The social worker arrived at the facility around 10:00 a.m. on October 13th. The resident was sleeping, so the worker sat by the bedside until they woke. When the resident turned to their left side, the social worker noticed the massive knot stretching from the front to the back of their head, with dried blood covering it.
Blood had also dried on the bed rail.
The social worker immediately went to the nurse's station to report the injury. The nurse had no idea what happened. When the nurse checked the resident's medical record to see if there was any documentation about an incident, there was nothing.
A certified nurse's aide had discovered the injury hours earlier but never reported it. The aide wrote in a statement that when checking on the resident that morning around 9:00 a.m. to get them ready for breakfast, they noticed "a big bruise on his/her forehead with a small amount of dried blood."
The aide didn't report it.
During interviews, the aide explained they hadn't received report when starting their shift that morning and didn't know the resident was injured. When they saw the large knot on the resident's head, they "did not say anything because he/she thought someone would have already reported it since the knot did not look new and the blood was dried on the cut."
Licensed Practical Nurse D wasn't working on the resident's floor that day but was standing at the nurse's station when hospice staff reported the injury. The nurse went with the floor nurse to assess the resident together, finding "a large knot on his/her head."
Nobody had told the nurse about any injury during shift change.
The resident's medical record revealed a troubling gap in care. Vital signs were documented on October 9th at 2:44 p.m., then not again until October 13th at 8:41 p.m. No vital signs were recorded for the four-day period in between.
More critically, no assessment or neurological checks were documented on October 13th between 9:00 a.m. and 11:30 a.m., the crucial hours when the aide discovered the injury but failed to report it and before the hospice worker intervened.
The facility's Director of Nursing acknowledged the failures during interviews. Staff should have immediately reported the injury to the nurse as soon as it was noticed, she said. Not reporting incidents or injuries "could delay assessment and care for the resident."
All the information should have been documented.
The Administrator echoed this expectation, saying he required staff to report all resident injuries immediately so care could be provided. The information should also be documented, he said.
The inspection report references an incident involving "the tray" that apparently hit the resident, though details of this incident aren't fully explained in the available documentation. The Director of Nursing said staff should have reported this incident to the nurse even if there were no immediate injuries visible.
The resident was under hospice care, suggesting they were in the facility's most vulnerable population. The social worker's discovery of the injury appears to have been the first time anyone with medical training assessed the resident's condition after the head trauma occurred.
The facility's response came only after the hospice worker's intervention. By then, dried blood had accumulated on the pillow and bed rail, and the massive knot had fully formed on the resident's head, stretching from front to back.
Federal inspectors cited Nazareth Living Center for failing to ensure accidents were immediately reported to the administrator or designee and that necessary care was provided. The violation was classified as causing minimal harm or potential for actual harm to a few residents.
The gap in vital signs monitoring and the absence of neurological assessments during the critical hours after the injury represent missed opportunities to evaluate the resident's condition and provide appropriate medical intervention.
The aide's assumption that someone else had already reported the obvious head injury highlights a dangerous breakdown in the facility's chain of communication and responsibility for resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nazareth Living Center from 2025-11-17 including all violations, facility responses, and corrective action plans.