The November incident prompted the resident's responsible party to demand the nurse's termination and drug testing, telling the administrator that the nurse "did nothing to stop Resident #1 from bleeding."
CNA B reported skin tears and bleeding to LVN A, but the licensed nurse continued administering medications instead of triaging the emergency. The resident remained unattended until RN C arrived for the 7:20 a.m. shift change and immediately provided care.
Federal inspectors found the facility failed to provide competent nursing staff as required by Medicare regulations. The violation resulted in actual harm to few residents.
The administrator confirmed LVN A "did not do her job correctly" during a facility investigation. He acknowledged that despite being busy with medication administration, the nurse should have prioritized assessing the bleeding resident when alerted by the certified nursing assistant.
"Though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding," the administrator told inspectors.
The responsible party expressed outrage over the nurse's competency and demanded immediate action. The administrator said the family member was "upset and complained about the competency of LVN A" and specifically "told him to terminate LVN A and demanded a drug test on her."
When inspectors pointed out that Resident #1 was left bleeding for approximately two hours until RN C's intervention at 7:20 a.m., the administrator responded that "LVN A should not have allowed that happened."
RN C provided immediate care upon starting her shift and continued follow-up throughout the day. However, the two-hour delay in treatment had already occurred during the critical morning hours when the bleeding was first reported.
The administrator placed a disciplinary report in LVN A's personnel file following the investigation. He also mandated additional training for nursing staff on preventing, recognizing and reporting abuse and neglect, as well as expectations for reporting during shift changes.
Records show the facility conducted an in-service on September 15, 2025, addressing shift-to-shift reporting requirements. The training 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."
Approximately 20 staff members attended the September training session, according to facility documentation reviewed by inspectors.
The facility's staffing policy, revised in August 2022, requires "sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents." The policy defines competency as "a measurable pattern of knowledge and skills abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully."
All nursing staff must meet specific competency requirements defined by state licensing and certification requirements. The policy mandates that staff demonstrate skills in resident rights, person-centered care, communication, basic nursing skills, medication management, infection control, and skin and wound care.
Licensed nurses and nursing assistants must demonstrate competency in "identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities," according to facility policy.
The incident highlights critical gaps between written policies and actual practice. While the facility maintains detailed competency requirements and reporting procedures, LVN A failed to follow basic triage principles when faced with a bleeding resident.
The two-hour delay in care occurred during a vulnerable period when proper assessment and intervention could have prevented extended bleeding and potential complications. The failure to prioritize emergency care over routine medication administration represents a fundamental breakdown in nursing judgment.
CNA B followed proper protocol by reporting the skin tears and bleeding to the licensed nurse. However, the communication breakdown occurred when LVN A failed to respond appropriately to the urgent situation.
The administrator's acknowledgment that the nurse "did not do her job in a timely manner" confirms the severity of the care failure. His statement that RN C "took care of" the resident immediately upon arrival underscores what should have happened two hours earlier.
The facility maintains an annual performance evaluation program for all employees, but the incident suggests ongoing supervision and competency validation may be inadequate. The need for additional training following the incident indicates systemic issues beyond individual nurse performance.
The responsible party's demand for drug testing suggests concerns about impairment affecting the nurse's judgment and response time. While the administrator did not confirm whether testing occurred, the request highlights the family's perception of the severity of care failures.
Federal regulations require nursing homes to provide sufficient staffing with appropriate competency levels. The inspection finding of actual harm indicates the facility's failure to meet this fundamental requirement during the November incident.
The violation demonstrates how communication failures and poor clinical judgment can result in preventable harm to vulnerable residents. Despite having policies requiring competent care and proper reporting, the facility failed to ensure these standards were met when a resident needed immediate attention.
The incident left Resident #1 bleeding and unattended for two hours while nursing staff continued routine tasks instead of responding to an emergency situation.
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.