Resident 5 told different versions of what happened. The person said they fell out of bed and "a man picked them up," then later claimed "white men came and picked them up." But nursing staff said no men were working that shift.
Care companions found the resident on November 7 with visible injuries and reported it to nursing staff at 9 AM, then to management at 4 PM. When inspectors observed the resident that afternoon, they documented a raised bump on the right frontal forehead that was green and yellow in color, approximately the size of a 50-cent piece.
The Assistant Director of Nursing, Staff C, described additional injuries on the resident's back. The right side showed red purple discoloration that felt raised and "looked like their skin was pinched."
The bed had no side rails. Instead, soft side bolsters were in place, which Staff C said they installed a couple of days after Resident 5's admission.
Staff D, the Charge Nurse, acknowledged the resident was "only oriented to self" and conducted a neurological assessment after the discovery. The nurse placed fall mats at the family's request and updated the care plan. Staff D noted the forehead bruise was yellow and green, "indicating it was an old bruise."
When asked about protocol for injuries of unknown origin, Staff D said the expectation was to "call the provider and file a report." But when asked directly if they had filed an incident report, Staff D replied no. The nurse explained their "mindset was to find out if the resident fell."
Staff E, the Unit Manager, said they interviewed some staff members but acknowledged there were "still people they needed to talk to." Despite the investigation, Staff E stated they "determined the resident did not fall" but "were not able to determine what occurred."
The Director of Nursing, Staff B, provided more details about the conflicting accounts. Staff B said Resident 5 claimed they "fell on the floor and white men came and picked them up." But when Staff E questioned the night shift workers, "there were no white men on duty" and "the aids working denied the resident fell."
Staff B emphasized that none of the aides "could have picked the resident up and put them to bed." The Director concluded that Resident 5 was "confused, cognitively impaired and what they said occurred did not occur."
The timing of the injuries raised additional questions. Staff B noted the yellow bruise on the forehead would be "by definition more than seven days/a week old," but "the resident was not in the facility that long."
When inspectors asked if the bruise qualified as an unknown origin injury "in an area not vulnerable to trauma," Staff B replied yes.
Federal regulations require nursing homes to immediately investigate any injury of unknown origin and report it to the administrator and other officials. The facility's failure to file an incident report violated these requirements, even as staff conducted informal interviews with workers.
The inspection found the facility failed to ensure that alleged violations involving mistreatment, neglect, or abuse were immediately reported and thoroughly investigated. The violation affected few residents but represented minimal harm or potential for actual harm.
Resident 5's case illustrates the challenges nursing homes face when cognitively impaired residents suffer unexplained injuries. The person's confused state made it difficult to determine what actually happened, but facility policy still required proper documentation and reporting procedures.
The facility's investigation remained incomplete at the time of the inspection. Staff had interviewed some workers but not others, and they could not explain how a resident who had been at the facility for less than a week developed what appeared to be a week-old bruise on their forehead.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Birch Creek Post Acute & Rehabilitation from 2025-11-19 including all violations, facility responses, and corrective action plans.
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