The incident occurred on September 18, 2025, when three nursing assistants struggled to change Resident #2, who had soiled himself and was fighting their attempts to provide care. According to witness statements obtained by inspectors, the staff raised the bed to hip level and used physical restraint when the resident became combative.
"We always have two people and both of us have to try to care for him," wrote nursing assistant NA C in a signed statement. "He is combative everytime we try to change him and we have to hold him down."
The situation escalated when the two initial caregivers could not control the resident's movements. They texted for backup from nursing assistant NA B, who joined them in the room.
CNA A provided detailed testimony about the restraint technique used. She stated that NA B initially held the resident's hands while NA C tried to prevent him from kicking. When NA B could not turn the resident's upper body, they switched positions.
"CNA A got both hands and held them on his left shoulder with one hand and turned him with the hand while NA B finished cleaning the BM from his right side," according to the inspection report. The resident was turned on his right side facing the wall during this process.
NA C acknowledged in her statement that CNA A "had her knee on Resident #2 to hold him down."
The nursing assistants described the resident as unusually combative that day. "Wherever we were holding him he was able to get away from us," NA C wrote. She noted that the resident's behavior seemed worse at night and in mornings, but "on this day I think he was worse than most days."
CNA A told investigators she "remembered that day clearly because Resident #2 had never been that combative before or hit her like that before."
The bed height added to the dangerous nature of the restraint. With the bed raised to CNA A's hip level, inspectors calculated it stood approximately 23 to 25 inches above the floor, creating a significant fall risk for the resident.
After the struggle, the nursing assistants managed to get a brief on the resident and position him to eat breakfast. "They were able to get his brief on and then they were only able to put a draw sheet under him," the report stated.
The inspection revealed that staff had received recent training on handling combative residents. On September 27, 2025, just nine days after the incident, the facility conducted an in-service on abuse and neglect prevention. The training specifically instructed staff that "when a resident is combative walk away from the resident and go and get your charge nurse."
The training materials noted that "sometimes a resident will get care from someone else" and reminded staff that "the change in personality is the disease process." However, only 36 of the facility's 98 staff members attended this training session.
Federal inspectors found that the facility had policies in place regarding abuse prevention. The facility's policy titled "Identifying Types of Abuse," originally dated 2001 and revised in September 2022, was part of what inspectors described as "the abuse prevention strategy" for volunteers, employees and contractors.
The policy designated the administrator as the abuse prevention coordinator, providing a cell phone number for staff to report any allegations of abuse, neglect, or exploitation when not at the facility.
Despite these policies and procedures, the September 18 incident represented a clear violation of federal regulations protecting nursing home residents from abuse. The use of physical restraint, particularly placing a knee on a resident during personal care, constituted what inspectors classified as immediate jeopardy to resident health and safety.
The immediate jeopardy designation represents the most serious level of deficiency citation available to federal inspectors. It indicates that the facility's conduct placed residents in immediate danger of serious injury, serious impairment, or death.
While the inspection report indicates that few residents were affected by this particular violation, the nature of the restraint technique raised serious concerns about staff training and supervision. The incident demonstrated a fundamental failure to follow established protocols for managing combative residents safely.
The timing of the training session, occurring just over a week after the incident, suggested the facility recognized the need for immediate corrective action. However, the low attendance rate at the mandatory training raised questions about the facility's ability to ensure all staff received proper instruction on appropriate care techniques.
The resident's combative behavior, while challenging for staff, did not justify the use of physical restraint techniques that could cause injury. Federal regulations require nursing homes to explore alternative approaches to care delivery, including different staff assignments, timing adjustments, or involvement of clinical supervisors.
The three nursing assistants involved in the incident demonstrated they understood the resident's typical behavior patterns and care needs. They recognized that keeping him upright helped maintain his calm demeanor and that he required two-person assistance for personal care.
However, their response to his increased combativeness on September 18 violated fundamental principles of resident safety and dignity. The decision to use knee restraint while the resident was positioned on an elevated bed created multiple safety hazards.
The inspection findings highlighted broader systemic issues at Avir at Magnolia regarding staff supervision and emergency response procedures. The nursing assistants' decision to text for additional help rather than involving clinical staff suggested a gap in understanding proper escalation protocols.
Federal inspectors documented this incident as part of a complaint investigation, indicating that concerns about resident care had been reported to state authorities. The immediate jeopardy citation requires the facility to develop and implement immediate corrective actions to protect resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Magnolia from 2025-11-05 including all violations, facility responses, and corrective action plans.