Oaks On Parkwood Skilled Nursing Facility

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

wheelchair by the handles at this time to push (him/her) out of the room and to the nurse, however (RI #2) put (his/her) legs on the ground and pushed backwards. This action pinned (RI #140) between (RI #2's) wheelchair and (RI #140's) bed. (RI #140) stated I was really scared I was going to fall and get hurt, but (he/she) started leaving the room and thankfully I didn't. While discussing what actions to take moving forward, (RI #2) came out of (his/her) room and started yelling and cursing at staff. (RI #2) was already currently on behavior monitoring for being resistive and kicking/spitting/cursing at staff members. due to (RI #2's) behavioral history and current situation . resident to be sent to hospital . to . Geri-Psych (Geriatric-Psychiatric). After investigation, . (RI #2) came into the resident room intentionally and cursed at (RI #140).

RI #2's departmental notes were reviewed for the month leading up to the verbal abuse and revealed RI #2 had behaviors of cursing staff, kicking staff, trying to trip staff, exhibiting anger and frustration, threatening to spit on staff, and calling residents names.

Contained within the facility's investigative file was a nurse's progress note signed by LPN #22, dated 03/31/2025 which documented, . Writer answered call light . heard yelling and screaming. Writer heard resident . (RI #2), who was in . (RI #140's) room, say bitch . (I am) not going anywhere.

On 09/24/2025 at 4:59 PM an interview was conducted with LPN #22 per phone. LPN #22 was asked about

the incident involving RI #2 and RI #140 on 03/31/2025. She stated she remembered answering the call light for RI #140 and he/she said to come and get RI #2 out of his/her room. LPN #22 further documented

she heard RI #2 say bitch I am not going anywhere. LPN #22 said if she documented the incident then that was what happened and it was considered verbal abuse when she heard RI #2 curse RI #140. LPN #22 further stated that a reasonable person's feelings would be hurt and would be upset.

On 09/26/2025 at 9:01 AM the Social Services Director (SSD) was asked about the incident that occurred between RI #2 and RI #140. The SSD read the nurses progress note dated 03/31/2025 signed by LPN #22.

The SSD stated LPN #22 documented that she was answering a call light for RI #140 and heard RI #2 say bitch I am not going anywhere, and RI #140 said come get him/her out of the room. The SSD further stated that when RI #2 said bitch, I am not going anywhere that was considered verbal abuse and that would make a reasonable person angry. The SSD reported RI #2's behaviors included foul language, being aggressive, yelling, cursing staff, and being demanding.

On 09/26/2025 at 10:35 AM the ED was asked how he became aware of the incident that occurred between RI #2 and RI #140 on 03/31/2025. The ED stated, LPN #22 called him and told him that RI #2 had gone into RI #140's room. RI #140 alleged RI #2 cursed him/her and RI #140 asked RI #2 to leave the room. The ED stated the investigation determined that RI #2 did go into RI #140's room and called him/her

a bitch and LPN #22 overheard it on the communication system. The ED further stated that when RI #2 cursed RI #140 that was considered verbal abuse. The ED said RI #2 had a history of behaviors and using foul language, but he did not know how the verbal abuse could have been prevented.

A review of RI #2's care plans revealed they did not include the level of supervision RI #2 required to prevent RI #2 from abusing residents.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oaks on Parkwood Skilled Nursing Facility

2625 Laurel Oak Drive Bessemer, AL 35022

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and worked with the same residents. A review of the employee timecards indicated:The timecards indicated NAT #17 continued working in the facility and worked the following dates and times, after the witnessed abuse went unreported leaving RI #137 and all other residents in the facility unprotected from abuse by NAT #17: 05/04/2024 in at 2:51 PM and out at 10:57 PM05/05/2024 In at 2:59 PM and out at 10:56 PM05/06/2024 In at 2:57 PM and out at 10:55 PM The timecard indicated CNA #16 worked the following dates and times: 05/04/2024 In at 2:57 PM and out at 10:58 PM05/05/2024 In at 6:58 AM and out at 03:00 PM05/06/2024 was not scheduled or clocked in05/07/2024 In at 6:57 AM and out at 03:05 PM A review of NAT #17's personnel file indicated NAT #17 was hired by the facility on 02/21/2024 and completed abuse training on 02/27/2024. Further reviewed indicated NAT #17 was suspended on 05/07/2024 for Violation of Abuse, inappropriate and unprofessional behavior toward a resident and terminated on 05/14/2024. On 09/25/2025 at 2:53 PM the ED stated during an interview with CNA #16 on 05/07/2024 she alleged she witnessed NAT #17 verbally abuse RI #137 the night prior. He stated CNA #16 should have reported it immediately. The ED was asked about the concern of an employee not reporting an abuse allegation immediately and the ED stated if any time lapsed, they were not in compliance and needed to keep the resident safe and have effective reporting. On 09/25/2025 at 6:05 PM in a follow up interview with the he was asked to clarify when the incident of abuse occurred. The ED stated that he reviewed the timecards again and should have checked the timecards closer. The ED stated that CNA #16 did not work on 05/06/2024, but did work on 05/04/2024, 3-11 with NAT #17. The ED stated the incident had to occur on 05/04/2024 which was the only date that month that they worked together. The ED was asked what type of disciplinary action was done with CNA #16 for not reporting the incident and he stated Director of Nursing (DON) conducted a one on one with CNA #16 on reporting abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oaks on Parkwood Skilled Nursing Facility

2625 Laurel Oak Drive Bessemer, AL 35022

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 interviews, record review, and a facility policy titled Abuse, Neglect, and Exploitation the facility failed to ensure Certified Nursing Assistant (CNA) #16 immediately reported verbal abuse she witnessed on 05/04/2024 when Nurse Aide Trainee (NAT) #17 called Resident Identifier (RI) #137 a bitch. This incident was discovered by the facility during their investigation into an allegation of physical abuse reported on 05/07/2024 affecting RI #137, one of eight residents sampled for abuse. This deficient practice was cited as

a result of the investigation of complaint/intake number 468255.Findings Include: Cross-reference F-F600 and F-F607. On 05/07/2024 at 11:45 AM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse when Licensed Practical Nurse (LPN) #19 was informed by RI #137 that the night prior a male CNA came into his/her room and poked him/her on the forehead multiple times. A review of a policy titled Abuse, Neglect, and Exploitation with an effective date of 02/2020 documented: . IntroductionThe resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. D. Report to State agency all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, immediately but no later than 2 hours from forming the suspicion or allegation. RI #137 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. RI #137's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/25/2024 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition.A review of NAT #17 and CNA #16's timecards from May 2024 revealed the incident occurred on 05/04/2024 the only day the two employees worked together. On 09/25/2025 at 6:05 PM an interview was conducted with the Executive Director (ED) and he was asked to provide clarification regarding the timing of the abuse incident. The ED stated he had reviewed the timecards and acknowledged he should have looked at them more closely and confirmed that CNA #16 did not work on 05/06/2024, but she did work on 05/04/2024, from 3 PM to 11 PM with NAT #17.

The administrator said that the incident would have taken place on 05/04/2024 as that was the only day in that month when they worked together.Review of the facility investigative file revealed an Incident Summary

in which the facility determined physical abuse could not be substantiated. The Summary documented the facility did determine that NAT #17 was verbally abusive to RI #137 when he called RI #137 a bitch. Facility disciplinary actions included NAT #17's termination on 05/14/2024. On 09/24/2025 at 10:51 AM an

interview was held with CNA #16, and she was asked about the incident involving RI #137. She said that

she requested NAT #17 to help her provide care to RI #137, upon entering the room RI #137 used profanity toward NAT #17, referring to him as a bitch. CNA #16 said, in response NAT #17 called RI #137 a bitch.

CNA #16 expressed that she viewed NAT #17's cursing at RI #137 as verbal abuse. CNA #16 said she did not report the incident immediately and it should have been reported when it was witnessed. CNA #16 said

the importance of reporting abuse immediately was to ensure the safety and protection of the resident. On 09/25/2025 at 2:53 PM the ED was questioned regarding the verbal abuse allegation involving RI #137. The ED stated that CNA #16 should have reported the allegation immediately. The ED said that any delays in reporting abuse allegations would result in the facility being non-compliant and it was important to ensure resident safety.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oaks on Parkwood Skilled Nursing Facility

2625 Laurel Oak Drive Bessemer, AL 35022

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety

corrective actions had been implemented the Immediate Jeopardy was removed on 09/28/2025. The scope/severity level of F-F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oaks on Parkwood Skilled Nursing Facility

2625 Laurel Oak Drive Bessemer, AL 35022

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had been rough with RI #136. RN #27 said, RI #136's care plan guided staff to get help, give RI #136 a break, calm down and reapproach. On 09/25/2025 at 11:13 AM an interview was conducted with the Social Services Director (SSD) regarding RI #136's behaviors and the facility's process on behavior monitoring.

The SSD said she was responsible for reporting resident behaviors every day in morning meeting and every Friday they discussed anyone on the behavior monitoring program in the weekly Sub Committee meeting. The SSD said behavior data was pulled for the week, and the team discussed who needed to be added or taken off, what changes were needed or additional interventions to be implemented. When asked about RI #136's behaviors, she said according to the progress notes RI # 136 was having hitting, kicking, combative aggressive behaviors on 08/11/2024, 08/16/2024, 08/31/2024 and 09/02/2024, and she would not be aware of them until the morning meeting, if the nurse communicated the information. When asked what interventions were in place to help guide staff in how to manage RI # 136's combative behavior, she said staff were to provide redirection, assess for unmet needs, allow the resident to control and participate and allow time for the resident to calm down. On 09/25/2025 at 2:53 PM an interview was conducted with

the Director of Nursing (DON) regarding RI #136's combative behaviors and the incident on 09/15/2024.

When asked about RI #136's behaviors, the DON said RI #136 exhibited aggressive combative behavior toward staff. The DON said RI #136 was on a Behavior Monitoring Program (BMP) through 08/09/2024. The DON said the BMPs were not typically ongoing, and unless there were issues, they would stop after a period of time. When asked if RI #136 was exhibiting behaviors after the 08/09/2024, the DON said, yes, according to the notes RI #136 continued to have behaviors of hitting, kicking, and scratching staff. The DON said interventions in place for staff to help deescalate RI #136's behaviors would be talk in a calm manner, allow time to calm and reapproach and provide redirection. When asked what could have been done to prevent the incident on 09/15/2024, the DON said staff should have let RI #136 calm down and reapproached at a later time. The DON said, she was not sure why RI #136 was not included on behavior monitoring after 08/09/2024 leading up to the incident on 09/15/2024.

Event ID:

Facility ID:

If continuation sheet