Nurse Care Of Buckhead

F-F584.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on observation, interview, record review, and review of facility policy titled, Enhanced Barrier Residents Affected - Some Precautions, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during care for one of three residents (R) (Resident R53) reviewed for high-contact care.

Findings included:

A review of facility in-service training titled, Enhanced Barrier Precautions, dated March 2024, revealed, . Enhanced Barrier Precautions (EBP)- include the use of gloves and gown when caring for residents with chronic wounds or indwelling medical devices during high-contact resident activities .Residents requiring EBP (gowns and gloves for care) include chronic wounds, wounds with dressings . Gloves and gowns are to be worn when providing the following high-contact resident activities. Dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting. Any care that requires close contact .

A review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed Resident R53 was admitted to the facility on [DATE REDACTED] with diagnoses that included a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), a gastrostomy tube (a feeding tube which provides nutrition to people who cannot eat by mouth) and dementia.

A review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/6/2024 revealed Resident R53 was severely impaired in cognition, was dependent on staff for all activities of daily living (ADL) care, had one stage four pressure ulcer, and received nutrition via a gastrostomy tube.

During an observation on 7/23/2024 at 10:00 am, Certified Nursing Assistant (CNA) YYY and CNA GG were observed setting up supplies to give Resident R53 a bed bath. Neither CNA was observed to be wearing a gown. CNA YYY removed her gloves and left the room, upon returning to the bedside, she donned new gloves without using hand hygiene. CNA YYY removed Resident R53's brief and with the same gloves, cleaned the front peri area. Resident R53 was turned onto her right side by CNA GG and the soiled brief, with feces, was removed. CNA YYY did not remove her soiled gloves after she placed the soiled brief into the plastic bag. With the same gloves, and without performing hand hygiene, CNA YYY removed the draw sheet, obtained a clean washcloth, and cleaned her buttocks. CNA YYY and CNA GG were asked if they had been in-serviced on EBP and what the requirements were when providing high-contact care, such as a bed bath. CNA YYY shrugged and stated, I don't know.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0880 During the same observation, at 10:09 am, Licensed Practical Nurse (LPN) EE entered the room and set up her supplies to perform wound care on Resident R53. LPN EE placed her supplies on the overbed using a barrier, Level of Harm - Minimal harm or however, the supplies were next to the plastic container being used by CNA YYY for Resident R53's bath. LPN EE potential for actual harm applied double gloves but was not observed to wear a gown during the high-contact care. LPN EE was asked if she was aware of the EBP requirements when providing high-contact care such as wound care. LPN Residents Affected - Some EE stated, Barrier precautions are resident-to-resident, and you are supposed to wear a gown when providing high-touch care. LPN EE was asked if she wore a gown during wound care. She stated, No, I didn't. LPN EE further stated that the Infection Preventionist (IP) was going around and putting up signs. LPN EE stated, I don't think there was a gown for me to use on the cart outside the door. LPN EE was asked if

the facility had enough personal protective equipment (PPE) such as gowns and gloves, which were readily available for staff use. LPN EE stated, Yes.

An observation of the linen cart, outside Resident R53's room, revealed there were no gowns for staff use during high-contact care, and there was no PPE cart readily available outside the resident room.

During an interview on 7/23/2024 at 10:40 am, the IP stated, I think there has been confusion related to EBP.

We might need to reevaluate EBP. I am going to get with the Administrator and change the policy. The IP was asked what she meant by reevaluate. She stated, To get rid of EBP.

During an interview on 7/29/2024 at 9:24 am the IP confirmed that she and the Unit managers on each floor are responsible for educating on EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on interviews, record review, and review of facility policy titled Influenza and Pneumococcal Residents Affected - Few Immunizations, the facility failed to assess for eligibility and ensure residents were offered and/or administered influenza and pneumococcal vaccines; and failed to provide documentation that the resident and/or resident representative were informed of the risks verse benefits of refusing the vaccines for two residents of five sampled residents (R) (Resident R28 and Resident R55) reviewed for immunizations. This failure placed residents at risk of complications from being unvaccinated.

Findings included:

A review of the facility policy titled, Influenza and Pneumococcal Immunizations, revised November 2022 revealed, .It is the standard of practice of this facility to offer and administer immunizations to the resident unless it is medically contraindicated to prevent and minimize house acquired infection, unnecessary hospitalization , and even death in the elderly population associated with influenza and incidence of pneumonia .All residents of this facility will be offered the influenza vaccine annually. Assessment will be documented in the facility computer software program, Point Click Care (PCC) within the resident's medical

record (immunizations tab) .Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine and when indicated will be offered unless medically contraindicated or the resident has been immunized .The resident/legal representatives have the right to refuse vaccination .If refused, appropriate entries will be documented in the resident's electronic clinical record indicating the date of refusal of the vaccine .

1. A review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed that Resident R28 was originally admitted on [DATE REDACTED].

A review of the Quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 5/26/2024 revealed Resident R28 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated she was severely impaired in cognition for daily decision-making.

A review of the Immunizations tab in the EMR revealed, Influenza .consent refused, and Pneumovax 23 . consent refused.

A review of the Miscellaneous tab in the EMR revealed no documentation that the resident and/or legal representative were informed of the risks vs benefits of the vaccines and documentation of consent refusal.

A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no immunization history.

During an interview on 7/29/2024 at 9:24 am, the Infection Preventionist (IP) and Administrator confirmed that Resident R28 had no information regarding having been offered/administered the influenza and/or pneumococcal vaccines.

2. A review of the Admission Record located in the Profile tab of the EMR revealed that Resident R55 was admitted to

the facility on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0883 A review of the Medical Diagnosis tab in the EMR, revealed Resident R55 had multiple sclerosis (a disease in which

the immune system eats away at the protective covering of nerves.) Level of Harm - Minimal harm or potential for actual harm A review of the Immunizations tab in the EMR revealed, Pneumococcal dose 1 .consent refused and Prevnar 23 .consent refused. Residents Affected - Few

A review of the Miscellaneous tab in the EMR revealed that Resident R55's resident representative had refused consent for the pneumococcal vaccines on 10/10/2018.

A review of the annual MDS located in the MDS tab of the EMR with an ARD of 12/11/2018 revealed Resident R55 had a BIMS score of nine out of 15 which indicated she was moderately impaired in cognition for daily decision-making.

A review of the annual MDS located in the MDS tab of the EMR with an ARD of 7/7/2024 revealed, that Resident R55 had a BIMS score of 13 out of 15 which indicated she was cognitively intact for daily decision-making.

A review of the Miscellaneous tab in the EMR did not show, when Resident R55's cognition improved, had been educated on the risks vs benefits and/or refused consent for the pneumococcal vaccine.

A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no pneumococcal immunization history.

During an interview on 7/29/2024 at 9:24 am, the Administrator and Infection Preventionist were asked if the facility had readdressed the pneumonia vaccines with Resident R55 since 2018. The Administrator stated, No, we haven't. Since we started in May of this year, we are still getting immunizations up and running and getting

the documentation together.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513

Residents Affected - Few Based on interviews, record review, and review of the facility policy titled Testing of Resident and Staff for COVID-19, the facility failed to offer/administer or provide documentation of consent or refusal by the resident representative for the COVID-19 vaccines for one of five sampled residents (R) (Resident R28) reviewed for COVID-19 vaccinations. This failure placed the resident at risk for complications related to being unvaccinated.

Findings included:

A review of facility policy titled, Testing of Resident and Staff for COVID-19, revised in May 2023 revealed, .It is the policy of [facility] to maintain and attain best practices in the prevention and spread of infection. The facility follows all recommendations from CMS (Center for Medicare/Medicaid Services), CDC (Center for Disease Control), and state and local regulatory agencies .

A review of the electronic medical record (EMR) revealed that Resident R28 was originally admitted to the facility on [DATE REDACTED].

A review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/26/2024 revealed Resident R28 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated she was severely impaired in cognition for daily decision-making.

A review of the Immunization tab in the EMR revealed no documentation of the initial COVID-19 vaccines including any boosters for Resident R28.

A review of the Miscellaneous tab in the EMR revealed no documentation that the Resident R28 and/or legal representative were informed of the risks and/or benefits of the vaccines. There was no documentation in the EMR of consent or refusal of vaccines.

A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no immunization history for Resident R28.

During an interview on 7/29/2024 at 9:24 am the Administrator confirmed that Resident R28 had no documented COVID-19 vaccinations or consent/refusals in her medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 49470 potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure that essential equipment Residents Affected - Many was maintained in a safe and operable manner related to wheelchairs, ice machines, and the walk-in freezer.

Findings included:

A record review of the facility policy titled, Maintenance Service last revised in April 2022, revealed the following:

Maintenance service shall be provided to all areas of the building, grounds, and equipment.

Policy Interpretation and Implementation. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at, all times. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards.

1. During an interview on 7/1/2024 at 11:10 am Resident R49 stated she had been unable to utilize her wheelchair for months due to the brakes not working. She stated that despite her repeated efforts and notifications to the maintenance department, nothing had been done to repair her wheelchair.

During an interview on 7/1/2024 from 12:00 pm, Resident R48 stated that on 6/1/2024, Registered Nurse (RN) SSSS attempted to maneuver her wheelchair and placed the gear in reverse and the wheelchair malfunctioned.

She stated that she had been unable to utilize her wheelchair since then and expected that the facility was going to make the necessary repairs. she stated that she declined to use a regular wheelchair when the maintenance department offered her one and explained she was paralyzed on one side and was unable to utilize a manual wheelchair.

During an interview on 7/8/2024 at 10:01 am, Maintenance Director VV revealed part of his job description was to repair wheelchairs and to repair inoperable equipment. He stated residents with wheelchairs that were beyond repair were provided with a new chair and explained that Resident R48's wheelchair was beyond repair.

During an interview on 7/8/2024 at 2:24 am, Social Worker XXX revealed the process regarding inoperable equipment is to notify the maintenance department through a ticket system. She stated she would expect the maintenance department to make the necessary repairs including fixing inoperable wheelchairs for the residents, however, the facility does not assist residents with electrical wheelchair concerns. Social Worker XXX stated Resident R48 reported a grievance regarding her electrical wheelchair which was out of service and that

she spoke to Resident R48 regarding her wheelchair. Social Worker XXX stated on 6/1/2024, Certified Nursing Assistant (CNA) RRRR observed RN SSSS in Resident R48's wheelchair and confirmed that the wheelchair was operable until RN SSSS attempted to operate Resident R48's wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0908 During an interview on 7/8/2024 at 4:12 pm, Administrator AA stated she explained to Resident R48 facility would provide Resident R48 with a manual wheelchair. She stated that she was unaware that Resident R48's wheelchair Level of Harm - Minimal harm or malfunctioned while RN SSSS was riding Resident R48's wheelchair. She stated that the facility would be responsible potential for actual harm for the specific repairs.

Residents Affected - Many 2. During observation and interview on 7/1/2024 at 3:05 pm, Dietary [NAME] PP opened the ice machine which was observed to be inoperable. They stated that it had not been functional for over two weeks.

During an interview on 7/1/2024 at 3:50 pm, Licensed Practical Nurse (LPN) RR revealed that the ice machine located on the Fourth Floor had been inoperable for over a month. LPN RR stated the maintenance department was made aware. They stated that the maintenance department takes several months for equipment to be repaired.

During an interview on 7/1/2024 at 4:07 pm, CNA TT revealed the ice machine on the Fourth Floor was inoperable and explained staff usually have to rely on the ice machine located on the First Floor, but now the First Floor icemaker was down and inoperable as well.

During an interview on 7/1/2024 at 4:01 pm, Maintenance Worker SS stated that they were aware that the ice machines on the Fifth Floor and Second Floors were inoperable.

3. During observations on 7/11/2024 at 3:05 pm, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees Fahrenheit (F).

During observations on 7/13/2024, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees F throughout the day.

During observations on 7/15/2024 at 8:49 am, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees F.

During observations on 7/16/2024 at 10:45 am, the walk-in freezer in the kitchen revealed an internal temperature of 23 degrees F.

During an interview on 7/31/2024 at 10:52 am, Dietary Manager GGGGG, confirmed that the walk-in freezer had not been able to keep the required holding temperatures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0924 Put firmly secured handrails on each side of hallways.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on observation and interview, the facility failed to ensure that handrails were securely affixed to the Residents Affected - Many wall and had end caps on four of five floors (Second Floor, Third Floor, Fourth Floor, and Fifth Floor).

Findings included:

A review of the facility policy titled, Maintenance Services, dated April 2022, revealed that maintenance services shall be provided to all areas of the building, grounds, and equipment . Maintaining the building in good repair and free from hazards.

During an initial observation on 7/18/2024 at 9:05 am on the Fifth Floor, the following issues were identified:

~The handrail under the sign 510-518 had a loose end cap, and the handrail was unsecured at that point at

the wall.

~The handrail under the sign 519-527 was missing an end cap to the handrail and had exposed metal.

~The handrail under the dayroom sign had a missing end cap with exposed metal. The handrail was loose and not secured tightly to the wall.

~The handrail on the left side of the hall, as you enter the day room was loose and not tightly secured to the wall.

During an observation on 7/22/2024 at 8:18 am on the Second Floor, the following issues were identified:

~The handrail to the right of the sign which read, Janitor closet, was loose and not tightly affixed to the wall.

During an observation on 7/22/2024 at 8:25 am, on the Third Floor, the following issues were identified:

~The handrail under the fire extinguisher door in the middle hall was loose and not tightly affixed to the wall.

~The long handrail, on the right going into the dining room, the end cap was missing, and the handrail was not tightly affixed to the wall.

~The handrail under the sign 310-318 was not tightly affixed to the wall.

~The handrail next to room [ROOM NUMBER] was missing and duct tape was covering the opening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0924 During an observation on 7/22/2024 at 8:35 am, the following issues were identified on the Fourth Floor:

Level of Harm - Minimal harm or ~The handrail to the left of room [ROOM NUMBER] was not tightly affixed to the wall. potential for actual harm ~The handrail under the fire extinguisher sign on the north side was not tightly affixed to the wall. Residents Affected - Many

During an interview on 7/22/2024 at 8:48 am, the Maintenance Director and Assistant Maintenance Director both confirmed the loose handrails. They stated that due to low staffing, they have not been able to complete

the inspection of the handrails. The Maintenance Director stated, We know there are lots of things that need to be done however, we had not been told about the handrails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49470 potential for actual harm Based on observations, record review, interviews, and review of the facility policy titled facility policy, titled Residents Affected - Many Pest Control Policy, the facility failed to have an effective pest control program in place. The census was 189.

Findings included:

A review of the facility policy titled Pest Control Policy last reviewed on 11/15/2022, documented that the policy aims to ensure that, as far as possible, pests (rats, mice, roaches, ants, fruit flies, silverfish, etc.) within

the premises are kept to an absolute minimum with the ideal being eradication but due to the resilience and persistence of some species this ideal is impossible to achieve. The Pest Control Contractor shall rid the premises of pests using only approved pesticides and maintain the locations to the required standard for the duration of the contract. The contractor will also respond to unscheduled requests to effectively rid the premises of further pests. The contractor will supply all goods and materials to carry out the service.

A review of the Pest Prevention Service Report (dates 9/26/2023 through 6/24/2024) revealed that the pest control company was present on site on the following dates and treated for the following pests:

On 9/26/2023 pest control treated for crickets.

On 10/13/2023 pest control treated for crickets, ants, and flies around the dumpster.

On 10/16/2023 pest control treated for crickets.

On 11/6/2023 the facility was billed for pest prevention, but no details for treatment were given.

On 12/11/2023 the facility was billed for pest prevention, but no details for treatment were given.

On 1/16/2024 rat traps were placed out and roach gel was put out in the facility.

On 1/22/2024 pest control serviced the kitchen area and physical therapy by applying fly bait to the doors and treated the drains in the kitchen area for fruit flies.

On 1/29/2024 pest control serviced and cleaned utilities on all floors for roaches.

On 2/5/2024 pest control treated the interior and ground-level hallway in the laundry room and bathrooms with granules and rodent stations. Pest control also serviced the dumpster with fly granules.

On 2/12/2024 pest control serviced all floors with 48-hour rodent traps, it was noted that the facility had recently caught rodents with previously installed 48-hour traps.

On 2/29/2024 pest control treated drains on the third floor in the shower rooms and kitchenettes, the drains

in the kitchen and dishwasher area, and the floor drains for fruit flies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0925 On 2/26/2024 pest control treated the kitchens and utility rooms on all floors.

Level of Harm - Minimal harm or On 3/4/2024 pest control service the interior and the exterior of the building, dumpster, interior on basement potential for actual harm level entryways, common areas around employees, lockers, bathrooms service exterior with granules, max force, and fly baits. It was noted that drains, kitchens, and kitchenette utility rooms on floors were treated Residents Affected - Many where fruit flies had been reported.

On 3/11/2024, pest control serviced, cleaned, and inspected all rodent stations and 48-hour traps on all floors. Pest control also treated drains with chemicals for fruit flies.

On 3/18/2024 pest control treated the kitchen area to include the drains, floor drains and sinks, and bathroom drains for fruit flies.

On 3/25/2024 pest control treated drains on all floors, kitchenettes, and utility rooms for fruit flies.

On 4/5/2024 pest control documented that roaches were reported to have been seen at all nurses' stations and residents' rooms. Pest control was treated for roaches during this visit.

On 4/15/2024 pest control was treated for ants in offices and treated dumpster for flies.

On 4/22/2024 pest control treated the kitchen for siting of rodents and switched our fly glue board and fly light.

On 5/15/2024, pest control serviced the exterior building and dumpster with fly bait and one resident's room for ants.

On 5/13/2024 pest control treated the first-floor conference room for ants (reported by maintenance). This service summary also noted a need for an order for fruit flies.

On 5/24/2024 pest control serviced the center of the building, hallways, service drains and kitchen area for fruit flies and with fly lights. Pest control also treated the office area for ongoing ants.

On 5/29/2024 pest control noted that maintenance reported ongoing issue with fruit flies that was reaching to residents' rooms. Pest control documented that the treatment that was being used was, over and above standard contract treatment, and discussed problems with food being left around the kitchenette, nurses' stations, and other cleaning issues.

On 6/3/2024 pest control treated the exterior building and dumpster for rodents.

On 6/17/2024 pest control was serviced for fruit flies. Pest control noted that after speaking with maintenance

it was believed that fruit flies were riding the meal carts from the kitchen area and getting onto the residents' floors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0925 On 6/24/2024 pest control treated kitchen drains again for fruit flies. It was noted that residents' rooms were found to have issues that could be increasing pests, such as remnants of food and a bowl underneath a table Level of Harm - Minimal harm or and dishes with food. It was also noted that directives to clean up and maintain cleaning to avoid further fruit potential for actual harm fly issues were discussed.

Residents Affected - Many During an observation on 6/26/2024 at 5:10 pm, flies and gnats were observed in room [ROOM NUMBER]B.

The resident in that room stated that the flies and gnats had been there for a while. Certified Nursing Assistant (CNA) LL revealed flies were a major concern for two months.

During an observation in the kitchen on 6/26/2024 at 5:20 pm, a live fly was flying around in the kitchen in the food prep area.

During an observation on 6/26/2024 at 5:29 pm, a live gnat flew around in the conference room.

During an interview on 6/26/2024 at 7:05 pm, Licensed Practical Nurse (LPN) KK revealed that flies were a concern and stated that maintenance was made aware. LPN KKK stated several residents had raised concerns regarding flies in their rooms.

During an observation on 6/26/2024 at 8:46 pm, a live fly was observed in the conference room on the table.

During an observation on 6/27/2024 at 8:47 am, the kitchen door that leads to the outside was ajar about seven inches.

During an interview on 6/27/2024 at 9:48 am, the Ombudsman stated there was an issue with rats in the kitchen earlier in the year. She further stated that the facility had rats in the kitchen, but she had always observed that the kitchen's back door was always ajar. She stated that there have also been resident complaints related to the fruit flies in resident rooms.

During an observation on 6/27/2024 at 10:07 am a live fly was observed on a chair in the conference room.

During an observation on 6/27/2024 at 2:24 pm the outside kitchen door was opened.

During an observation on 7/1/2024 at 8:31 am the door to the kitchen that leads to the outside that is located towards the parking lot was propped open. There was a rock used to prop it open.

During an observation on 7/1/2024 at 8:41 am and 9:20 am, the outside kitchen door was observed to be still open.

During an interview on 7/1/2024 at 9:40 am, Maintenance Director VV revealed the facility was infested with fruit flies and flies and that the facility was working on eliminating the spread of fruit flies, with the assistance of a specified pest control company. Maintenance Director VV stated residents and staff voiced concerns related to mice in the kitchen area and flies in resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 48 115129 Department of Health & Human Services Printed: 09/17/2025 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 115129 B. Wing 08/01/2024

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

Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305

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 0925 During an interview on 7/1/2024 at 10:01 am, Assistant Maintenance Director XX stated that not too long ago there had been some issues with rats downstairs in the kitchen area. He stated that residents have Level of Harm - Minimal harm or complained about rats in the hallways and on the second floor. Assistant Maintenance Director XX further potential for actual harm stated that gnats have been a huge issue because residents have food and flowers in their rooms.

Residents Affected - Many During an interview on 7/1/2024 at 10:34 am Certified Medical Technician (CMT) NN stated she had seen live mice and flies in the building. She stated that the residents have complained to her about the fly infestation in their rooms.

On 7/1/2024 at 10:39 am, Resident R25 was observed lying in her bed. Her breakfast tray was observed unconsumed

on the bedside table with four slices of bacon, bread, and oatmeal. Multiple fruit flies were observed flying around the room and landing on the food. Resident R25 stated that she was unable to enjoy her meal because of the excessive amounts of fruit flies in her room. Resident R25 added that the fruit flies had been a concern for over a month and concluded she had reported her concerns to several staff members.

On 7/1/2024 at 3:10 pm, an observation of the first-floor pantry revealed a plethora of small dark brown particles along the edge of the wall and in the corners. [NAME] PP stated that the small particles were mouse feces. Further observations along the edges of the wall area showed there was evidence of mice infestation in the kitchen area. [NAME] PP confirmed they were aware, and that pest control placed mouse traps around the facility.

During an interview on 7/1/2024 at 3:20 pm, Dietary Aide QQ stated there was evidence of mice in the kitchen. He stated that he observed mouse droppings in the pantry and on the kitchen floors.

During an interview on 7/1/2024 at 3:36 pm the Assistant Maintenance Director XX revealed the small dark droppings in the kitchen pantry showed mouse infestation was a concern.

During an observation on 7/2/2024 at 8:28 am the door to the kitchen leading outside towards the parking lot was propped open. There was a rock used to prop it open.

During an observation on 7/02/2024 at 8:49 am the outside kitchen door was opened with a rock inside to keep it ajar.

During an interview on 7/2/2024 at 9:28 am Maintenance Director VV stated the facility had a pest control program, but he was not confident its ability to eliminate the flies.

During an observation on 7/2/2024 at 3:26 pm a dead fly was observed on the table in the conference room.

During an observation on 7/3/2024 at 12:40 pm a dead fly was observed on the table in the conference room.

During an observation on 7/5/2024 at 8:51 am the kitchen door that leads out to the parking lot was left ajar.

On 7/15/2024 at 9:50 am, a live fly was observed in the conference room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 48 115129