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F0600
D

Failure to Protect Resident from Staff Intimidation and Verbal Aggression

Beverly Hills, Michigan Survey Completed on 09-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nurse aide (CNA) engaged in intimidating and verbally aggressive behavior toward a resident with moderate cognitive impairment, including Alzheimer's disease, schizophrenia, and an anxiety disorder. The incident began when the resident used profane language toward the CNA, who then left the building, retrieved a baseball bat from their car, and re-entered the facility. The CNA displayed the bat in a threatening manner, including hitting it on the ground, in the presence of the resident. This act was witnessed by another resident and a maintenance employee, both of whom confirmed the intimidating behavior. The resident who was the target of the intimidation was unable to recall the incident and denied experiencing fear, pain, or distress when interviewed. No physical harm or injuries were observed or reported. The witness resident, who was alert and oriented, reported feeling upset by the incident but stated they felt safe in the facility. The maintenance employee also confirmed that the CNA did not physically approach or chase the resident with the bat but did display it in a manner that drew attention and was inappropriate. The facility's policy defines abuse to include intimidation and verbal aggression, both of which were substantiated in this incident. The event was not immediately reported to facility management, and the CNA's actions were later confirmed by multiple staff and resident interviews. The incident was reported to law enforcement, and the facility's investigation concluded that the CNA's conduct constituted mistreatment and failed to protect the resident from abuse and intimidation.

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