Smoky Mountain Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Smoky Mountain Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF655Mar 17, 2022

  Based on facility policy review, medical record review, hospital documentation review, interview, and facility investigation review, the facility failed to initiate baseline care plans to ensure interventions were implemented for residents who were high risk for falls for 8 residents (Residents #7, #1, #4, #5, #8, #9, #11, and #13) of 11 residents reviewed for baseline care plan. The facility's failure resulted in Resident #7 sustaining a fall on 12/29/2021, resulting in a laceration to the right side of her head which required 4 sutures and caused actual harm to the resident. […]

• Immediate jeopardy, patternF657Mar 17, 2022

  Based on facility policy review, medical record review, fall investigation review, interview, and facility census review, the facility failed to revise comprehensive care plans after falls for 6 residents (Resident #1, #13, #6, #7, #12, and #14) of 8 residents reviewed for comprehensive care plans. The facility's failure resulted in Resident #1 falling on 1/13/2022 and sustaining a right [CONDITION(S)], and Resident #13 falling and sustaining a subdural hematoma on 2/5/2022 and falling on 2/13/2022 and sustaining a superior and inferior pubic rami (pelvic) fracture and a L1 (first lower back vertebrae) compression fracture, which caused actual harm to Resident #1 and #13. […]

• Immediate jeopardy, patternF689Mar 17, 2022

  Based on facility policy review, medical record review, facility investigation review, hospital documentation review, interview, facility census review, and observation, the facility failed to provide adequate supervision to prevent falls for 3 residents (#7, #1 and #13); failed to implement interventions to prevent falls for 10 residents (#7, #1, #13, #4, #5, #6, #8, #9, #11, and #14); failed to complete fall risk assessments for 11 residents (#7, #1, #13, #4, #5, #6, #8, #9, #11, #12, and #14); failed to complete post fall documentation for 6 residents (#7, #1, #13, #8, #12, and #14); and failed to complete a thorough investigation to determine the cause of the fall for 11 residents (#7, #1, #13, #4, #5, #6, #8, #9, #11, #12, and #14) of 11 residents reviewed for accidents. […]

• Immediate jeopardy, patternF867Mar 17, 2022

  Based on facility policy review, review of the facility Plan of Correction (POC) dated 10/18/2019 and 11/5/2021, medical record review, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency and implement interventions to address the facility's failure to implement and effective falls prevention program which resulted in 3 residents (Resident #7, #1, and #13) sustaining falls with injuries and actual harm, and resulted in 8 residents (Residents #4, #5, #6, #8, #9, #11, #12, and #14) sustaining falls with potential for major injuries. […]

• Immediate jeopardy, isolatedF689Apr 5, 2024

  Based on review of facility policy, medical record review, review of the facility incident logs, review of facility fall investigations, emergency medical services (EMS), police records, police body camera (cam) footage, hospital records , observations, and interviews, the facility failed to provide supervision to prevent recurrent falls, review and revise the Care Plan, and implement fall interventions for 1 Resident (Resident #1) of 7 residents reviewed for falls. Resident #1, a severely cognitively impaired resident with a history of 6 falls since he admitted to the facility on [DATE], fell on [DATE] and staff were unaware he had fallen until they were notified by police officers who responded to a call for a welfare check. […]