Whispering Pines Rehabilitation And Nursing Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

he/she was able to express due to aphasia. An interview with NA #2 on 1/28/26 at 12:43 PM identified she worked on 12/25/25 from 3 PM to 11 PM and that she did not see or provide care to Resident #2 until after NA #1 left for the evening. After NA #1 left, NA #2 assisted Resident #2 with incontinent care and at that time, observed injuries. She further identified Resident #2 was incontinent of stool, required assistance of two (2) staff to provide personal care, and that stool was found on the floor near the bed. Review of the written statement and interview with LPN #1 on 1/28/26 at 12:49 PM identified on 12/25/25 LPN #1 was passing medications when NA #1 approached him in an upset and erratic manor and stated she should not be working because it was her mother's birthday, NA #1 reported to the supervisor and left for the remainder of the shift. LPN #1 then went into Resident #2's room to administer medications and discovered injuries. Resident #2 was unable to identify what occurred. An interview with Resident #2 (with Person #1 present) on 1/28/26 at 1:10 PM was conducted. Due to Resident #2's aphasia, he/she had difficulty processing questions and answered some questions with a delayed response. Resident #2 was aware NA #1 no longer worked at the facility and was able to indicate satisfaction. Resident #2 verbally identified NA #1 struck him/her causing the injuries identified on 12/25/25 and demonstrated through forming a fist with his/her right hand and then touching hand to forehead. Resident #2 acknowledged through yes/no format that he/she fell but was unable to provide any details. Interview with the DON (Director of Nursing) on 1/28/26 at 2:55 PM identified Resident #2 told her he/she fell but after being asked multiple ways was never able to indicate how the fall occurred or how he/she got back up. The DON further identified Resident #2 would not have had the ability to get up independently and would have likely required the assistance of two (2) staff members. The DON identified there were no residents on the unit who wandered or had a history of aggression and that LPN #1 was in the hallway during the evening and would have seen or heard if a resident wandered into Resident #2's room. When the DON proceeded to inform Resident #2 that NA #1 would no longer work at the facility, Resident #2 became teary eyed and shook his/her head okay. The facility terminated NA #1 due to lack of cooperation with the investigation. Interview with NA #1 on 1/29/26 at 10:20 AM identified she worked from 3 PM to 11 PM on 12/25/26. NA #1 was the NA assigned to provide care for Resident #2 and had worked with Resident #2 several times since she began work at the facility approximately three (3) months prior. NA #1 identified no one else provided care for Resident #2 until she left her shift early due to feeling unwell. NA #1 denied that Resident #2 sustained a fall and identified if he/she fell, at least two (2) people and possibly a Hoyer lift would have been required to transfer Resident #2 off the floor. NA #1 denied harming Resident #2. Although attempted, a call was not returned by RN #1 or by the detective assigned to the case. Review of the facility policy for Resident's Rights directed in part that the Resident had the right to be free from verbal, sexual, physical or mental abuse. Review of the facility policy for Abuse, Neglect, and Exploitation identified residents would not be subjected to abuse by anyone. The policy further identified injuries of unknown origin would be investigated as if they could be a result of abuse if the source of injury was not observed, the source of injury can't be explained, or the injury is suspicious because of the extent of injury, the location of injury, the number of injuries, or the incidence of injuries over time.

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