Fountain Inn Post Acute

Based on interview, record review, and facility policy review, the facility failed to implement a comprehensive person-centered care plan to maintain the resident's highest physical well-being for 1 (Resident (R)29) of 3 sampled residents reviewed for falls.

Findings included:A facility policy titled, Falls - Clinical Protocol, revised 03/2018, revealed, 1.

For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall.

The policy specified, 3.

The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.

Treatment/Management 1.

Based on the preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling.An admission Record revealed the facility admitted R29 on 04/15/2025.

According to the admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain, atrial fibrillation, and hypertension.

Per the admission Record, R29 discharged from the facility on 11/13/2025.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025, revealed R29 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment.

The MDS revealed the resident required partial/moderate assistance with rolling left and right in bed and chair/bed-to-chair transfers.R29's Care Plan Report included a focus area initiated 04/17/2025, that indicated the resident was at risk for falls with or without injury related to altered balance while standing and/or walking, altered mental status, antidepressant medication, antihypertensive medication, cardiovascular disease, decreased muscular coordination, history of falls, unsteady gait, and visual impairment.

Interventions directed staff to conduct every-one-hour rounding (initiated 05/06/2025).R29's Rehab - Status Post-Fall Screen, electronically signed by Physical Therapist #9 and dated 05/05/2025 at 5:37 PM, revealed that on 05/05/2025 at 12:00 PM, R29 had an unwitnessed fall onto the floor in the resident's room and was found underneath their bed in the resident's room by a certified nursing assistant, with no signs or symptoms of skin bruising, tearing, or discoloration.

The Rehab - Status Post-Fall Screen revealed the fall incident was discussed with the Interdisciplinary Team and an intervention for hourly rounds was implemented.During an interview on 12/19/2025 at 10:25 AM, the Director of Nursing stated she was not able to find any documentation in R29's medical record that indicated that one-hour rounding was being conducted in accordance with the resident's care plan.

During an interview on 12/19/2025 at 12:02 PM, the Administrator stated he would expect facility staff to follow the resident's care plan.

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.

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