The resident regularly hit, bit and scratched staff members, yet administrators remained unaware of the ongoing behavioral problems until a September 18 incident triggered the federal complaint investigation.
CNA K told inspectors during interviews in late September that the resident "was often combative" and that staff discovered the resident responded better when cared for by two aides of opposite genders. CNA K said the resident "did not like staff of the same gender to care for him/her."
Despite caring for this challenging resident, CNA K "did not have any kind of dementia training," according to the inspection report.
The facility's communication failures ran deep. CNA K frequently received reports from CNA I, who shared the same gender as the resident, describing how "Resident #1 was combative, aggressive, or cursed" during care. Yet this pattern of behaviors never reached nursing supervisors or administrators.
CNA I, interviewed October 1, described the resident's violence in stark terms: "Resident #1 had been very combative and yelled out. The resident had hit CNA I many times before, bit and scratched him/her." Staff found they "could not redirect the resident when he/she was angry," with episodes lasting approximately 45 minutes before the resident calmed down.
The facility had modified the resident's transfer method from a two-person assist with a gait belt to a mechanical sit-to-stand lift due to safety concerns. But even with the equipment, problems persisted. "Once the resident was in the standing position in the sit to stand lift, he/she would let go of the handles and flail his/her arms almost every time," CNA K reported.
Nursing assistant NA J faced additional obstacles beyond the resident's combative behavior. NA J "did not have access to the resident's care plan" and "had to ask during report how to care for the residents," inspectors documented.
The MDS/Care Plan Coordinator acknowledged responsibility for updating resident care plans after behavioral incidents but admitted failing to update this resident's plan following the September 18 event. The coordinator also confirmed that "not all CNAs knew how to access a resident's care plan on the computer."
Director of Nursing interviews revealed a disconnect between policy and practice. The DON told inspectors she "expected staff to notify her if a resident had behaviors" through a chain of communication from CNAs to nurses to the DON. She claimed "all staff know non-pharmacological interventions" including leaving the resident alone and returning later, redirection, and identifying behavioral triggers.
Yet the DON acknowledged "the care plan should have been updated by the MDS/Care Plan Coordinator" after the September incident.
Administrator interviews exposed the extent of the communication breakdown. The administrator said she "did not know the resident did not like or had a problem with CNA B until the incident on 9/18/25. None of the staff let her know." She also remained unaware that "the resident did not like or had a problem with CNA I and had behaviors when CNA I provided care to the resident."
The resident's Psychiatric Nurse Practitioner, interviewed September 30, expressed surprise at learning about the behavioral issues. "He/She was not aware the resident had behaviors. This was the first time she heard Resident #1 exhibited behaviors of any kind," the inspection report states.
The psychiatric provider had visited the facility on September 25 and spent time with the resident alongside the Social Services Director, who reported the resident "was doing fine and had no problems." The provider expected staff notification of behavioral issues, explaining that "just because a problem appeared to be resolved, it did not mean the behavior was over or wouldn't occur again."
The psychiatric provider emphasized the importance of proper training and care plan access: "If staff haven't been trained properly or don't have access to care plans to know how to care for residents, it could be hard for both the staff and the resident."
Both the Director of Nursing and Administrator claimed staff received dementia care training upon hire, contradicting CNA K's statement about lacking such training.
The inspection revealed a facility where front-line staff lacked essential training and tools while caring for vulnerable residents with complex behavioral needs. CNAs worked without dementia training, couldn't access care plans, and had no clear pathway to communicate ongoing safety concerns to supervisors who remained unaware of daily violence against their own employees.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lincoln County Nursing & Rehab from 2025-11-17 including all violations, facility responses, and corrective action plans.
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