She revealed if she had completed an internal investigation and found the allegations were hallucinations the harm was not present so she would not report this to the state," inspectors documented.
The former Administrator, who was in charge when the incidents occurred, provided similar reasoning. She told inspectors that Resident #1 would make comments about "someone transforming into different, not realistic things so they deemed these comments as hallucinations."
The former Administrator confirmed there were no staff members, healthcare providers, or vendors with the name the resident mentioned. She said they didn't report to the state "because it was not suspicious and it was not a realistic allegation based on her comments."
Federal regulations require nursing homes to report suspected abuse immediately, regardless of the mental health status of the person making the allegation. The facility's own policy, titled "Abuse Guidance: Preventing, Identifying, and Reporting" and dated February 2017, requires staff to report alleged or suspected abuse to the Health and Human Services Commission within specific timeframes.
According to the policy, allegations must be reported "immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury."
The facility failed to follow its own policy or federal requirements. Instead of treating rape allegations as potential crimes requiring investigation, staff and administrators dismissed them as psychiatric symptoms that could be managed by changing the resident's room assignment.
The inspection found the facility violated federal tag F609, which requires nursing homes to ensure residents are free from abuse and neglect. Inspectors determined the violation caused minimal harm or potential for actual harm and affected some residents.
The case highlights a troubling gap in how nursing homes handle abuse allegations from residents with mental health conditions. Rather than investigating claims from vulnerable residents, The Heights of Atascosa chose to treat serious criminal allegations as medical symptoms that could be documented and dismissed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Heights of Atascosa from 2025-11-24 including all violations, facility responses, and corrective action plans.