Waynesboro Post Acute & Rehabilitation

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

The Administrator was asked per the facility policy should all injuries of unknown origin be reported. The Administrator stated, Yes, per our new policy. I can't tell you what the old policy said. I don't have access to

the old policy. The Administrator was asked what was determined to be the cause of the fracture revealed

on 11/18/2022 to Resident #1's right humerus. The Administrator stated, .Root cause analysis determined

the CNAs did not use the lift sling.transferred resident per 2 person assist. The Administrator was asked if surveyors should be able to see those records. The Administrator stated, .Yes, you should be able to see them, however I am unable to produce them due to lack of cooperation from our previous owners. Refer to F-842

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waynesboro Post Acute & Rehabilitation

104 J V Mangubat Drive Waynesboro, TN 38485

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Medical Director was asked if all injuries of unknown origin should be reported. The Medical Director stated, Yes, they should. During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked to review the incident report that had been provided to the surveyors by the facility related to Resident #1's bruising to right upper arm and right upper back of arm identified on 11/10/2022. The Administrator was then asked what do you see when you look at the incident report for 11/10/2022. The Administrator stated, I see bruises without a cause listed. The Administrator was asked if injuries of unknown origin should be reported. The Administrator stated, that if that was all the information they had it would have been reported, but root cause analysis led them to the lift sling as the cause of the bruising. The Administrator was asked where the documentation was that showed that determination and the investigation process involved. The Administrator stated, I can't provide the documentation for the investigation for 11/10/2022, I do not have access to those records. The Administrator was asked per facility policy should all injuries of unknown origin be reported. The Administrator stated, .Yes per our new policy. I can't tell you what the old policy said.

I don't have access to the old policy. The Administrator was asked was this injury reported. The Administrator stated, No, it was not.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waynesboro Post Acute & Rehabilitation

104 J V Mangubat Drive Waynesboro, TN 38485

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

CN [Charge Nurse] r/t [related to] resident c/o [complaints of] pain to R [right] arm. Arm noted with bruising that had previously been noted and observed. ROM [range of motion] limited to fingers and pain upon touch .Resident returned to facility from [Named Medical Center] with Xray report noting displaced fracture of R humerus . Review of the Nurses Notes dated 11/18/2022, revealed .Called to residents [Resident #1] room pe CN [Charge Nurse] Resident c/o pain to R arm R arm noted with bruising that had previously been reported/observed. Noted with [arrow pointing down[decrease] in ROM to arm . Resident #1 presented with complaints of pain and bruising to right upper arm on 11/10/2022, and on 11/18/2022 Resident #1 had an X-ray of the right upper arm/shoulder due to pain and a decline in range of motion that revealed a right humerus fracture. The facility was unable to provide an investigation to determine the cause of the injuries until 11/18/2022, at which point the facility was also unable to provide the education and training material provided to staff. Review of the X-Ray report dated 11/18/2022, revealed a displaced acute right humerus fracture (sudden broken right upper arm usually from trauma). The facility was unable to provide documentation to show hospice residents were assessed in relation to the 11/18/2022 incident involving Resident #1. Review of the In-service Training sheet dated 11/18/2022, revealed .Instructor [ADON H].Subjects.Resident care plans related to transferring status. The in-service was signed by staff members from multiple hospice agencies. The facility was unable to provide documentation of the In-service materials/ education provided on 11/18/2022. Review of Hospice LPN G's witness statement dated 11/18/2022, revealed, .11/8/2022.CNA called [Hospice LPN G] r/t pt [patient] shoulder popped upon transferring pt [.] pt stated to CNA it hurt. SN to make a visit and vitals within normal limits for pt, pt with no bruising or discomfort noted at this x to right shoulder. Told CNA to evaluate upon next visit. No other issues noted. Review of Hospice CNA S's witness statement dated 11/18/2022, revealed .11/8/22 [11/8/2022] .[Hospice CNA F] and I [Hospice CNA S] went to put her [Resident #1] in bed after shower. We pivot the patient an [and] her shoulder popped .After we called [Hospice LPN G]. We used a [mechanical] lift to put her back in bed. Review of Hospice CNA F's written witness statement dated 11/22/2022, revealed, .While transferring patient her right arm pooped (popped). I called her hospice LPN and reported it. Patient didn't complain no nurse or CNA was at the desk when I left. The facility was unable to provide the Incident/Accident form for the 11/18/2022 incident for Resident #1. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed a Brief Interview for Mental Status (BIMS) score was unable to be completed. Resident #1 was moderately impaired for decision making skills. Resident #1 had impairment on 1 side of upper extremities. No falls or surgery were noted. During a phone interview on 10/22/2025 at 2:25 PM, the Medical Director was asked if following the discovery of the multiple bruising on 11/10/2022 and a right humerus fracture on 11/18/2022 if there should have been a thorough investigation completed to determine the cause and prevent reoccurrence for Resident #1. The Medical Director stated, .Yes. During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked if a thorough and complete investigation was completed to determine the cause of Resident #1's injuries noted on 11/10/2022 and 11/18/2022. The Administrator stated, .we stated we provided education to our staff, unfortunately I cannot produce that education for you guys. The Administrator was asked if anything else could be provided for those investigations. The administrator stated, , .I do not have access to those records. Review of the facility documentation for Resident #1 for injury of unknown origin, revealed an incomplete investigation for dates 11/10/2022 and 11/18/2022.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waynesboro Post Acute & Rehabilitation

104 J V Mangubat Drive Waynesboro, TN 38485

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

change of status MDS dated [DATE REDACTED], revealed Resident #7 had a BIMS score of 15, which indicated Resident #7 was cognitively intact. The facility was unable to access or provide medical records for Resident #7 prior to 6/18/2024. 7. Review of the medical record review revealed Resident #8 was admitted to the facility on [DATE REDACTED], with diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Diabetes, and Atrial Fibrillation. Review of the admission MDS dated [DATE REDACTED], revealed Resident #8 rarely/never understood. The facility was unable to access or provide, medical records for Resident #8 prior to 6/18/2024. 8. Review of the medical record review revealed Resident #9 was admitted to the facility

on [DATE REDACTED] with diagnosis including Diabetes, Guillain-Barre Syndrome, Peripheral Vascular Disease, Diabetes and Depression. Review of the quarterly MDS dated [DATE REDACTED], revealed Resident #9's BIMS score was not assessed. The facility was unable to access or provide, medical records for Resident #9 prior to 6/18/2024. 9. Review of the medical record review revealed Resident #10 was admitted to the facility on [DATE REDACTED], with diagnoses including Paraplegia, Heart Disease, Chronic Pain Syndrome, and Cardiac Pacemaker. Review of the quarterly MDS dated [DATE REDACTED], revealed Resident #10 had a BIMS score was 15, which indicated Resident #10 was cognitively intact. The facility was unable to access or provide medical records for Resident #10 prior to 6/18/2024. 10. Review of the medical record review revealed Resident #11 was admitted to the facility on [DATE REDACTED], with diagnoses including Paraplegia, Heart Disease, Chronic Pain Syndrome, and Cardiac Pacemaker. Review of the quarterly MDS dated [DATE REDACTED], revealed Resident #11 had a BIMS score of 15, which indicated Resident #11 was cognitively intact. The facility was unable to access or provide medical records for Resident #11 prior to 6/18/2024. 11. Review of the medical record

review revealed Resident #12 was admitted to the facility on [DATE REDACTED], with diagnoses including Hypertensive Kidney Disease, Parkinson's Disease, Dementia, and Tremors. Review of the quarterly MDS dated [DATE REDACTED], revealed Resident #12 had a BIMS score of 3, which indicated Resident #12 was severely cognitively impaired. The facility was unable to access or provide medical records for Resident #12 prior to 6/18/2024.

During an interview on 10/22/2025 at 4:22 PM, the Administrator was asked about the dates of the company's transition. The Administrator stated, [Named previous facility owner] ended 6/18/2024 at 12:01 AM, we had to go to paper documentation. [Named EMR] went live on 7/16/2024. The Administrator was asked how long should records be kept and accessible to the facility, residents and outside entities. The Administrator stated, It's either 7 or 10 years . The Administrator was asked who has current access to

these records prior to 6/18/2024. The Administrator stated, I would say someone with the old [Named previous facility owner.] The Administrator was asked, have you been successful in retrieving any of these medical records. The Administrator stated, No.

Event ID:

Facility ID:

If continuation sheet