Vista Springs Greenbriar

Based on review of the facility Self-Reported Incident (SRI), interviews with staff, and review of facility policy, the facility failed to ensure allegations of abuse were timely reported to the State agency, thoroughly investigated and staff education timely implemented to mitigate risk of further incidents of staff-to-resident abuse. This affected seven residents (#116, #118, #151, #159, #165, #172 and #179) out of seven residents reviewed for abuse, neglect and misappropriation. The facility census was 80. Findings include: Review of the facility Self-Reported Incident (SRI) dated 07/30/25 timed at 5:07 P.M. and related investigation revealed on 07/29/25 the facility found overwhelming evidence that staff-to-resident abuse was occurring on the memory care unit. The investigation indicated that Personal Wellness Partner (PWP) #590 had hit Resident #159 with a decorative pillow many times in retaliation whenever the resident was combative, and PWP #590 had injured Resident #165 who was found with finger marks on her shoulder and was flinching when staff cared for her. In addition, another alleged perpetrator, PWP #591, was witnessed placing a pillow over a resident's (unnamed) face. Both alleged perpetrators (PWP #590 and PWP #591) were suspended pending completion of the investigation. Resident #159 was unable to provide meaningful information when interviewed. Resident #165 was able to identify PWP #590 as the staff member who had hurt her, and a skin check determined the resident had finger marks on her shoulders. The evidence gathered determined that PWP #590 hit multiple residents (unnamed) with pillows, left marks on Resident #165, and PWP #591 had mishandled multiple residents (unnamed) by tossing them into bed, being rough and even putting pillows over their faces when they were too loud. PWP #590's employment was terminated effective 07/29/25 and PWP #591 was terminated on 08/05/25. The allegation was ultimately substantiated. Review of the written witness statement by former employee, PWP #600, dated 07/29/25, revealed while working sometime in May or June of 2025, she noticed PWP #591 became violent towards multiple residents (unnamed). On one occurrence, PWP #591 had helped her put Resident #118 to bed. She witnessed PWP #591 pick the resident up and throw her onto the bed so hard that her body jumped back up from the impact. Afterward, the resident was checked and changed. While doing so, PWP #591 turned Resident #118 toward him and pulled her leg so she would keep having a bowel movement. Although it was clear the resident was in pain, PWP #591 would not stop until PWP #600 told him to stop. In addition, while they were both with another resident (unnamed) PWP #591 was rough and threw the resident into the bed. PWP #600 then identified three residents (#116, #118 and #165) who she witnessed receiving rough care by PWP #600. After she questioned PWP #600 as to what he was doing, he replied, I don't care. I'm fed the [expletive] up with this place. Review of an additional written witness statement by PWP #600, dated 07/29/25, revealed that in the past few weeks the PWP witnessed another employee, PWP #590, hit Resident #159 with a couch pillow, but was unable to recall the dates due to it having happened over several occurrences. Whenever Resident #159 became combative or violent, PWP #590 would grab the couch pillow from the front of the room and proceed to hit the resident all over and wherever she could, stating, hold on, I got something for his [expletive]. Review of the written witness statement by PWP #568, dated 07/31/25, revealed the PWP witnessed PWP #590 harass residents (unnamed), and would tickle Resident #179 until she would yell, ball up her fists and then become combative in response. PWP #590 would also rustle and shake the shoulders of Resident #151 until he was agitated, yelling and loudly complaining. Review of the written witness statement by Medication and Treatment Professional (MTP) #550, dated 07/31/25, revealed on one day (not specified) the MTP was in Resident #118's room with PWP #591 laying the resident down for bedtime when Resident #118 spat out during the care, so PWP #591 placed a pillow over her face. Review of the written witness statement by former employee, PWP #601, dated 07/31/25 revealed while providing personal care to Resident #159 he begged her not to hit him and said he loved her and would do whatever she wanted. PWP #601 also indicated Resident #172's family had noticed the resident was flinching and believed someone was hitting him. Review of the written witness statement from Assistant Managing Partner (AMP) #564, dated 08/04/25, revealed AMP #564 participated in an interview by phone with Health and Wellness Officer (HWO) #549 and PWP #592 using a speaker. PWP #592 reported she quit without notice because while working with PWP #591 who was her trainer, PWP #591 was rough while handling residents and giving care. His behavior towards residents was to get them agitated by poking at them which escalated their behavior. PWP #591 found it amusing and would say things about their appearance and make fun of them. Review of the written witness statement by HWO #549, dated 08/04/25, revealed participation in an interview with AMP #564 and PWP #592 via telephone using a speaker. HWO #549 confirmed PWP #592 reported leaving the company abruptly because her trainer, PWP #591, was rough with the residents and would tell them to shut up. He covered their mouths either with a pillow or his hand and did it on quite a few residents (unnamed). For one (unnamed) resident, PWP #591 would push the resident back into her room and throw clothes at her. On another occasion with another (unnamed) resident whose bottom was raw, PWP #591 would wipe the resident's bottom being very rough. When PWP #592 was questioned as to why she did not report it, she responded it was because PWP #591 told her, My sister is the coordinator, and they will not fire meBased on review of the facility Self-Reported Incident (SRI), interviews with staff, and review of facility policy, the facility failed to ensure allegations of abuse were timely reported to the State agency, thoroughly investigated and staff education timely implemented to mitigate risk of further incidents of staff-to-resident abuse. This affected seven residents (#116, #118, #151, #159, #165, #172 and #179) out of seven residents reviewed for abuse, neglect and misappropriation. The facility census was 80.

Findings include:

Review of the facility Self-Reported Incident (SRI) dated 07/30/25 timed at 5:07 P.M. and related investigation revealed on 07/29/25 the facility found overwhelming evidence that staff-to-resident abuse was occurring on the memory care unit. The investigation indicated that Personal Wellness Partner (PWP) #590 had hit Resident #159 with a decorative pillow many times in retaliation whenever the resident was combative, and PWP #590 had injured Resident #165 who was found with finger marks on her shoulder and was flinching when staff cared for her. In addition, another alleged perpetrator, PWP #591, was witnessed placing a pillow over a resident's (unnamed) face. Both alleged perpetrators (PWP #590 and PWP #591) were suspended pending completion of the investigation. Resident #159 was unable to provide meaningful information when interviewed. Resident #165 was able to identify PWP #590 as the staff member who had hurt her, and a skin check determined the resident had finger marks on her shoulders. The evidence gathered determined that PWP #590 hit multiple residents (unnamed) with pillows, left marks on Resident #165, and PWP #591 had mishandled multiple residents (unnamed) by tossing them into bed, being rough and even putting pillows over their faces when they were too loud. PWP #590's employment was terminated effective 07/29/25 and PWP #591 was terminated on 08/05/25. The allegation was ultimately substantiated.

Review of the written witness statement by former employee, PWP #600, dated 07/29/25, revealed while working sometime in May or June of 2025, she noticed PWP #591 became violent towards multiple residents (unnamed). On one occurrence, PWP #591 had helped her put Resident #118 to bed. She witnessed PWP #591 pick the resident up and throw her onto the bed so hard that her body jumped back up from the impact. Afterward, the resident was checked and changed. While doing so, PWP #591 turned Resident #118 toward him and pulled her leg so she would keep having a bowel movement. Although it was clear the resident was in pain, PWP #591 would not stop until PWP #600 told him to stop. In addition, while they were both with another resident (unnamed) PWP #591 was rough and threw the resident into the bed. PWP #600 then identified three residents (#116, #118 and #165) who she witnessed receiving rough care by PWP #600. After she questioned PWP #600 as to what he was doing, he replied, I don't care. I'm fed the [expletive] up with this place.

Review of an additional written witness statement by PWP #600, dated 07/29/25, revealed that in the past few weeks the PWP witnessed another employee, PWP #590, hit Resident #159 with a couch pillow, but was unable to recall the dates due to it having happened over several occurrences. Whenever Resident #159 became combative or violent, PWP #590 would grab the couch pillow from the front of the room and proceed to hit the resident all over and wherever she could, stating, hold on, I got something for his [expletive].

Review of the written witness statement by PWP #568, dated 07/31/25, revealed the PWP witnessed PWP #590 harass residents (unnamed), and would tickle Resident #179 until she would yell, ball up her fists and then become combative in response. PWP #590 would also rustle and shake the shoulders of Resident #151 until he was agitated, yelling and loudly complaining.

Review of the written witness statement by Medication and Treatment Professional (MTP) #550, dated 07/31/25, revealed on one day (not specified) the MTP was in Resident #118's room with PWP #591 laying the resident down for bedtime when Resident #118 spat out during the care, so PWP #591 placed a pillow over her face.

Review of the written witness statement by former employee, PWP #601, dated 07/31/25 revealed while providing personal care to Resident #159 he begged her not to hit him and said he loved her and would do whatever she wanted. PWP #601 also indicated Resident #172's family had noticed the resident was flinching and believed someone was hitting him.

Review of the written witness statement from Assistant Managing Partner (AMP) #564, dated 08/04/25, revealed AMP #564 participated in an interview by phone with Health and Wellness Officer (HWO) #549 and PWP #592 using a speaker. PWP #592 reported she quit without notice because while working with PWP #591 who was her trainer, PWP #591 was rough while handling residents and giving care. His behavior towards residents was to get them agitated by poking at them which escalated their behavior. PWP #591 found it amusing and would say things about their appearance and make fun of them.

Review of the written witness statement by HWO #549, dated 08/04/25, revealed participation in an interview with AMP #564 and PWP #592 via telephone using a speaker. HWO #549 confirmed PWP #592 reported leaving the company abruptly because her trainer, PWP #591, was rough with the residents and would tell them to shut up. He covered their mouths either with a pillow or his hand and did it on quite a few residents (unnamed). For one (unnamed) resident, PWP #591 would push the resident back into her room and throw clothes at her. On another occasion with another (unnamed) resident whose bottom was raw, PWP #591 would wipe the resident's bottom being very rough. When PWP #592 was questioned as to why she did not report it, she responded it was because PWP #591 told her, My sister is the coordinator, and they will not fire me

Based on observation, interview and facility policy review, the facility failed to properly store frozen and refrigerated foods in a manner to protect it against contamination, freezer burn and spoilage. This had the potential to affect all 80 residents residing in the facility.

Findings include:

Observation on 10/15/25 at 8:44 A.M. of the kitchen with Culinary Services Director (CSD) #548 revealed the walk-in freezer had one large, opened bag of beef patties, one large, opened bag of chicken tenders, and one large, opened bag of mixed vegetables, all of which were exposed to the air and undated. The walk-in refrigerator had one large container of mandarin oranges which were uncovered and undated. Interview at the time of the observation with CSD #548 verified the opened and undated foods located in the refrigerator and freezer.

Review of the facility policy titled, Food Storage

Based on observation, interview and facility policy review, the facility failed to maintain a functioning three sink cleaning system to dispense adequate levels of sanitizing solution for the cleaning and sanitizing of kitchen dishes including pots, pans and large utensils. This had the potential to affect all 80 residents residing in the facility.

Findings include:

Observation on 10/15/25 at 8:44 A.M. of the kitchen's three sink cleaning system with Culinary Services Director (CSD) #548 revealed there were no chemical strip testing logs for the monitoring of chemical sanitization on each shift. The three sink cleaning system contained an automatic dispenser for detergent followed by a sanitizing solution for final rinse. A test of the final rinse sink water detected there was no sanitizing solution dispensed into the final rinse. The posted manufacturer's recommendations indicated the final rinse was to have 200 parts per million (PPM) of the sanitizing solution.

Interview with CSD #548 on 10/15/25 at 8:50 A.M. verified the absence of chemical strip testing logs as well as the malfunction of the automatic dispenser system which resulted in no sanitizing solution detected in the final rinse.

Review of the facility policy titled, Culinary Services Safety Practices-Equipment Storage

Based on observation, review of the facility Self-Reported Incident (SRI) and investigation, record review, interview, and review of facility policy, the facility failed to protect each resident's right to be free from mental, emotional, verbal and physical abuse resulting in reoccurring staff to resident abuse. This affected seven residents (#116, #118, #151, #159, #165, #172 and #179) of seven residents reviewed for abuse. The facility census was 80. Actual physical and psychological harm was identified on 07/30/25 when Resident #165 was assessed with multiple areas of bruising as a result of staff abuse. A subsequent facility investigation revealed a pattern of abuse by Personal Wellness Partners (PWP) #590 and #591 affecting Residents #116, #118, #151, #159, #165, #172 and #179. All seven residents were severely cognitively impaired and required supervised, assisted care by staff on a memory care unit. PWP #590 and #591 inflicted aggressive handling of body parts, tickling to induce combative behavior, hitting with pillows, covering of face and mouths with pillows or hands to silence them and mocking of the residents. In addition to Resident #165 having multiple areas of bruising because of the abuse, per staff and family interviews all seven residents had changes in behavior/ signs of fearfulness after the abuse. Additionally, facility staff failed to timely report to administration incidents of abusive behavior towards residents by PWP #590 and #591 at the times of occurrence resulting in repeated incidents of abusive acts and further delaying resident safety until Resident #165 presented with multiple areas of bruising on 07/30/25. The acts of abuse resulted in identified harm and/or harm using the reasonable person concept in these situations. Findings include: Review of the facility Self-Reported Incident (SRI) dated 07/30/25 and related investigation revealed on 07/29/25 the facility found overwhelming evidence that staff to resident abuse was occurring on the memory care unit. The investigation indicated that Personal Wellness Partner (PWP) #590 had hit Resident #159 with a decorative pillow many times in retaliation whenever the resident was combative, and PWP #590 had injured Resident #165 who was found with finger marks on her shoulder and was flinching when staff cared for her. In addition, another alleged perpetrator, PWP #591, was witnessed placing a pillow over a resident's (unnamed) face. Both alleged perpetrators (PWP #590 and PWP #591) were suspended pending completion of the investigation. Resident #159 was unable to provide meaningful information when interviewed. Resident #165 was able to identify PWP #590 as the staff member who had hurt her, and a skin check determined the resident had finger marks on her shoulders. The evidence gathered determined that PWP #590 hit multiple residents (unnamed) with pillows, left marks on Resident #165, and PWP #591 had mishandled multiple residents (unnamed) by tossing them into bed, being rough and even putting pillows over their faces when they were too loud. PWP #590's employment was terminated effective 07/29/25 and PWP #591 was terminated on 08/05/25. The allegation was ultimately substantiated. Review of the written witness statement by former employee, PWP #600, dated 07/29/25, revealed while working sometime in May or June of 2025, she noticed PWP #591 became violent towards multiple residents (unnamed). On one occurrence, PWP #591 had helped her put Resident #118 to bed. She witnessed PWP #591 pick the resident up and throw her onto the bed so hard that her body jumped back up from the impact. Afterward, the resident was checked and changed. While doing so, PWP #591 turned Resident #118 toward him and pulled her leg so she would keep having a bowel movement. Although it was clear the resident was in pain, PWP #591 would not stop until PWP #600 told him to stop. In addition, while they were both with another resident (unnamed) PWP #591 was rough and threw the resident into the bed. PWP #600 then identified three residents (#116, #118 and #165) who she witnessed receiving rough care by PWP #591. After she questioned PWP #591 as to what he was doing, he replied, I don't care. I'm fed the (expletive) up with this place. Review of an additional written witness statement by PWP #600, dated 07/29/25, revealed that in the past few weeks the PWP witnessed another employee, PWP #590, hit Resident #159 with a couch pillow, but was unable to recall the dates due to it having happened over several occurrences. Whenever Resident #159 became combative or violent, PWP #590 would grab the couch pillow from the front of the room and proceed to hit the resident all over and wherever she could, stating, hold on, I got something for his (expletive). Review of the written witness statement by PWP #568, dated 07/31/25, revealed the PWP witnessed PWP #590 harass residents (unnamed), and would tickle Resident #179 until she would yell, ball up her fists and then become combative in response. PWP #590 would also rustle and shake the shoulders of Resident #151until he was agitated, yelling and loudly complaining. Review of the written witness statement by Medication and Treatment Profession (MTP) #550, dated 07/31/25, revealed on one day (not specified) the MTP was in Resident #118's room with PWP #591 laying the resident down for bedtime when Resident #118 spat out during the care, so PWP #591 placed a pillow over her face. Review of the written witness statement by former employee, PWP #601, dated 07/31/25 revealed while providing personal care to Resident #159 he begged her not to hit him and said he loved her and would do whatever she wanted. PWP #601 also indicated Resident #172's family had noticed the resident was flinching and believed someone was hitting him. Review of the written witness statement from Assistant Managing Partner (AMP) #564, dated 08/04/25, revealed AMP #564 participated in an interview by phone with Health and Wellness Officer (HWO) #549 and PWP #592 using a speaker. PWP #592 reported she quit without notice because while working with PWP #591 who was her trainer, PWP #591 was rough while handling residents and giving care. His behavior towards residents was to get them agitated by poking at them which escalated their behavior. PWP #591 found it amusing and would say things about their appearance and make fun of them. Review of the written witness statement by HWO #549, dated 08/04/25, revealed participation in an interview with AMP #564 and PWP #592 via telephone using a speaker. HWO #549 confirmed PWP #592 reported leaving the company abruptly because her trainer PWP #591 was rough with the residents and would tell them to shut up. He covered their mouths either with a pillow or his hand and did it on quite a few residents (unnamed). For one (unnamed) resident, PWP #591 would push the resident back into her room and throw clothes at her. On another occasion with another (unnamed) resident whose bottom was raw, PWP #591 would wipe the resident's bottom being very rough. When PWP #592 was questioned as to why she did not report it, she responded it was because PWP #591 told her, My sister is the coordinator and they will not fire meBased on observation, review of the facility Self-Reported Incident (SRI) and investigation, record review, interview, and review of facility policy, the facility failed to protect each resident's right to be free from mental, emotional, verbal and physical abuse resulting in reoccurring staff to resident abuse. This affected seven residents (#116, #118, #151, #159, #165, #172 and #179) of seven residents reviewed for abuse. The facility census was 80.

Actual physical and psychological harm was identified on 07/30/25 when Resident #165 was assessed with multiple areas of bruising as a result of staff abuse. A subsequent facility investigation revealed a pattern of abuse by Personal Wellness Partners (PWP) #590 and #591 affecting Residents #116, #118, #151, #159, #165, #172 and #179. All seven residents were severely cognitively impaired and required supervised, assisted care by staff on a memory care unit. PWP #590 and #591 inflicted aggressive handling of body parts, tickling to induce combative behavior, hitting with pillows, covering of face and mouths with pillows or hands to silence them and mocking of the residents. In addition to Resident #165 having multiple areas of bruising because of the abuse, per staff and family interviews all seven residents had changes in behavior/ signs of fearfulness after the abuse. Additionally, facility staff failed to timely report to administration incidents of abusive behavior towards residents by PWP #590 and #591 at the times of occurrence resulting in repeated incidents of abusive acts and further delaying resident safety until Resident #165 presented with multiple areas of bruising on 07/30/25. The acts of abuse resulted in identified harm and/or harm using the reasonable person concept in these situations.

Findings include:

Review of the facility Self-Reported Incident (SRI) dated 07/30/25 and related investigation revealed on 07/29/25 the facility found overwhelming evidence that staff to resident abuse was occurring on the memory care unit. The investigation indicated that Personal Wellness Partner (PWP) #590 had hit Resident #159 with a decorative pillow many times in retaliation whenever the resident was combative, and PWP #590 had injured Resident #165 who was found with finger marks on her shoulder and was flinching when staff cared for her. In addition, another alleged perpetrator, PWP #591, was witnessed placing a pillow over a resident's (unnamed) face. Both alleged perpetrators (PWP #590 and PWP #591) were suspended pending completion of the investigation. Resident #159 was unable to provide meaningful information when interviewed. Resident #165 was able to identify PWP #590 as the staff member who had hurt her, and a skin check determined the resident had finger marks on her shoulders. The evidence gathered determined that PWP #590 hit multiple residents (unnamed) with pillows, left marks on Resident #165, and PWP #591 had mishandled multiple residents (unnamed) by tossing them into bed, being rough and even putting pillows over their faces when they were too loud. PWP #590's employment was terminated effective 07/29/25 and PWP #591 was terminated on 08/05/25. The allegation was ultimately substantiated.

Review of the written witness statement by former employee, PWP #600, dated 07/29/25, revealed while working sometime in May or June of 2025, she noticed PWP #591 became violent towards multiple residents (unnamed). On one occurrence, PWP #591 had helped her put Resident #118 to bed. She witnessed PWP #591 pick the resident up and throw her onto the bed so hard that her body jumped back up from the impact. Afterward, the resident was checked and changed. While doing so, PWP #591 turned Resident #118 toward him and pulled her leg so she would keep having a bowel movement. Although it was clear the resident was in pain, PWP #591 would not stop until PWP #600 told him to stop. In addition, while they were both with another resident (unnamed) PWP #591 was rough and threw the resident into the bed. PWP #600 then identified three residents (#116, #118 and #165) who she witnessed receiving rough care by PWP #591. After she questioned PWP #591 as to what he was doing, he replied, I don't care. I'm fed the (expletive) up with this place.

Review of an additional written witness statement by PWP #600, dated 07/29/25, revealed that in the past few weeks the PWP witnessed another employee, PWP #590, hit Resident #159 with a couch pillow, but was unable to recall the dates due to it having happened over several occurrences. Whenever Resident #159 became combative or violent, PWP #590 would grab the couch pillow from the front of the room and proceed to hit the resident all over and wherever she could, stating, hold on, I got something for his (expletive).

Review of the written witness statement by PWP #568, dated 07/31/25, revealed the PWP witnessed PWP #590 harass residents (unnamed), and would tickle Resident #179 until she would yell, ball up her fists and then become combative in response. PWP #590 would also rustle and shake the shoulders of Resident #151until he was agitated, yelling and loudly complaining.

Review of the written witness statement by Medication and Treatment Profession (MTP) #550, dated 07/31/25, revealed on one day (not specified) the MTP was in Resident #118's room with PWP #591 laying the resident down for bedtime when Resident #118 spat out during the care, so PWP #591 placed a pillow over her face.

Review of the written witness statement by former employee, PWP #601, dated 07/31/25 revealed while providing personal care to Resident #159 he begged her not to hit him and said he loved her and would do whatever she wanted. PWP #601 also indicated Resident #172's family had noticed the resident was flinching and believed someone was hitting him.

Review of the written witness statement from Assistant Managing Partner (AMP) #564, dated 08/04/25, revealed AMP #564 participated in an interview by phone with Health and Wellness Officer (HWO) #549 and PWP #592 using a speaker. PWP #592 reported she quit without notice because while working with PWP #591 who was her trainer, PWP #591 was rough while handling residents and giving care. His behavior towards residents was to get them agitated by poking at them which escalated their behavior. PWP #591 found it amusing and would say things about their appearance and make fun of them.

Review of the written witness statement by HWO #549, dated 08/04/25, revealed participation in an interview with AMP #564 and PWP #592 via telephone using a speaker. HWO #549 confirmed PWP #592 reported leaving the company abruptly because her trainer PWP #591 was rough with the residents and would tell them to shut up. He covered their mouths either with a pillow or his hand and did it on quite a few residents (unnamed). For one (unnamed) resident, PWP #591 would push the resident back into her room and throw clothes at her. On another occasion with another (unnamed) resident whose bottom was raw, PWP #591 would wipe the resident's bottom being very rough. When PWP #592 was questioned as to why she did not report it, she responded it was because PWP #591 told her, My sister is the coordinator and they will not fire me