Health inspection·July 7, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and procedures, staff and resident interviews, the facility failed to protect the resident's right to be free from physical, and verbal abuse for 1(Resident #999) of 3 residents reviewed for abuse.The findings included: Review of the facility policy N-1265 Abuse, Neglect, Exploitation and Misappropriation effective 11/30/14 (revised 11/16/22) documented It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse . Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse . No employee may at any time commit an act of physical, psychological, or emotional abuse . against any resident . Acts of abuse directed against residents are absolutely prohibited. Any action that may cause or causes actual physical, psychological or emotional harm which is not caused by simple negligence, constitutes abuse . All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Review of the clinical record revealed Resident #999 was a [AGE] year-old, Spanish speaking female with an admission date of 5/10/25. Diagnoses included displaced fracture of fifth cervical (neck) vertebra, peg tube (a tube inserted into the stomach to provide nutrition and hydration) placement, type 2 diabetes mellitus, hypothyroidism, and pain. Review of the Medicare 5 day Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/22/25 documented Resident #999 was dependent to go from sitting to standing and for transfers. The MDS noted Resident #999 scored 06 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were severely impaired.On 7/7/25 at 9:09 a.m., Resident #999 was interviewed with the assistance of Registered Nurse (RN) Staff E translating in Spanish. The resident said a male therapist came to her room and yelled at her because she had pain in her back. He was very angry for no reason. She said he pulled her from the wheelchair (w/c) and forcibly put her into bed. She did not know why he did not take her to the therapy room. She does not speak English, did not understand him and did not offer her a translator. The resident said the therapist was fine when he came in but got angry with her, because she did not understand the instructions he gave her. When he put her in bed, she hurt her cervical area, she had a fracture there and had recently had surgery. She said she told the therapist he had hurt her, he smiled at her. Resident #999 said the therapist used a gait belt to lift her up out of the wheelchair and he threw her into bed. The resident said there was no other person in the room when the male therapist was providing care. She said she was yelling and crying. A female therapist and the nurse came into her room when they heard her yelling.She said when she started to yell and cry, the therapist left her room; he was very angry. He did not say anything to me. He told her about the therapy, and she did not understand him.Resident #999 said after it happened, she was anxious and fearful, she did not expect that to happen to her. She was Page 1 of 3 106000 106000 07/07/2025 Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901

F 0600 Level of Harm - Actual harm Residents Affected - Few screaming and crying because he had hurt her.Review of the facility's incident investigations revealed on 6/13/25 the facility initiated a physical and verbal abuse investigation for Resident #999.Review of the investigation revealed:On 6/13/25 at 3:30 p.m., Physical Therapy Assistant (PTA) Staff A and Occupational Therapist (OT) Staff D were assisting Resident #999 to transfer from her bed to the wheelchair. During the transfer PTA Staff A grabbed the resident's arms and started to yell at her and shake her for not following his directions for the transfer.Registered Nurse (RN) Staff C in her statement said on 6/13/25 at approximately 3:25 p.m., she was one room down the hallway and heard Resident #999 screaming out. She went to the resident's room and saw a male therapist with his hands on both of the resident's arms yelling and shaking her and he stated very loudly I told you not to do this. This is why you keep getting hurt. The resident was crying and stated that he hurt her and was pointing to her peg tube area.RN Staff C had a certified nursing assistant stay with the resident while she went to report the abuse.PTA Staff A said in his written statement that around 3:00 p.m., when he arrived in Resident #999's room, the resident was upset and started to complain in rapid Spanish which he didn't understand. The PTA gave her detailed instructions on how to transfer from the bed to the wheelchair and how to place her hands. After detailed instructions, the resident grabbed the wrong armrest and started to twist her arm and gave out a loud scream. PTA Staff A asked why, in a loud voice, she grabbed the wrong armrest despite all instructions given. That's when RN Staff C came into the room and witnessed the PTA's question to the resident and said, This is patient abuse.OT Staff D in her statement said she was in the room assisting PTA Staff A with Resident #999's transfer. The resident was positioned properly and educated numerous times by PTA Staff A on safe transfer techniques. The resident grabbed the wrong armrest, would not let go, started screaming and was very fearful. PTA Staff A became very loud and upset at Resident #999 stating she needed to listen to him so that she doesn't get hurt.The investigation noted on June 13, 2025, at approximately 3:45 p.m., the Administrator interviewed PTA Staff A and asked the PTA what happened with Resident #999. PTA Staff A replied, You can fire me now. I lost my cool and was rough with the patient and yelled at the patient. He went on to describe and show how he was attempting to get Resident #999 to transfer from the bed to the wheelchair.The facility verified the allegation of abuse.On 7/7/25 at 11:39 a.m., in a telephone interview OT Staff D said she had provided treatment to Resident #999 for a couple weeks. OT Staff D said she was standing nearby when PTA Staff A went to transfer Resident #999. Once the resident had transferred to the wheelchair, PTA Staff A yelled at her loudly that she needed to listen to him. She left the room when he was yelling. OT Staff D said PTA Staff A raised his voice because Resident #999 did not understand and did not listen. PTA Staff A spoke with the resident in some Spanish. OT Staff D said Resident #999 understands English way better then she pretends. She said they had done the transfer many times before. The resident gets very scared, he explained the procedure. PTA Staff A was frustrated because Resident #999 was screaming. OT Staff D said after the resident got into the wheelchair, I decided I did not need to be there. The door was open, and I left. The nurse came after the fact, she was not there to see anything, I don't know what she saw. I left the room to document the therapy provided. I was involved with the initial transfer into the wheelchair. I was not there when he transferred her to bed.On 7/7/25 at 12:32 p.m., in a telephone interview, RN Staff C said she was working on 6/13/25 and was administering medications. RN Staff C said, [Resident #999] yelled out and I thought they were probably moving her. The resident yelled again, extremely loud and I walked to her room. I was two doors away. When I entered the room I saw [PTA Staff A] had both hands on the resident's arms and he was shaking her. I asked him what the hell are you doing? The resident was yelling and crying. He said, this is what we have to do with her. I 106000 Page 2 of 3 106000 07/07/2025 Aspire at Evans 3735 Evans Ave Fort Myers, FL 33901

F 0600 Level of Harm - Actual harm Residents Affected - Few saw [OT Staff D] standing across the hall, looking in the room. I went to her and I asked her, are you going to let him do that to her? She put a piece of paper in front of her face and said, I see nothing, and I hear nothing. I went to the Administrator right away and I told him, and we went together to the resident's room. The resident was in her bed. The Administrator had a Spanish speaking staff member to translate, and the resident said, He threw me in the bed.RN Staff C said she did not witness PTA Staff A put the resident in bed. She said, I witnessed the therapist shaking her and yelling at her, he was very angry. The resident was crying. The resident was in the wheelchair when he was shaking her. He was shaking her, and he was so angry with her. I left the room and went to the Administrator. I did not see him put her into bed.RN Staff C said, I notified the resident's son. He came to the facility and wanted her sent to the emergency room. We did what he asked.On 7/7/25 at 1:20 p.m., in a telephone interview PTA Staff A said, I think I want to give a background first. I worked with the resident for 8 or 9 sessions, and I was very aware of her function and abilities and how she communicates. I think we had good communication and relationship. I had her up and taking 3-4 steps the day before. Her goal was to walk 30 to 40 feet with a walker and assistance. Her right leg and arm are pretty strong; her left leg is weaker. She was able to stand the day before. The resident was in bed supine (on her back). I greeted her and I said let's go and she said yes. I gave her maximum assistance to sit on the edge of the bed. I placed my gait belt around her under her buttocks because of the peg tube. She was very willing to transfer. I placed the wheelchair on her right side. I asked her to place her hand on the far side not the near side, it was very important that she placed her hand on the far side. I gave her a 1,2,3 count, and maximum assistance. She grabbed onto the near side of the arm rest and she started to scream. I thought she was very uncomfortable, it made me nervous because I never heard her screaming like that. She was screaming at the top of her lungs. I thought she was hurting. I kind of shook her hand a little to see if she had pain, and she said no. A nurse came into the room because she heard the resident scream, she said this was patient abuse. Maybe I was shaking her hands at that time, or checking the gait belt, or checking something. No one else was in the room with me, only the patient. I asked her if she was in pain and she said no. I raised my voice asking her why did you put your hand here. That is my one regret, I raised my voice with her. I never yelled at any patient. I shook her hand; I was checking her. If that is deemed shaking, I never shook her body. I was shaking her hand and arm to see if she was okay, to see did she have pain. She was crying, she was sitting in the wheelchair. I put her into bed after that, I thought she was okay. Her right side was stronger, and she was able to stand and get to the edge of the bed. She was losing her balance, and she was screaming again. No one was watching me at all. I think the resident got so scared and was very afraid. I think that is why she screamed. I did not ask her why she was screaming. They think I abused the resident, but I do not think from my point of view that I abused her.On 7/7/25 at 1:47 p.m., in an interview the Director of Nursing (DON) said she was not at the facility when it happened. The Administrator started the investigation. She said, The PTA was not here long and he had a short fuse I guess. The DON said, I do know the resident is not the easiest person to give directions to. She is timid, scared and hesitant to do tasks. The DON said something was going on with the PTA to cause him to have this reaction. 106000 Page 3 of 3