Hickory VLG NRSG & RHB

In the surveyor’s words

From the most serious findings on record at Hickory VLG NRSG & RHB, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 7, 2025

  Based on interviews and record reviews, the facility failed to effectively supervise a resident with history of alcohol abuse. This deficient practice affected one resident (R1) out of three reviewed for supervision of an avoidable incident. R1 was able to go out into the community independently, while on a restricted community pass, somehow obtain two 1.0-liter bottles of mouthwash with alcohol, and being hospitalized later with an alcohol level of 183 (normal range is 0-10) and subsequently expiring the follow day. The Death Certificate documents the cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. The Immediate Jeopardy began on 1/12/25 when R1 was found yelling and screaming and with altered mental status. […]

• Immediate jeopardy, isolatedF600Jan 25, 2024

  Based on interview and record review, the facility failed to follow their abuse policy by not protecting /preventing a vulnerable resident from being sexually assaulted by another resident. This affected two of four residents (R1, R2) reviewed for sexual abuse. This failure resulted in R2 entering R1's room approximately 3 hours after being admitted to the facility and sexually assaulting R1 after R1 said no to sex. The Immediate Jeopardy began on 1/8/24 when R2 entered R1's room and sexually assaulted R1. V1 (Administrator) was notified on 1/18/24 at 2PM of the Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF600Nov 2, 2023

  Based on interviews and record reviews the facility failed to prevent an incident of staff to resident inappropriate sexual behavior, failed to prevent an incident of resident to resident sexual assault, and failed to prevent an incident of staff to resident verbal abuse. This affected four of four residents (R1, R9, R10 and R5) reviewed for sexual and verbal abuse. This failure resulted in V4 taking advantage of R1 with a diagnosis of major depression and traumatic brain injury by engaging in sexual intercourse with R1. This failure also resulted in R10 being touched and kissed inappropriately by R9. This was identified as an Immediate Jeopardy which began on 9/06/2023 when R1 was observed having sexual intercourse with V4. […]

• Actual harm, isolatedF689Jan 14, 2025

  Based on interview and record review, the facility failed to supervise one resident who was identified as a high fall risk as well as dependent on staff for bed mobility and toileting, by leaving the resident on their side unattended on an elevated bed (approximately 3 feet). This affected one of three (R1) residents reviewed for falls. This failure resulted in R1 having an unwitnessed fall, being transferred to the hospital, and sustaining a pelvis fracture. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of rheumatoid arthritis, depressive disorder, bilateral osteoarthritis of knees, restless leg syndrome, and fibromyalgia. R1's Brief Interview for Mental Status score dated 11/20/24 documents a score of 14/15 which indicates cognitively intact. […]

• Actual harm, isolatedF689Mar 24, 2022

  Based on observation, interview and record review, the facility failed to monitor and keep residents free of accidental hazards for 1 of 3 residents(R36) at risk for falls and with history of falls in the sample of 15. This failure caused R36 to sustain 3 unobserved falls, with the 3rd fall causing emergent transfer to the hospital emergency room for treatment of head contusion, eye lacerations and nasal fractures. Findings include: R36 is a [AGE] year-old with diagnoses listed in part with [CONDITION(S)], [CONDITION(S)], cognitive communication deficit, [CONDITION(S)] and diabetes. […]