Savanna House

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