Three nursing assistants at Mountain City Rehab Center witnessed LPN #3 yell at, jerk and pull Resident #4's arms during the December 16, 2024 incident. All three reported the behavior as abuse.
The resident had fallen out of bed around midnight when nursing assistants discovered them on the floor covered in vomit. As staff helped transfer the patient back to bed, LPN #3 became aggressive while trying to obtain vital signs.
"She witnessed LPN #3 yell at the resident to stop moving so much and witnessed her pushing, pulling, and jerking [Resident #4] around," GNA #2 wrote in her statement about the incident.
GNA #4 described finding the resident covered in vomit on the floor. After they helped the patient back to bed, the resident sat on the edge of the bed while LPN #3 positioned herself behind them.
"LPN #3 was behind the resident on the bed and stuck her knee against the resident's back while pulling up and she had one of the resident's arms behind them pulling on it also," GNA #4 stated during her October interview with inspectors.
The nurse's behavior escalated as she struggled to take the resident's blood pressure. GNA #5 witnessed LPN #3 tell her directly about breaking equipment in frustration.
"LPN #3 told her that she was so mad that she ripped a blood pressure cuff off the resident and broke it because the resident would not stop moving," according to GNA #5's written statement.
The licensed nurse also "spoke to the resident rudely when the resident was on the floor," GNA #4 observed.
All three nursing assistants independently concluded they had witnessed abuse. They discussed the incident among themselves before reporting it to LPN #6, the other nurse on duty that night.
"The three GNAs discussed the incident and agreed it was abuse and then reported it to LPN #6," GNA #5 told inspectors during her October interview.
GNA #2 was explicit about her reasoning. During her October 8 interview, she "stated she reported it to LPN #6 because she thought it was abuse."
The rough handling occurred as LPN #3 attempted to remove the resident's clothing and obtain vital signs. "LPN #3 pulled on and jerked Resident #4's arms while struggling to remove the resident's t-shirt and obtain the resident's blood pressure," GNA #2 told inspectors.
GNA #5 described the nurse's behavior as systematic roughness. "LPN #3 handled Resident #4 roughly by pulling, grabbing, and yelling at the resident in an attempt to have the resident lie still so that the LPN could obtain a blood pressure reading."
The supervising nurse took immediate action when the assistants reported the incident. "As soon as the GNAs reported the alleged abuse, she called her supervisor (the current DON, who was the ADON at the time of the incident) immediately," LPN #6 told inspectors.
Management investigated and reached a clear conclusion. During her October 13 interview, the Director of Nursing "stated that they determined that abuse did occur."
The incident occurred under previous facility leadership. When inspectors interviewed the current Administrator on October 13, she "stated that she was not familiar with the incident involving Resident #4 because she was not the Administrator yet at the time of the incident."
The written statements from the three witnesses, all dated December 17, 2024, provided consistent accounts of the nurse's behavior. GNA #4's statement indicated "she witnessed LPN #3 be mean to Resident #4 and yelled at the resident to stop moving."
The statements documented not just the physical roughness but the verbal abuse. "LPN #3 pulled the resident's arm really hard and yelled at the resident," GNA #4 wrote.
GNA #5's statement emphasized the nurse's admission about the broken equipment. The LPN "told her that she was so mad that she ripped a blood pressure cuff off the resident and broke it because the resident would not stop moving."
The incident unfolded as multiple staff members were present to assist with the fall. "She, along with LPN #3, GNA #2, and GNA #5, assisted Resident #4 following the resident's fall out of bed," GNA #4's statement indicated.
But instead of professional care during a vulnerable moment, the resident encountered aggression from the licensed nurse responsible for their medical needs.
The nursing assistants' decision to report the incident demonstrated their understanding of appropriate patient care standards. Despite the hierarchical nature of healthcare settings, all three recognized the behavior as crossing the line into abuse.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But for Resident #4, lying on the floor covered in vomit after a fall, the licensed nurse's anger and rough handling represented a fundamental breach of the trust patients place in their caregivers.
The broken blood pressure cuff became a symbol of the nurse's loss of professional control, a piece of medical equipment destroyed in anger while a vulnerable resident needed care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mountain City Rehab Center from 2025-11-07 including all violations, facility responses, and corrective action plans.