Tatum Glen Assisted Living Home

Based on record review, documentation review, and interview, the manager failed to ensure when a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver, documents the following: the date and time of the accident, emergency, or injury; description of the accident, emergency, or injury; the names of individuals who observed the accident, emergency, or injury; the actions taken by the caregiver or assistant caregiver; the individuals notified by the caregiver or assistant caregiver; and any action taken to prevent the accident, emergency, or injury from occurring in the future. The deficient practice posed a risk as there was no plan to ensure the health and safety of residents in an emergency. Findings include: 1. A review of R1's medical record revealed that an incident report was not completed when the resident was transported to the hospital on May 18, 2025. 2. A review of R1's medical records revealed, a "Narrative Note" dated August 17, 2025, which stated, "In the morning [R1's representative] felt R1 [and noticed the resident ] had fever and sleeping. [E1 was told] to call the ambulance and R1 was transported to Mayo Hospital." 3. A documentation review of the facility's Policies and Procedures titled, "Incident Reports" stated, "An incident report will be completed if a resident, staff member, or visitor experiences an accident, emergency, or injury that results in the resident needing medical services, incident that is unusual, improper or harmful." 4. In an interview, E1 acknowledged the manager did not complete an incident form as required for R1 who needed emergency services for an accident, injury, or emergency.