The incident occurred November 14 during a transfer at Las Alturas Nursing & Transitional Care. Nursing Assistant in Training A was working alongside two certified nursing assistants when Resident #1 became visibly uncomfortable and began crying during her transfer.
The resident insulted CNA C, calling her "a daughter of a bitch mother." Resident #1 then hit CNA C on the arm. CNA C hit Resident #1 back on her left arm in retaliation, according to the nursing assistant's account to federal inspectors.
NAIT A told inspectors he thought he witnessed physical and mental abuse. He said he didn't report it immediately because "he froze in the moment and did not know what to do."
Three days passed.
On November 17, NAIT A finally told his charge nurse what he had witnessed. The nursing assistant acknowledged he had been trained in school to report abuse immediately to keep residents safe.
The facility's Director of Nursing told inspectors that any staff member who witnessed potential abuse should immediately remove the resident from the situation and inform the administrator. The DON said the facility had two hours to report any allegations of abuse to all appropriate parties.
"The DON stated it was important to report all allegations immediately to keep residents safe and initiate the investigation as soon as possible," according to the inspection report.
She said she didn't know why NAIT A waited three days to report his allegation. The DON confirmed all nursing assistants in training were taught at orientation to report any possible abuse immediately to the administrator.
LVN D served as the charge nurse for Resident #1 on November 17. She told inspectors someone from administration instructed her to perform a head-to-toe skin assessment on the resident that day, though she couldn't remember who gave the order.
The assessment showed no abnormalities.
The administrator learned about the alleged abuse on November 17, three days after it occurred. He told inspectors NAIT A should have tried to stop any abuse he thought he witnessed when it happened, then immediately reported it to administration.
"The ADM stated he did not know why NAIT A did not report the alleged abuse to the administrative staff immediately," the inspection report states.
Once notified, the administrator reported the allegation to all necessary parties within the required two-hour timeframe. He conducted his own investigation and concluded there wasn't enough evidence to substantiate the abuse allegation.
The administrator emphasized the importance of immediate reporting to ensure residents weren't being treated by individuals accused of abusing them.
The facility's abuse prevention policy requires all alleged or suspected violations to be "promptly reported to appropriate state agencies." The policy mandates reporting allegations immediately, but no later than two hours after an allegation is made if events involve abuse or result in serious bodily injury.
"The team member is required to report any abuse or neglect should it occur," the policy states.
Federal inspectors cited the facility for failing to ensure all alleged violations of abuse were immediately reported to the administrator. The violation affected few residents and resulted in minimal harm or potential for actual harm.
The three-day delay meant the facility couldn't begin its investigation immediately, potentially leaving a resident in the care of someone accused of striking her. It also meant the administrator couldn't fulfill his duty to report the allegation within the required two-hour window from when it actually occurred.
NAIT A's training had prepared him for exactly this situation. He knew the rules. He understood the urgency. But when confronted with what he believed was abuse, he froze.
The resident who was allegedly struck continued receiving care at the facility while the incident went unreported for 72 hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Alturas Nursing & Transitional Care from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Las Alturas Nursing & Transitional Care
- Browse all TX nursing home inspections