The incident at Avir at Kingsland unfolded during a morning shift change on September 13, 2025, when a certified nursing assistant discovered a resident with skin tears that were actively bleeding. The assistant immediately reported the condition to Licensed Vocational Nurse A, who was administering medications at the time.
LVN A failed to assess the resident.
The resident remained unattended and bleeding until 7:20 a.m., when Registered Nurse C arrived for her shift and immediately provided care. By then, two hours had passed since the initial report of bleeding.
That afternoon, the resident's responsible party stormed into the administrator's office, visibly upset about the nurse's competency. The family member told Administrator that LVN A "did nothing to stop Resident #1 from bleeding" and demanded both her termination and a drug test.
"The RP told him to terminate LVN A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding," the administrator recounted during a September 8 interview with federal inspectors.
The administrator acknowledged that LVN A "did not do her job correctly." While he noted she was busy administering medications, he said she should have "triaged and prioritized assessing Resident #1" when the nursing assistant reported the bleeding.
During the facility's internal investigation, the administrator found that although RN C provided immediate care once her shift began, the two-hour delay was inexcusable. When inspectors pointed out that the resident "was left unattended bleeding for about two hours until 7:20am," the administrator responded that "LVN A should not have allowed that happened."
The incident exposed gaps in the facility's shift change procedures and nursing priorities. Despite having policies requiring sufficient nursing staff with appropriate skills, the facility failed to ensure timely response to a bleeding resident.
Following the incident, the administrator placed a disciplinary report in LVN A's personnel file. The facility also conducted mandatory training on September 15 for nursing staff about proper shift-to-shift reporting and triage responsibilities.
The training session, attended by approximately 20 staff members, emphasized that "shift to shift report must be given to oncoming staff" and that "nurses and CNAs must be given a detailed report after every shift." Staff received additional instruction on "triaging nursing care and reporting issues that needed continuity of care, during handover at shift changes."
The Director of Nursing stated that staff were now being observed and reviewed daily, with any issues discussed during daily staff meetings. The facility also provided in-service training on preventing, recognizing and reporting abuse and neglect, along with expectations for reporting during shift changes.
Facility policy requires nursing staff to demonstrate competency in "identification of changes in condition" and mandates that licensed nurses and nursing assistants be "trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities."
The policy, revised in August 2022, states the facility "provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment."
However, the September incident revealed a breakdown in these systems when LVN A failed to respond to a nursing assistant's report of active bleeding. The two-hour delay occurred during a critical period when the resident needed immediate assessment and intervention.
The administrator's investigation found that while RN C provided appropriate follow-up care throughout the day after taking over the shift, the initial failure to respond left the resident vulnerable during those crucial morning hours.
Federal inspectors cited the facility for failing to ensure nursing staff provided timely care when notified of a resident's bleeding condition. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The facility's annual performance evaluation program for all employees remained in place, though the incident highlighted the need for more rigorous oversight of nursing priorities during medication administration times.
The September 13 incident demonstrated how competing nursing responsibilities can compromise resident safety when staff fail to properly triage urgent conditions. While medication administration is a critical nursing function, the facility's own policies required staff to identify and respond to changes in resident condition.
The resident's family reaction underscored the emotional impact on loved ones when nursing care falls short of expectations. Their demand for both termination and drug testing reflected deep concerns about the nurse's competency and decision-making during a medical emergency.
The two-hour delay between the nursing assistant's report and actual nursing intervention created unnecessary risk for a resident already experiencing active bleeding from skin tears. Such delays can complicate wound healing and increase infection risks, particularly in elderly residents with fragile skin.
The facility's response included immediate disciplinary action, mandatory staff retraining, and enhanced daily oversight procedures. However, the incident raised questions about whether existing staffing levels and training programs adequately prepared nurses to handle competing priorities during busy shifts.
The nursing assistant who initially reported the bleeding condition followed proper protocol by immediately notifying the licensed nurse. The breakdown occurred when LVN A failed to respond appropriately to this report, leaving the resident without needed care until the next shift arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Kingsland from 2025-11-11 including all violations, facility responses, and corrective action plans.