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32 | when the charge nurse passed the phone to the resident to talk to the son the resident hides the nurse’s station phone inside their bag. Charge nurse tried to retrieve the phone, but the resident started striking at the nurse. After a couple minutes of the resident holding onto the phone and striking at the nurse, the charge nurse got the bag from the resident and retrieved the phone from the resident. February 16, 2026, Resident demanded to go back to bed. It was also observed by this nurse and CNA that resident was hitting themselves (right hand to her right leg). This nurse tried to stop the resident. Resident continued and was very upset. February 19, 2026, at 3:38pm resident was observed to be confused and verbalized wanting to go outside "run home". nurse and CNA attempted redirection, however resident became combative, hitting nurse and CNA and striking themselves by hitting their legs. February 24, 2026, Resident refused to stay in her room and aide assisted resident to the activity room. Resident was very anxious and agitated. At 1:30pm resident stated that they wanted to go home and resident became combative. Interview with 2 of 2 staff stated that R1 was observed with a change of condition by R1 becoming combative, agitated and combative with staff. Facility has cameras in common spaces, and it was observed that videos were looked at and saw nothing but redirecting and there was no aggressive behavior. Interview with 6 of 6 of the residents stated they had not seen staff being aggressive towards any resident.
It is alleged that facility staff did not communicate about the residents’ incident appropriately. Records review revealed progress notes dates from February 08, 2026, to March 25, 2026, on all incidents staff notified son of R1 of the incidents. On numerous occasions calls went unanswered and voicemail was full so that staff would not be able to leave a message. The notes reflect 2/8/26 charge nurse called son to calm R1 and son came to facility to aid, 2/10/26 unwitnessed fall, daughter in law was in lobby at time of incident and was notified, daughter in law present when paramedics arrived, 2/16/26 at 1:10pm resident tried to walk out of facility and was redirected at 2:24pm son was notified, 2:45pm daughter in law arrived to facility, 2/19/26 resident was combative resident called son and spoke to him, son arrived at 4:00pm to aid with resident, 2/23/26 receive medication change son notified, 2/24/26 resident was agitated and son was notified, medication was updated and son was notified, 3/2/26 resident was anxious son notified and stated they would arrive to facility at 1:00pm, 3/3/26 unwitnessed fall 4:31pm son notified the son at 4:46pm multiple times but calls went straight to voicemail, 3/7/26 resident refused medication son notified and he was ok with resident refusing medication, 3/7/26 unwitnessed fall at 3:40pm attempted to notify son from 4:02pm – 4:19pm no answer and voicemail message left at 4:19pm son returned call, 3/7/26 resident had an unwitnessed fall at 10:50pm and attempted to notify son at 10:59pm and was unable to leave message, |