Crestview Health & Rehab Ctr

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

occurred between Resident R4 and Resident R5 on 8/11/2025, she revealed that Resident R4 was visibly upset and crying, she stated Resident R4 was taken to the day room where other residents were sitting. She revealed that Resident R4 started screaming and yelling. She revealed that Resident R5 was walking down the hall back and forth as she normally did and as she approached towards Resident R4, Resident R4 hit Resident R5 and was verbally aggressive, calling Resident R5 a curse word and to get away from her. She revealed that this was typical behavior for Resident R4, especially when she didn't get her way.During

an interview on 8/20/2025 at 4:36 pm with Certified Nursing Assistant (CNA) DD, she revealed that she witnessed an incident between Resident R4 and Resident R5 on 8/11/2025. She stated that Resident R4 was upset about not getting ice-cream and pudding after lunch, which was provided to Resident R4 by another staff. She stated that Resident R4 started rolling down the hallway crying and having a tantrum. She stated that she took Resident R4 to the TV room, which was by the nurse's station. She stated that Resident R5 had dementia and was walking up and down the hall as she normally did. She went on to state that Resident R5 was curious as she saw Resident R4 crying. She stated Resident R5 was confused because Resident R4 was crying. She further stated that Resident R4 was in a wheelchair crying and Resident R5 went close to her wheelchair and that's when Resident R4 hit Resident R5, just one time, and then they were separated. She revealed that Resident R4 called Resident R5 a curse word.During an interview on 8/20/2025 at 5:02 pm with CNA CC, she revealed that she witnessed an incident between Resident R4 and Resident R5. She stated that Resident R4 was upset because she couldn't go back to her room and was up and down the hall screaming and crying. She stated that she rolled Resident R4 down to a chair in the dayroom and told Resident R4 to be quiet because she was crying. She stated that Resident R4 got in her wheelchair and started pushing stuff off the table. She further stated that when Resident R5 was walking towards the table because Resident R5 had a drink on that table, she stated that Resident R4 was banging her hands and said to Resident R5, move your stupid ass ‘curse word', and grabbed Resident R5. She stated that when Resident R4 hit Resident R5 that Resident R5 looked like she wanted to hit her back, but they moved Resident R5 away. She stated that Resident R5 walked up and down the hall all day from the time she woke up until her bedtime and didn't bother anyone.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestview Health & Rehab Ctr

2800 Springdale Road Atlanta, GA 30315

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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

informed her supervisor, LPN HH. She stated that she had no idea what happened to the teeth and knew that she did not throw them away. She stated that she asked the housekeepers, and they all stated that they did not see or take the teeth. She stated that she was not sure of the housekeeper that was working in the hall on that day and not sure they were still here in the facility. She stated that they have different housekeepers every day. She stated that no one from social services came to inquire about the missing teeth. During an interview on 8/21/2025 at 11:24 am, LPN HH revealed that she did not see the gold grill that covered the teeth. She stated that the nurse told her that she had wrapped the teeth and obviously were not properly secured. She stated that she found out the next day that it was missing. She stated that

the grill should have been secured properly. She stated that they didn't have a specific place to secure it, so

it was placed at the bedside. She stated that they sent Resident R3 out on two occasions for the fitting of the grill that

she thought was replaced. She stated that once they realized it was missing, they reported it to social services. She stated that she, the nurse and CNAs looked for the grill. She stated that the investigation was between social services and the Quality and Risk Manager.During an Interview on 8/21/2025 at 12:09 pm with Quality and Risk Manager (QRM) NN, she revealed that Resident R3 filed a grievance for the missing gold grill.

She stated that Social Services, Director of Nursing and Administrator went over the incident with Resident R3. She stated that they looked at grievances to determine if it was reportable and then she would step in if it was reportable to investigate. She stated that she thought the grill was accidentally disposed of.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestview Health & Rehab Ctr

2800 Springdale Road Atlanta, GA 30315

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

admission that Resident R3 always wanted to go back to the community. When asked how much notice the residents were getting, she revealed that it just depended on the situation, that Resident R3's locations changed but was always back to the community. She revealed that Resident R3 was discharged to his uncle's home. She stated that

the facility did not give a 30-day discharge notice to residents. She stated that they only gave verbal notice starting from the day of admission.Review of the EMR for Resident R3 revealed there was no 30-day notice provided to Resident R3 or their representative. 2. Review of the EMR revealed Resident R6 was admitted to the facility on [DATE REDACTED] with diagnoses that included but not limited to encephalitis and encephalomyelitis, unspecified, nontraumatic intracerebral hemorrhage, unspecified, compression of brain, unspecified severe protein-calorie malnutrition, epilepsy, unspecified, not intractable, without status epilepticus, vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, adjustment disorder with mixed anxiety and depressed mood, schizoaffective disorder, bipolar type, schizophrenia, unspecified, and bipolar disorder, unspecified.Review of Resident R6's MDS with an ARD of 7/1/2025 Discharge Return Not Anticipated revealed Resident R6 had BIMS score of 15, which indicated the resident is not cognitively impaired.Review of the EMR revealed Resident R6 was discharged on 7/1/2025 with no written 30-day notice.3.

Review of the EMR revealed Resident R7 was admitted to the facility on [DATE REDACTED] with diagnoses that included but not limited to unspecified severe protein-calorie malnutrition, polyneuropathy, unspecified, alcohol abuse, uncomplicated, foot drop, left foot, muscle weakness (generalized), and mild cognitive impairment of uncertain or unknown etiology.Review of Resident R7's quarterly MDS with an ARD of 7/29/2025 Discharge Return Not Anticipated revealed Resident R7 had a BIMS score of 15, which indicated the resident is not cognitively impaired. Review of a Progress Note dated 7/3/2025 at 08:55 (8:55 am) revealed, SW (Social Worker) met with (Resident R7) on 6/23 (2025) and during initial assessment he stated that he was living in a town home he was renting but is no longer a tenant of that home. (Resident R7) stated he has no income and no family that he can live with regarding discharge. (Resident R7) stated to SW that as of now he wants to be LTC (long term care) due to lack of income and resourcesReview of the EMR revealed Resident R7 was not given a written 30-day notice prior to discharge on [DATE REDACTED].During an interview on 8/20/2025 at 11:20 am with the Medical Social Worker Manager (MSWM) MM regarding discharge/transfer. She stated that during the first 48 hours after admission that they asked residents if they wanted to return home or to stay in long-term care. She stated that they identified the resident's plan upon admission. She stated if the residents were going home and were receiving rehabilitation, once they met their therapy goal, rehab notified Social Services, and they agreed on a date to discharge the resident. She stated that they do not give 30-day notices to discharging residents.

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

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestview Health & Rehab Ctr

2800 Springdale Road Atlanta, GA 30315

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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

issues.3. Review of Resident R7's EMR revealed Resident R7 was admitted to the facility with diagnoses that included but not limited to unspecified severe protein-calorie malnutrition, local infection of the skin and subcutaneous tissue, unspecified, unspecified convulsions, pressure ulcer of foot drop, right foot, hypokalemia, alcohol abuse, uncomplicated, unspecified lack of coordination, and mild cognitive impairment of uncertain or unknown etiology.Review of Resident R7's quarterly MDS assessment with an ARD of 7/29/2025 Discharge Return Not Anticipated revealed Resident R7 had a BIMS score of 15, which indicated the resident is not cognitively impairedReview of a Progress Note dated 6/20/2025 at 17:23 (5:23 pm for Resident R7 revealed, Pt (patient) admitted to facility from ‘name of hospital' with Dx (diagnosis) of infected sacral decubitus ulcer, sacrum wound. Head to toe skin assessment completed with no complaints of pain or discomfort. Pt skin is expected color for ethnicity, warm and dry and intact with no rashes or lesions present. Wound noted with pt right and left sacrum, right upper back, and right lateral ankle. Cleansed with NS (normal saline), pat dry, and covered with dry dressing. Denied any pain at this time. Pt alert and oriented X4 (person, place, time, and situation).Review of the EMR revealed Resident R7 was admitted to the facility from ‘name of hospital' hospital

on 6/20/2025 and was discharged to the community on 7/29/2025.Review of the MDS assessment dated [DATE REDACTED] for Resident R7 revealed under Section A (Identification Information) revealed that Resident R7 entered the facility from the community and Section A-2105 revealed Resident R7 was discharged to a short-term hospital. During the

interview on 8/21/2025 at 11:56 am with Minimum Data Set Coordinator (MDS) JJ, she stated that she completed the MDS discharge assessment on Resident R7. She acknowledged that Resident R7 did not enter the facility from

the community but from the hospital and discharged was to the community, not the hospital. She acknowledged that it was completed incorrectly.During an Interview on 8/21/2025 at 12:18 pm with Medical Social Worker (MSW) KK, she stated that she completed sections C (Cognitive Patterns), D (Mood), E (Behavior), and Q (Resident Referrals to Community) on the MDS assessment. She stated she looked at CNA (certified nursing assistant) notes where they checked off residents if there were any issues and went over progress notes and sometimes talked to the staff or residents for information to complete those areas of the MDS. She stated that her look back period was 7 days from the date the MDS was completed. She stated that it was an oversight for her (Resident R1). She acknowledged that she did not note the behavior incident

on 7/5/2025 on section E of the MDS completed on 7/11/2025 for Resident R1 and that it should have been noted on

the assessment.

Event ID:

Facility ID:

If continuation sheet