Spanish Trails Wellness & Rehabilitation

the staff helped him back to bed. R #1 was unable to recall if CNA #1 had caused the injury R #1

#1, he stated the night of 11/22/25, CNA #2 (who had been asked by LPN #1) came to ask him to help

his aggressive behavior. CNA #1 entered R #1's room and asked CNA #2 to stay at the door while he provided care. CNA #1 asked R #1 what was going and R #1 started yelling at him to leave. CNA #1 replied we are just here trying to help you. CNA #1 stated he went around the bed to have a better view of his ostomy bag (a collection pouch to catch urine or stool), and immediately R #1 jumped him and cornered him. R #1 started swinging at him and R #1 immediately fell to the floor and continued kicking CNA #1. CNA #1 stated that as soon as he was able to move away from R #1 (CNA #2, LPN #1 and another staff [does not recall the name of the staff]) started coming in and CNA #1 proceeded to leave the room. CNA #1 further stated that R #1 had a prior incident with another resident and he was the CNA that intervened in the incident, after that incident R #1 had a negative attitude toward him.G.

On 12/26/25 at 12:14 pm, during an interview with LPN #1, she recalled the night of 11/22/25, R #1 had a nasty attitude. LPN #1 went in the room after R #1 had a late shower to provide dressing change to his legs. LPN #1 stated she made the decision to remove herself from the situation (as she felt threatened by R #1's increase aggressive behavior) after providing wound care (does not remember the exact treatment provided) and asked CNA #2 to help R #1 pull his pants up. CNA #2 grabbed CNA #1 and entered the room. LPN #1 stated that a few minutes later, she heard CNA #2 yelling the resident is fighting [name of CNA.] LPN #1 quickly ran back to the room with the other night staff (do not recall which staff came in with her) and saw CNA #1 standing by bed A (bed A is empty, and R #1 is assigned to bed). LPN #1 further stated she did not see the actual altercation and saw R #1 on the floor. LPN #1 went straight to R #1 and asked him to try to calm down so they can assist him back to bed.H. On 12/26/25 at 2:06 pm, during an interview with the Administrator, she stated they took CNA #1 off the schedule immediately pending investigation.

The administrator also stated that she was unable to get a hold of CNA #1 and subsequently terminated him when she substantiated her investigation. On 11/24/25 she concluded that CNA #1 had all the opportunity to remove himself from the situation and that did not happen.

Immediately after the incident the administrator conducted abuse re-training and de-escalation training for the staff. On 11/28/25 they conducted safe interviews with all the residents, especially the residents CNA #1 was assigned and did not find any similar situations.

Administrator further stated that all staff when hired is giving an abuse/neglect training but not de-escalation or any other training for staff related to managing difficult or aggressive behaviors. De-escalation training was conducted with staff after 11/23/25. I.

On 12/29/25 at 8:03 am, during an interview with CNA #2, she stated LPN #1 asked her to help R #1 pull his pants up. CNA #2 stated she is not assigned to R #1 and is aware of R #1's behavior, so she asked CNA #1 for help. CNA #2 stated that as soon as R #1 saw CNA #1, he started yelling profanity to CNA #1. CNA # 2 stated that the next thing she saw was R #1 on his feet attacking CNA #1. CNA #2 quickly asked for help and LPN #1 and another nurse showed up. CNA #2 also stated that R #1 is nice to everyone except CNA #1 because of a prior incident (incident when CNA #1 intervened between R #1 and another resident). ˆ