MERIDIAN, MS — Federal inspectors issued an immediate jeopardy citation to The Oaks Rehabilitation and Healthcare Center after an investigation revealed a certified nurse aide physically assaulted a resident with dementia and verbally threatened a second cognitively impaired resident. The incidents, which occurred in March 2025, went unreported by witnessing staff members for 10 days due to what investigators determined was a pervasive fear of workplace retaliation.
The complaint survey, completed on April 4, 2025, found that the facility failed to implement its own abuse prevention policies and that staff members who witnessed the incidents did not intervene or promptly report what they observed — a direct violation of federal nursing home regulations under F600 and F607.
CNA Physically Assaulted Resident With Dementia
According to the federal inspection report, the incident occurred on March 7, 2025, at approximately 6:20 AM during the overnight shift. A licensed practical nurse on duty asked CNA #3 to assist CNA #1 with providing care to Resident #1, who had been described as combative.
Resident #1, who had been living at the facility since 2013, carried diagnoses of Parkinson's disease and dementia. A cognitive assessment completed in March 2025 showed she had moderately impaired cognition.
During the care encounter, Resident #1 swung at both aides. CNA #3 reported that she held the resident's hands gently and attempted to reassure her. The resident then pulled away and grabbed CNA #1 by the hair. According to CNA #3's account to investigators, CNA #1 responded by grabbing the resident's nose and twisting it upward, causing it to bleed.
CNA #3 told inspectors that CNA #1 then said: "This is how you deal with crazy [expletive] like you."
CNA #3 reported that she confronted CNA #1 immediately, telling her she could not treat or speak to the resident that way. She attempted to leave the room to locate the supervising nurse but could not find her nearby. Unwilling to leave the resident alone with CNA #1, she returned and offered to finish providing care. CNA #1 reportedly ignored the offer, continued providing care, cleaned the blood from the resident's face using the resident's own gown, dressed her, and transferred her to a chair before leaving the room.
Physical Assault of Cognitively Impaired Residents Poses Serious Medical Risks
Grabbing and twisting the nose of an elderly resident — particularly one with Parkinson's disease — presents significant medical concerns. Elderly individuals are more susceptible to tissue damage and bleeding due to thinning skin and fragile blood vessels, a condition known as senile purpura. Patients with Parkinson's disease may also take medications that affect blood clotting, increasing the risk of prolonged bleeding from even minor trauma.
Beyond the physical injury, rough handling of residents with dementia can trigger heightened agitation, anxiety, and behavioral responses that persist well beyond the initial incident. Residents with moderate cognitive impairment may not be able to articulate what happened to them, but they can retain emotional memories of distressing events that affect their willingness to accept care going forward.
Verbal Threats Directed at Second Resident
The inspection also documented a separate incident involving Resident #2, who had been admitted to the facility in 2019 with diagnoses of hypertension and major depressive disorder. Her cognitive assessment indicated severe impairment, with a BIMS score of just 3 out of 15. She was fully dependent on staff for toileting.
CNA #2 reported to investigators that she was in Resident #2's room providing care to a roommate when she overheard CNA #1 tell the resident: "If you [expletive] in the bed like you did yesterday, I'm going to beat your [expletive]."
CNA #2 stated she immediately told CNA #1 that she could not speak to a resident that way. CNA #1 reportedly responded: "I bet it works."
Threatening a severely cognitively impaired resident who is entirely dependent on staff for basic care represents a fundamental violation of resident rights protections. Residents with severe cognitive impairment and depression are among the most vulnerable individuals in long-term care settings, as they may be unable to report mistreatment or advocate for themselves.
Staff Knew But Did Not Report for 10 Days
One of the most concerning findings in the inspection was the systemic failure of staff to report the incidents. Despite federal regulations and the facility's own policy requiring immediate reporting of witnessed or suspected abuse, neither CNA #2 nor CNA #3 reported what they observed until March 17, 2025 — a full 10 days after the physical assault.
Both aides told investigators the same reason: they feared retaliation from other staff members. CNA #2 explained that people had recently been losing their jobs and there were concerns about false allegations being made through the facility's compliance hotline. CNA #3 confirmed she had received training on abuse reporting requirements but remained silent due to the same fears.
The reports ultimately surfaced through two anonymous letters found on the Administrator's desk on March 17. It was only after those letters were discovered that the facility launched its investigation.
Additional staff interviews painted a broader picture of a workplace culture that tolerated concerning behavior. CNA #4 told inspectors she had observed CNA #1 speaking to residents in an aggressive manner but was told by coworkers that it was "just her personality" and not to take it seriously. CNA #5 similarly reported hearing CNA #1 use an angry tone with residents but said he initially dismissed it as a personality trait.
LPN #2, who supervised CNA #1, described her as having "good days and bad days," noting that CNA #1 did not follow instructions well and often argued when asked to complete tasks. Despite these observations, LPN #2 acknowledged she never documented or reported these concerns to the Director of Nursing.
Federal Standards Require Immediate Intervention and Reporting
Under federal regulations at 42 CFR 483.12, nursing homes must develop and implement written policies prohibiting abuse, neglect, and exploitation. Staff members are required to report any witnessed or suspected abuse immediately — not days or weeks later.
The standard of care when a staff member witnesses a colleague mistreating a resident is clear: intervene to stop the behavior, ensure the resident's safety, and immediately notify a supervisor. Failure to report witnessed abuse is not merely a policy violation — as the facility itself acknowledged during its corrective action process, failure to report abuse is a crime under Mississippi law.
Proper protocols for managing care with combative residents involve de-escalation techniques, the use of gentle redirection, and requesting additional staff assistance. Physical retaliation against a resident who is exhibiting combative behavior due to a neurological condition like dementia is never an acceptable response and constitutes abuse under federal definitions regardless of the circumstances that preceded it.
Facility Response and Corrective Actions
The facility took several steps following the discovery of the abuse allegations. CNA #1 was suspended on March 17 and terminated on March 18, 2025. Body audits were performed on all residents in the wing where CNA #1 had worked, and cognitively intact residents were interviewed. No additional signs of physical abuse were identified.
A Quality Assurance Performance Improvement (QAPI) Committee meeting was held on March 26 and again on April 2 to review the incidents and determine root causes. The committee identified the root cause as employees being afraid of retaliation from other employees — a finding that points to organizational culture issues that extend beyond any single staff member's actions.
As part of the facility's removal plan, 100% of staff received re-education on the abuse and neglect policy with emphasis on reporting requirements. All facility staff members were individually contacted and asked whether they had ever witnessed abuse. All alert and oriented residents were interviewed using a quality improvement questionnaire.
The immediate jeopardy was removed on April 4, 2025, after state agency validation confirmed that corrective actions had been completed. However, the underlying deficiency was reduced from a J-level severity (immediate jeopardy) to a D-level severity while the facility develops a plan of correction to demonstrate sustained compliance.
What Families Should Know
The Oaks Rehabilitation and Healthcare Center is located at 3716 Highway 39 North in Meridian, Mississippi. The facility's federal provider identification number is 255261.
This inspection resulted in citations for both F600 (freedom from abuse) and F607 (failure to implement written abuse prevention policies), both at the immediate jeopardy level. The finding of Substandard Quality of Care triggers additional federal oversight requirements.
Families with loved ones at this facility may wish to review the complete inspection report, which is available through the Centers for Medicare & Medicaid Services and details the full scope of findings, staff interviews, and the facility's corrective action plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Oaks Rehabilitation and Healthcare Center from 2025-04-04 including all violations, facility responses, and corrective action plans.
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