Oaks on Parkwood: Abuse Reporting Failures - AL
By the time anyone reported what had happened to Resident 137, the nursing assistant who abused her had worked three more evening shifts — clocking in each afternoon, working past 10 p.m., and going home again.
The incident came to light through a September 2025 complaint inspection by federal surveyors, who reconstructed the timeline using employee timecards and interviews with facility leadership. What they found was a straightforward failure: a witnessed act of verbal abuse, a coworker who did not report it, and a resident left in the care of her abuser for days.
The nursing assistant, identified in inspection records as NAT #17, was hired by Oaks on Parkwood on February 21, 2024. Six days later, on February 27, she completed the facility's abuse training. On the evening of May 4, 2024, she verbally abused Resident 137 while working a 3-to-11 shift alongside a certified nursing assistant identified as CNA #16.
CNA #16 witnessed it. She did not report it that night.
NAT #17 returned the next evening, May 5, clocking in at 2:59 p.m. and clocking out just before 11. CNA #16 also worked that day, though on a different shift, coming in before 7 a.m. She still said nothing.
NAT #17 came back again on May 6, clocking in at 2:57 p.m. and leaving at 10:55 p.m. CNA #16 was not scheduled that day.
It was not until May 7 that CNA #16 finally told someone what she had seen three nights earlier. On that date, she reported that she had witnessed NAT #17 verbally abuse Resident 137 "the night prior" — a description that, as the facility's executive director later acknowledged, turned out to be imprecise. When he reviewed the timecards more carefully during a follow-up interview with surveyors on the evening of September 25, 2025, he realized that CNA #16 and NAT #17 had only worked together once that entire month. The abuse had to have occurred on May 4.
That meant the gap between the witnessed abuse and the report was not one night. It was three days.
NAT #17 was suspended on May 7, the same day CNA #16 finally came forward, for what the facility described as a violation of abuse policy and inappropriate and unprofessional behavior toward a resident. She was terminated on May 14.
The executive director, in his interview with surveyors, did not minimize what the delayed reporting meant. He said CNA #16 should have reported the abuse immediately. He said that any time that lapsed put the facility out of compliance. He said the obligation was to keep the resident safe and ensure effective reporting.
What he described as the consequence for CNA #16 was a one-on-one conversation with the Director of Nursing about reporting abuse.
That was it.
Resident 137 is not described in the inspection records beyond her resident number. The inspection does not say how old she is, what conditions brought her to the facility, or what NAT #17 said to her that evening. The record does not say whether she knew, during the three days that followed, that what happened to her had been witnessed and not reported. It does not say whether she was in the same room as NAT #17 during any of those subsequent shifts.
What the record does say is that surveyors cited the facility under federal tag F0607, which covers the obligation to protect residents from abuse and to report and investigate allegations when they arise. The level of harm was classified as minimal harm or potential for actual harm. A few residents were identified as affected.
The executive director's own words, offered to surveyors during the September 25 interview, capture the standard the facility failed to meet: if any time lapsed, they were not in compliance, and they needed to keep the resident safe.
By that standard, Oaks on Parkwood was out of compliance from the moment CNA #16 walked out of the building on the night of May 4 without saying a word.
The facility did not catch the delayed report through any supervisory mechanism. It did not surface through a review of timecards, a check-in with the resident, or a conversation with staff. It came out only because CNA #16 eventually decided, three days later, to say something. The inspection record does not explain what changed her mind.
NAT #17 had completed the facility's abuse training less than ten weeks before the incident. The training did not prevent the abuse. The training also did not prompt CNA #16, who presumably received the same instruction, to pick up the phone.
The inspection was completed September 28, 2025. It was a complaint inspection, meaning someone outside the facility, not a routine survey cycle, triggered the review. The inspection records do not identify who filed the complaint or when.
Resident 137 remains identified only by number. Whatever was said to her on the evening of May 4, 2024, is not in the record. What is in the record is the shape of what followed: three shifts, three evenings, the abuser clocking in and clocking out, and no one saying anything until the fourth day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oaks On Parkwood Skilled Nursing Facility from 2025-09-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
OAKS ON PARKWOOD SKILLED NURSING FACILITY in BESSEMER, AL was cited for abuse-related violations during a health inspection on September 28, 2025.
The nursing assistant, identified in inspection records as NAT #17, was hired by Oaks on Parkwood on February 21, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.