Complaint 2

Department of Health & Human Services Printed: 11/22/2023
Form Approved OMB

Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
445402 B. Wing 05/05/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bedrockhc at Spring Meadows, LLC 220 Highway 76

Clarksville, TN 37043
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Level of Harm - Minimal harm
or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 29706
Residents Affected - Some Based on policy review, medical record review, observations and interviews, the facility failed to revise and
update the Care Plan to include fall interventions and communicate to staff the residents with a fall risk for 7
of 8 sampled residents (Resident #1, #2, #3, #5, #6, #7 and #8) reviewed with falls.
The findings include:
1. Review of the facility's policy titled, Fall Risk Assessment, revised October 2022, revealed .It is the policy
of this facility to provide an environment that is free from accident hazards over which the facility has control,
and provides supervision and assistive devices to each resident to prevent avoidable accidents .An At Risk
for Falls care plan will be completed for each resident to address each item identified on the risk assessment
and will be updated accordingly. The At Risk for Falls care plan will include interventions, including adequate
supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce
the risk of an accident. Monitor the effectiveness of the care plan interventions, and modify the interventions
as necessary, in accordance with current standards of practice .
Review of the facility's policy titled, Fall Prevention, dated 10/2022, revealed .Each resident will be assessed
for fall risk and will receive care and services in accordance with their risk to minimize the likelihood of falls .
Protocols and intervention will be implemented on fall risk .When any resident experiences a fall, the facility
will: Review the resident's care plan and update as indicated .
Review of the facility's policy titled, Incidents and Accidents, dated 11/2022, revealed .The purpose of the
incident reporting can include: Assuring that appropriate and immediate interventions are implemented, and
corrective actions are taken to prevent recurrences and improve the management of resident care .
2. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses
of Vascular Dementia, Psychotic Disturbance, Hypertension, Transient Ischemic Attacks, Mood Disturbance,
History of Falls and Agitation.
Review of the Fall Risk assessment dated [DATE], documented Resident #1 scored a 14 which indicated at
risk for falls.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 1 of 7
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Form Approved OMB
A. Building
445402 B. Wing 05/05/2023


F 0657 Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was
assessed to have a Brief Interview of Mental Status (BIMS) score of 10, which indicated Resident #1 was
Level of Harm - Minimal harm or moderately impaired cognitively for daily decision making.
potential for actual harm
Review of the medical record revealed Resident #1 fell on [DATE] at 10:00 PM.
Residents Affected - Some
Review of Resident #1's undated Care Plan on 4/18/2023, revealed no documentation of the 3/7/2023, fall or
interventions for the fall.
Review of the Nurse Practitioner (NP) note dated 3/9/2023 at 1:04 PM, revealed .patient complained some
pain right leg .no indication for imaging at this time after physical assessment .
Review of the NP note dated 3/13/2023 at 1:44 PM, revealed .Patient seen for follow-up on left ankle pain,
swelling and bruising. Patient has had a couple falls in the last week, but bruising and swelling to left
foot/ankle reported over the weekend, significant swelling and bruising to left heel and toes noted, patient
reports painful-ordered STAT x-ray foot and ankle. Tylenol for pain. Ice topically for pain .
Review of Nurse's note dated 3/13/2023 at 10:47 PM, revealed .Late note, res [resident] xray of left ankle per
[named NP] shows fx [fracture], .transfer to ER [emergency room ] for eval and tx [treat], res [resident] left at
5:20 PM .
Review of Resident #1's hospital History & Physical dated 3/13/2023, revealed .Called to [named Long-Term
Care (LTC) facility] to speak with the nurse. Spoke with nurse [named person] who reports [Resident #1] fell
twice last week. First time was Tuesday [3/7/2023] and the resident complained of ankle pain once and then
started eating a sandwich, so they [staff] forgot about it .[Resident #1] fell again on Thursday [3/9/2023].
Over the weekend, the left ankle started to swell and for this reason, they [the facility staff] brought her to the
ER [emergency room ] for a checkup. He [RN #1] reports she [Resident #1] is normally non ambulatory,
using a wheelchair, he [RN #1] reports she [Resident #1] can try and walk and will take 2 steps before falling.
She [Resident #1] will intermittently try and get out of her chair without assistance in the setting of dementia .
diagnostic radiology results fracture of the lateral malleolus with minimal displacement. Fracture of the
medial malleolus [small bone on the inner side of the ankle at the end of the leg bone] without significant
displacement. The area associated soft tissue swelling around the ankle. Suggestion of small avulsion along
the anterior margin of the distal tibia [leg bone] .I had an extensive discussion with the patient and present
family members about their current situation and clinical status .After a mutual discussion, we agreed upon
intervention in the form of left ankle closed treatment without manipulation, wbat [weight bearing as tolerated]
with boot, FU [follow up] clinic 2-3 weeks repeat evaluation .
Review of the hospital Final Report dated 3/14/2023, revealed .Place her [Resident #1] in a orthopedic boot .
OK for stand to transfer in boot .elected for nonoperative treatment .
Review of NP note dated 3/16/2023 at 4:23 PM, revealed .Late entry reason for appointment readmission .
discussion .family and ortho felt non-operative approach was best-walking boot placed .

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Form Approved OMB
A. Building
445402 B. Wing 05/05/2023


F 0657 Review of Resident #1's undated Care Plan on 4/18/2023, revealed no revision to reflect the 3/13/2023 ER
visit with the diagnoses of fracture of the lateral malleolus with minimal displacement. Fracture of the medial
Level of Harm - Minimal harm or malleolus without significant displacement and small avulsion along the anterior margin of the distal tibia.
potential for actual harm Placement of boot for left ankle and activity of weight bearing as tolerated.
Residents Affected - Some Observations on 4/18/2023 at 4:00 PM, revealed Resident #1 sitting in a wheelchair in the common area
eating a sandwich. The boot was not on the resident's foot/leg. Registered Nurse (RN) #1 walked over to
Resident #1 and stated I need to put your boot on. Nurse #1 then proceeded to place the boot on Resident
#1's left foot/leg incorrectly. The resident started yelling no, it's wrong, no, no. RN #1 stated it is right.
Observation revealed the boot was placed incorrectly. Resident #1 continued to yell that is not right. RN #1
removed the boot and placed the boot on again. Resident #1 began yelling no, no it's wrong, no, no, no and
shaking her head. When RN #1 was asked if the boot was on correctly, he stated yes. Observation revealed
the boot was not on correctly and the surveyor went and got the Chief Nursing Officer (CNO). The CNO
removed the incorrectly placed boot and placed it on the resident correctly. The resident stated, that is right,
that feels much better.
During an interview on 4/18/2023 at 4:00 PM, the CNO confirmed Resident #1's boot was incorrectly placed
by the nurse.
During an interview on 4/18/2023 at 5:15 PM, Licensed Practical Nurse (LPN) Unit Manager #1 stated .I
have seen that splint [boot] on like that. I just thought she [Resident #1] had loosened it but really it was put
on wrong by [named RN]. We all need an in-service on how to apply splints, they all are so different .
During an interview on 4/19/2023 at 12:40 PM, when asked how was she aware of which residents were a
Fall Risk Resident, Certified Nursing Assistant (CNA) #1 stated, .We don't have anything written down like a
list or anything .We look at the tablet for our medical record .We don't have anything for Ms. [Resident #1]
about at risk for falls or for her to wear a boot on her left foot .There is nothing on any ADL [activities of daily
living] tabs first or second screen .the last tab is the care plan and we would have to look through the entire
care plan to find anything .No, we don't look at the care plan .
During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed there was no documentation
on Resident #1's care plan for the fall 3/7/2023, interventions for the fall, and the 3/13/2023 new diagnoses
of a fractured ankle bone.
3. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE], and readmitted
on [DATE], with diagnoses of Cerebral Infarction with Flaccid Hemiplegia Left Side, Heart Failure, Diabetes
Mellitus Type 2, Chronic Obstructive Pulmonary Disease and Osteoarthritis.
risk for falls.
Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was assessed to have a
BIMS score of 6, which indicated Resident #2 was severely impaired cognitively for daily decision making.

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Form Approved OMB
A. Building
445402 B. Wing 05/05/2023


F 0657 Review of Nurse's note dated 4/11/2023 at 2:35 PM, revealed at 12:30 PM patient complained of pain in left
shoulder, Nurse Practitioner notified ordered x-ray left humerus.
Level of Harm - Minimal harm or
potential for actual harm Review of Resident #2's x-ray report dated 4/11/2023, revealed .acute proximal left humerus fracture with
minimal displacement .
Review of the Physician's order dated 4/11/2023, revealed ensure that sling is in place left arm every shift for
left humerus fracture.
Review of Resident #2's undated Care Plan on 4/18/2023, revealed no documentation of sling to be applied
to left arm every shift for left humerus fracture.
Review of Resident #2's orthopedic physician visit dated 4/14/2023, revealed .upon review of imaging from
over a month ago in the hospital I do see on chest x-ray and CT scan [computerized tomography - detailed
xray] a 4-part displaced head split proximal humerus [arm] fracture of the left side. This was not seen on the
radiologist read but is apparent .device dispensed [sling] and fitted at this visit, shown how to properly apply
wear and care this medically necessary for treatment .
Review of electronic medical record the CNA accesses dated 4/19/2023, revealed no documentation or
communication to the staff of Resident #2's at risk for falls or application of left arm sling to be in place every
shift.
During an interview on 4/19/2023 at 12:40 PM, CNA #1 and #2 stated, .We don't have anything for Ms.
[Resident #2] about at risk for falls or for her to wear the sling on all shifts .There is nothing on any ADL
[activities of daily living] tabs first or second screen .
During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed no documentation on
Resident #2's care plan sling to be applied to left arm every shift for humerus fracture.
4. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] and readmitted
on [DATE] with diagnoses of Dementia without Behaviors, Repeated Falls, Hypertension and Anxiety.
risk for falls.
Review of the medical record revealed Resident #3 fell on [DATE] at 5:39 PM.
Review of Resident #3's undated Care Plan on 4/18/2023, revealed no documentation of the 2/17/2023 fall
or interventions for the fall.
risk for falls.
BIMS score of 3, which indicated Resident #3 was severely impaired cognitively for daily decision making.

445402
Form Approved OMB
A. Building
445402 B. Wing 05/05/2023


F 0657 Review of Nurse's note dated 4/2/2023 at 12:00 PM, revealed Resident #3 complained of pain in right hand
to her daughter, and there was minor swelling on the top of the resident's right hand. No bruising was noted.
Level of Harm - Minimal harm or An x-ray was ordered.
Review of radiology (xray) results dated 4/2/2023, revealed there was no fracture noted with the conclusion
Residents Affected - Some the resident has moderate degenerative joint disease.
Review of the undated Care Plan on 4/18/2023, revealed no documentation of diagnoses moderate
degenerative joint disease or hand pain.
During an interview on 4/19/2023 at 12:45 PM, when CNA #2 was asked how they were aware of which
Residents were at a Fall Risk, CNA #2 stated, .nothing is written down .sometimes we may be told in report I
guess .nothing officially .hit and miss .
on Resident #3's care plan for the 2/17/2023 fall and interventions for the fall. She also confirmed no
documentation of the 4/2/2023 diagnoses moderate degenerative joint disease or hand pain.
5. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses
of Dementia without Behaviors, Cerebral Infarction, Aphasia, Diabetes Mellitus Type 2, and Hypertension.
risk for falls.
The medical record revealed Resident #5 fell on [DATE] at 5:53 PM, and 3/28/2023 at 8:05 PM.
Review of Resident #5's undated Care Plan on 4/18/2023, revealed no documentation of the 3/25/2023, or
3/28/2023, falls or interventions for falls.
Review of the admission MDS assessment dated [DATE], revealed Resident #5 was assessed to have a
BIMS score of 15, which indicated Resident #5 was cognitively intact for daily decision making.
During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed no documentation on
Resident #5's care plan for falls 3/25/2023 and 3/28/2023 and interventions for the falls.
[DATE], with diagnoses Asthma, Intracranial Abscess and Granuloma, Hydrocephalus, Macular
Degeneration, Hypertension and Atrial Fibrillation.
Review of the admission MDS assessment dated [DATE], revealed Resident #6 was assessed to have a
BIMS score of 13, which indicated Resident #6 was cognitively intact for daily decision making.
risk for falls.
Review of the medical record revealed Resident #6 fell on the following dates:

445402
Form Approved OMB
A. Building
445402 B. Wing 05/05/2023


F 0657 3/28/2023 at 2:50 PM,
Level of Harm - Minimal harm or 4/4/2023 at 10:15 AM,

4/4/2023 at 2:50 PM,
4/7/2023 at 2:45 PM, and
4/14/2023 at 4:22 PM.
Review of Resident #6's undated Care Plan on 4/18/2023, revealed no documentation of the 3/28/2023 at
2:50 PM, 4/4/2023 at 10:15 AM, 4/4/2023 at 2:50 PM, 4/7/2023 at 2:45 PM, and 4/14/2023 at 4:22 PM falls
or interventions for the falls.
During an interview on 4/19/2023 at 1:13 PM, RN #2 was asked how he was aware of which residents were
at high risk for falls. RN #2 stated, .I think there is a list . RN #2 went to the nurse's desk and looked and
stated, .there is no list .Oh, I can pull up on PCC [Point Click Care electronic medical record] and see it .
[Resident #6] I know she had a recent fall . RN #2 pulled up Resident #6's information and stated, .no,
nothing documented about fall risk .I don't know .
on Resident #6's care plan for the falls on 3/28/2023, 4/4/2023 at 10:15 AM, 4/4/2023 at 2:50 PM, 4/7/2023,
and 4/14/2023 and interventions for the falls.
on [DATE], with diagnoses Dementia with Behaviors, Diabetes Mellitus Type 2, Asthma, Repeated Falls and
Hypertension.
risk for falls.
The medical record revealed Resident #7 fell on [DATE] at 6:06 PM.
Review of Resident #7's undated Care Plan on 4/18/2023, revealed no documentation of the 2/17/2023, fall
or interventions for the fall and no documentation of resident getting stuck backing out of areas in her
wheelchair and no interventions.
BIMS score of 8, which indicated Resident #7 was moderately cognitive impaired for daily decision making.
Review of the Nurse's note dated 4/5/2023 at 10:20 PM, revealed Resident #7 .resident getting stuck
backing out of areas in her wheelchair .

445402
Form Approved OMB
A. Building
445402 B. Wing 05/05/2023


F 0657 During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed there was no documentation
on Resident #7's care plan for the fall on 2/17/2023, interventions for the fall and no documentation of safety
Level of Harm - Minimal harm or interventions for the wheelchair. Unit Manager LPN #2 stated, .She [Resident #7] would get stuck backing
potential for actual harm her wheelchair up for example into the bed rail, under the over bed table, things that had a ledge .we would
assist her to get unstuck .
[DATE], with diagnoses of Parkinson's Disease, Cerebral Infarction, Seizures, History of Falls and Major
Depressive Disorder.
Review of the Fall Risk assessment dated [DATE] documented Resident #8 scored an 18 which indicated at
risk for falls.
The medical record revealed Resident #8 fell on [DATE] at 6:33 AM and 2/24/2023 at 8:31 PM.
Review of Resident #8's undated Care Plan on 4/18/2023, revealed no documentation of the 2/18/2023, or
2/24/2023, fall or interventions for the falls.
BIMS score of 8, which indicated Resident #8 was moderately cognitive impaired for daily decision making.
During an interview on 4/24/20223 at 5:15 PM, Unit Manager LPN #2 confirmed thee was no documentation
on Resident #8's care plan for the falls on 2/18/2023, and 2/24/2023, and interventions for the falls.
During an interview on 4/24/2023 at 5:15 PM, Unit Manager LPN #1 and #2 was asked how is it
communicated to staff if a resident is at risk for falls, Unit Manager LPN #1 stated, .Yeah, how do we do this .
During an interview on 4/24/2023 at 5:30 PM, the Administrator was asked when is the resident's care plan
revised and updated and how is it communicated to the staff which residents are at risk for falls. The
Administrator stated, .We have run into a lot of different issues and were not aware of until your visit .

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Department of Health & Human Services Printed: 11/22/2023

Form Approved OMB

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

The findings include:

(continued on next page)

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(continued on next page)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(continued on next page)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(continued on next page)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(continued on next page)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

F 0657 3/28/2023 at 2:50 PM,

Level of Harm - Minimal harm or 4/4/2023 at 10:15 AM,

4/14/2023 at 4:22 PM.

The medical record revealed Resident #7 fell on [DATE] at 6:06 PM.

(continued on next page)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bedrockhc at Spring Meadows, LLC 220 Highway 76

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

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