Health inspection·November 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation and mistreatment were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 4 residents (Resident #1) reviewed for reporting of allegation of Commission) an allegation of sexual abuse made by Resident #1. This failure could place residents at risk for harm to include neglect and a diminished quality of life. The findings included: Record review of Resident #1's admission record, dated 10/15/25, reflected a [AGE] year-old female, admitted [DATE] with diagnoses to include bipolar disorder (mental health condition that causes extreme mood swings) and schizoaffective disorder (mental health condition that can include psychotic symptoms such as hallucinations or delusions). Record review of Resident #1's care plan, undated, reflected focus Psycho-social/Behavioral Risk, initiated 08/27/25, with intervention RISK-BEHAVIORS MONITORING-Calm and re-assure resident/patient is safe, initiated 08/27/25. Record review of Letters of Guardianship, certified July 22, 2005, reflected Resident #1's family member was appointed guardian of Resident #1, an incapacitated person. Record review of TULIP (online system to streamline Long Term Care applications like facility reports of incidents) from July 2025 to September 2025, accessed 10/15/25, reflected no self-reports reflecting Resident #1 having sexual abuse allegations. Record review of Nursing Progress Note, dated 07/23/25 at 12:05 AM and authored by LVN A, reflected resident woke up from her sleep telling nurse that she thinks something is wrong. She thinks her rapist is back and going to get her pregnant and she will die. Vital signs taken. Nurse asked resident if she thinks she was just having a bad dream, she got upset saying I don't believe her. Record review of Nursing Progress Note, dated 07/25/25 at 11:58 PM and authored by LVN A, reflected resident turned on call light and told nurse that her rapist [unknown male] was back but not in person, now he is raping her by computer using new technology. Record review of Nursing Progress Note, dated 07/30/25 at 03:15 AM and authored by LVN E, reflected . Per resident, ‘I need to go to the hospital. I'm having a baby. It's [unknown male]'s baby. Nobody here will help me.'. Record review of Nursing Progress Note, dated 08/13/25 at 02:35 AM and authored by LVN D, reflected, . Resident began to speak of her rapist, who she states is named [unknown male], and believes he has changed form into facility aide. Record review of Nursing Progress Note, dated 08/19/25 at 11:44 PM and authored by LVN A, reflected, . Resident began to speak of her rapist, who she states is named [unknown male], and believes he has changed form into facility aide and her roommate. Record review of Nursing Progress Note, dated 09/20/25 at 09:39 PM and authored by LVN E, reflected, . Resident talking about [unknown male], raping [sic] me over and over again. My [family member] said to take a sleeping pill. I don't want to be raped again. He has rapped me three times.'. Interview on 10/15/25 at 09:21 PM, LVN A revealed Resident #1 had schizophrenia and hallucinations. She revealed Resident #1 had statements on Page 1 of 2 676181 676181 11/24/2025 The Heights of Atascosa 1855 W Goodwin Pleasanton, TX 78064

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and off and would refer to her rapist [unknown male]. She revealed Resident #1 would say people were transforming into [unknown male]. She revealed there was no one with this name that came into the facility. She revealed she reported this allegation to the DON and the DON told her to document everything in order to record Resident #1's delusions as Resident #1 had a history of delusion. LVN A further revealed if there was an allegation of abuse or neglect, she would report to ADM immediately. She revealed she should have called the Administrator to report this allegation. Interview on 10/16/25 at 10:01 AM, CNA B revealed Resident #1 had schizophrenia and would always mention she was raped. She revealed Resident #1 would say all kinds of statements and she would make sure to report these allegations to her nurse who would report to DON. She revealed there were no residents or staff members with this name. Interview on 10/16/25 at 10:13 AM, CNA C revealed Resident #1 hallucinated and had schizophrenia. She revealed she would say she was being raped in the facility. CNA C revealed she would report this allegation to her nurse. She revealed the DON knew about these allegations and would speak with Resident #1. Interview on 10/16/25 at 11:59 AM, LVN D revealed Resident #1 would have delusions at times but not every day. She revealed Resident #1 would say she had a rapist in the past and her roommate would change gender and become her rapist. She reported this to the DON about behaviors and delusions. Interview on 10/16/25 at 12:08 PM, LVN E revealed Resident #1 did make allegations of abuse, but Resident #1 had this issue prior. She revealed she reported this to her DON and the ADM immediately. Interview on 10/16/25 at 12:42PM, the DON and current ADM revealed they were aware of these allegations, but Resident #1 had these delusions due to her diagnoses to include schizophrenia, personality disorder, and bipolar disorder. They revealed 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 DON revealed Resident #1 would also say [unknown male] was a rapist from another facility. The DON revealed 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 there was no one with this name in the facility. The DON was also at another facility with this resident and Resident #1 made these allegations and it was not reported at the other facility when this happened. Interview on 10/16/25 at 01:09 PM, the current ADM revealed she was not at this facility when Resident #1 was a resident. She revealed she spoke with the DON and the facility had done an investigation where the facility found these 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. Interview on 10/16/25 at 01:16PM, the former ADM revealed Resident #1 would make some comments about someone transforming into different, not realistic things so they deemed these comments as hallucinations. She revealed there were no team members, health care providers, or vendors named [unknown male]. She revealed they did not report to the state because it was not suspicious and it was not a realistic allegation based on her comments. Record review of facility's policy Abuse Guidance: Preventing, Identifying, and Reporting, dated February 2017, reflected via TULIP reporting within designated time frames in accordance with HHSC's PL 19-17. Are 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. 676181 Page 2 of 2