Oaks On Parkwood: Behavioral Health Gaps - AL
The incident occurred May 4, 2024, when CNA #16 asked Nurse Aide Trainee #17 to help provide care to Resident #137. Upon entering the room, the resident used profanity toward the trainee, calling him "a bitch." The trainee responded by calling the resident "a bitch" back.
CNA #16 witnessed the exchange and recognized it as verbal abuse. But she didn't report it immediately, as required by federal regulations and facility policy.
The verbal abuse only came to light three days later during the facility's investigation of a separate physical abuse allegation involving the same resident. On May 7, Licensed Practical Nurse #19 reported that Resident #137 claimed a male nursing assistant had come into the room the night before and poked the resident on the forehead multiple times.
Resident #137 had intact cognition, scoring 15 on a mental status assessment conducted in April 2024. The resident was initially admitted to the facility on an undisclosed date and readmitted later.
During the facility's investigation into the physical abuse allegation, administrators discovered the earlier verbal abuse incident. A review of employee timecards showed May 4 was the only day in that month when CNA #16 and NAT #17 worked together, confirming when the verbal abuse occurred.
The facility's own investigative summary determined that physical abuse could not be substantiated. However, administrators concluded that NAT #17 was verbally abusive when he called the resident "a bitch." The trainee was terminated May 14, 2024.
CNA #16 acknowledged her failure during a September 24, 2025 interview with federal inspectors. She said she viewed the trainee's cursing at the resident as verbal abuse and admitted she should have reported the incident immediately when she witnessed it.
"The importance of reporting abuse immediately was to ensure the safety and protection of the resident," CNA #16 told inspectors.
The facility's abuse policy, effective February 2020, is explicit about reporting requirements. It states that residents have the right to be free from verbal, sexual, physical and mental abuse. The policy requires staff to "report to State agency all alleged violations involving abuse, neglect, exploitation, or mistreatment immediately but no later than 2 hours from forming the suspicion or allegation."
Executive Director confirmed the policy violation during his September 25, 2025 interview with inspectors. He stated that CNA #16 should have reported the allegation immediately and acknowledged that any delays in reporting abuse allegations would result in the facility being non-compliant.
"It was important to ensure resident safety," the executive director told inspectors.
The executive director initially provided confused information about the timing of the incident but later clarified after reviewing employee timecards more closely. He confirmed that CNA #16 worked May 4, 2024, from 3 PM to 11 PM alongside NAT #17, making that the date of the verbal abuse.
The State Agency received the Facility Reported Incident about the physical abuse allegation at 11:45 AM on May 7, 2024. But the verbal abuse that CNA #16 witnessed three days earlier was never reported through proper channels until it emerged during the investigation.
Federal regulations require nursing homes to immediately report suspected abuse, neglect, or theft to proper authorities. The failure to report puts vulnerable residents at risk and prevents swift intervention when abuse occurs.
This case illustrates how unreported incidents can remain hidden until other allegations surface. The verbal abuse against Resident #137 might never have been addressed if the physical abuse complaint hadn't triggered a broader investigation.
The inspection was conducted September 28, 2025, as part of a complaint investigation numbered 468255. Inspectors found the facility failed to ensure immediate reporting of witnessed abuse, affecting one of eight residents sampled during the abuse investigation.
CNA #16 continues working at the facility despite acknowledging she witnessed verbal abuse and failed to report it immediately. The trainee who committed the verbal abuse was terminated nearly four months after the incident occurred.
Resident #137 experienced both the original verbal abuse and the facility's failure to properly investigate and report it through appropriate channels when it happened.
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: June 20, 2026 · Our methodology
OAKS ON PARKWOOD SKILLED NURSING FACILITY in BESSEMER, AL was cited for violations during a health inspection on September 28, 2025.
The incident occurred May 4, 2024, when CNA #16 asked Nurse Aide Trainee #17 to help provide care to Resident #137.
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.