Savanna House Assisted Living & Memory Care.

“Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. Findings include: 1. A review of policies and procedures revealed a wandering policy, but it did not cover the whereabouts of a resident based on the level of assisted living services. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, for one resident who had an accident, emergency, and injury, resulting in the need for medical services, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact. The deficient practice posed a risk if the facility failed to immediately notify the resident's responsible party of an accident, emergency, or injury that resulted in several fractures, and the facility provided false and misleading information to the Department.   Findings include:   1. In record review, R1's medical record included documentation of a "...Occurrence Report," which documented, "Date of incident - 3/20/2025 Time of Incident - 08:45PM... Was family/resident's representative notified? - Yes If yes, person contacted O1 no response voicemail... Time notified: 03/20/25 8:45pm... Was attending physician notified? - Yes... Trask Mobile Time notified: 8:30PM.. went on voicemail..." The occurrence report provided was unsigned. However, another report was provided for review, and included the signatures of management personnel. 2. In record review, R1's medical record included the following "Narrative Charing," notes: 3/21/2025 3:48 AM.. Follow up charting... Resident complained of pain in ribcage. Writer called and left message on emergency traks line and faxed traask to see about xray. No response as of yet. Resident was given prn for pain and was semi effective. Writer will follow up with trask in the morning. Signed by (E6) 3/21/2025 5:30AM Late Entry Entered On: 03/23/2025 2:28pm.. Fall Follow Up Contacted MPOA (O1) on 3/21/2025 at 5:37 and left message informing ... of the fall from previous night... Signed by (E5) 03/21/2025 05:44 AM Follow up charting Called trask emergency line 3-4 times, left message. Still awating response for next steps. Tylenol given to (R1) again for prn pain... is resting now. Tylenol seems to be effective. Will call trask again for next steps. Signed (E6) 3/21/2025 05:50 AM Follow up charting Traks answered and resident is scheduled for x-ray after 10am today. Signed (E6) 03/01/2025 (NOTE DATE) 8:30 AM Late Entry Entered On: 03/23/2025 2:31 PM Fall Follow Up Contacted MPOA and left message with update that we are expecting x-ray after 10am and that let us know if ... would like resident to be sent out to ER. This writer also checked on resident with Med Tech. Resident was resting at the time but Med Tech stated (R1) had exhibited pain when E6 checked on (R1) a short time ago. Signed (E5)   3. In record review E1's personnel record, (hired June 5, 2024, as a caregiver, and terminated from employment on March 20, 2025), included documentation titled, "Associate Action Plan for Improvement," that documented, "... General rules of Conduct: ... Failing to maintain acceptable standards of respect for residents.. And... Failing to follow safety rules and practices... 3/20/2025... On 3/20/2025, E1 was the Medication Technician on duty in the ... Neighborhood ... Resident (R1) experienced a fall and sustained injuries. E1 failed to complete an IR and did not follow through with calling EMS or Family or notifying oncoming staff that a fall occurred. This resulted in a delay of care for the resident... B. Improvement(s) Required: N/A Immediate Termination." 4. In documentation review, the facility's Incident Reporting policy, on page 106, documented, "... 4. Incidents are immediately reported to the resident's family/responsible party and physician. a. The date and time of such report to the family/responsible party and physician is documented in the narrative charting section of the resident record and documented on the incident report under notifications." 5. During an interview, E4 and E5 reported E1, E2, and E3 were working at the facility during the shift, when R1 fell. E4 and E5 acknowledged the facility's documentation of an Occurrence Report indicated R1's family was notified of the event at 8:45 pm on March 20, 2025. E5 reported (E5) contacted R1's representative (O1) at 8:30 am on March 21, 2025, and reported the fall and injury to O1.”