Nurse Care Of Buckhead

F-F729, and 940

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 38997 potential for actual harm Based on staff interviews and review of the facility policies titled, Abuse, Neglect and Exploitation of Residents Affected - Few Residents and Background Screening and Investigation, and the Human Resource Director Job description,

the facility failed to have two of fourteen employee files selected on site for review, failed to ensure that a criminal background check was completed for one of two Registered Nurses (RN) and one of one Licensed Practical Nurse (LPN), failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for two of two Administrators, three of three Certified Medication Aide Techs, one of one Certified Nursing Assistants (CNA), one of one Regional Director of Business Development, and one of one Maintenance Director. The facility also failed to re-fingerprint two of two CNAs whose fingerprint checks had not been retained under Rap Back per the Rules and Regulations of the State of Georgia.

Findings include:

Review of the facility policy titled Abuse, Neglect and Exploitation of Residents with a review date of 10/24/2022 revealed under IV. Procedure: A. Seven Components of Prevention and Detection: 1. Screening (Refer to: Nurse Aide Registry and Criminal Background Checks): All employees undergo a criminal background check.

Review of the facility policy titled Background Screening and Investigation with a revision dated March 2019 revealed under Policy Statement: Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents (direct access employees). Under Policy Interpretation and Implementation: . 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment.

Review of the Human Resource Director Job Description revealed: Pre-Employment Functions: Conduct reference checking, abuse registry checks, and certification/ licensure checks (if applicable), prior to giving a job offer. Conduct criminal background checks, as required, on all post-offer applicants.

During a record review on 3/19/2025 at 3:30 pm with the Human Resource Director of twelve of the fourteen selected employee files revealed the following:

1. Registered Nurse SS's employee file revealed a hire date of 2/5/2025, full-time as the Minimum Data Set (MDS) Director. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the RN's employee file revealed there was no criminal background check conducted.

2. License Practical Nurse TT's employee file revealed a hire date of 12/10/2024, full-time as the MDS Coordinator. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the LPN's employee file revealed there was no criminal background check conducted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0607 3. Administrator BB's employee file revealed a hire date of 1/9/2025, full-time as the Administrator. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the Level of Harm - Minimal harm or Administrator's employee file revealed no GCHEXS fingerprint check was conducted. potential for actual harm 4. Administrator CC did not have an employee file in the facility to review. Residents Affected - Few 5. Certified Medication Aide Tech LL did not have an employee file in the facility to review.

6. Certified Medication Aide Tech MM's employee file revealed a hire date of 9/11/2024, full- time CMAT to administer medications to the residents in the facility. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the CMAT's employee file revealed no GCHEXS fingerprint check was conducted.

7. Certified Medication Aide Tech NN's employee file revealed a hire date of 1/27/2023, full-time CMAT to administer medications to the residents in the facility. Further review of the CMAT's employee file revealed no GCHEXS fingerprint check was conducted.

8. Certified Nursing Assistant QQ's employee file revealed a rehire date of 10/23/2024 as a full- time CNA hired to perform direct resident care duties. Further review of the CNA's employee file revealed no GCHEXS fingerprint check was conducted.

9. Regional Director of Business Development HH's employee file revealed a hire date of 5/1/2024 full-time as the Admission Coordinator. Further review of the employee's file revealed no GCHEXS fingerprint check was conducted.

10. Maintenance Director RR's employee file revealed a hire date of 9/12/2024 full-time, hired to maintain the building which includes the residents' rooms. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the employee's file revealed no GCHEXS fingerprint check was conducted.

11. Certified Nursing Assistant OO's employee file revealed a hire date of 3/14/2011 as a full- time CNA hired to perform direct resident care duties. Further review of the CNA's employee file revealed the last satisfactory GCHEXS fingerprint check was conducted on 5/21/2021.

12. Certified Nursing Assistant PP's employee file revealed a hire date of 11/15/2021 as a full-time CNA hired to perform direct resident care duties. Further review of the CNA's employee file revealed the last satisfactory GCHEXS fingerprint check was conducted on 5/21/2021.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0607 An interview on 2/20/2025 at 12:34 pm with the Regional Human Resource/Payroll Director II revealed she oversaw the function of human resources in fourteen facilities. Some of the responsibilities included training Level of Harm - Minimal harm or newly hired human resource directors on processes and procedures in the human resource department and potential for actual harm resolving any human resource issues that the facility may have. Also, she conducted audits on employee files to ensure that the files had everything in place (I9, policies, ensure certifications, license, and Residents Affected - Few background checks). She stated the last employee working in the human resource department was not doing

the job. The Regional Human Resource/Payroll Director stated she realized that the background checks and/or fingerprints check were not being done. The person was terminated, and the facility just recently hired another Human Resource Director. She stated the human resource department will be cleaned up, organized and an audit will be done to ensure that the employee files were meeting the State of Georgia and Federal requirements. The Regional Human Resource/Payroll Director confirmed that the employees' fingerprints had not been retained under the Rap Back program, and she was unable to produce an employee roster for the surveyor to review. She stated she will commit to weekly and monthly audits of the employee files to ensure all processes are in place.

An interview on 2/25/2025 at 4:44 pm with the Regional Human Resource/Payroll Director II confirmed that RN SS and LPN TT did not have a criminal background check. She confirmed that Administrator BB, Administrator CC, CMAT LL, CMAT MM, CMAT NN, CNA QQ Regional Director of Business Development HH, and Maintenance Director RR did not have a GCHEXS Fingerprint check conducted. She also confirmed CNA OO, and CNA PP did not have an up-to-date satisfactory GCHEXS.

Per an email correspondence dated 3/7/2025 with __ Unit Manager WW revealed the system showed no background checks had been completed for the facility.

Review of the employee files on 2/19/2025 with the Human Resource Director, the files of Administrator CC and CMAT LL were not located in the facility and unavailable for the surveyor to review.

An interview on 2/19/2025 at 3:30 pm with the Human Resource Director (HRD) while reviewing the selected employee files, the HRD stated she was hired on 2/10/2025. The HRD stated she could not locate Administrator CC and CMAT LL employee files. She stated she would continue to look for the files and let

the surveyor know if the employee files were located.

An interview on 2/25/2025 at 4:44 pm with the Regional Director of Human Resource and Payroll confirmed that Administrator CC and CMAT LL's employee files could not be located.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997 potential for actual harm Based on record review and staff interviews, the facility failed to ensure physician's orders were followed for Residents Affected - Few two of 31 sampled Residents (R) (Resident R1 and Resident R29) to obtain laboratory tests.

Findings include:

1. Review of the Admission Record for Resident R1 revealed she was admitted to the facility with diagnoses of but not limited to nonrheumatic aortic (valve) insufficiency and chronic systolic (congestive) heart failure.

Review of the resident's most recent quarterly assessment Minimum Data Set (MDS) dated [DATE REDACTED] revealed

a Brief Interview for Mental Status (BIMS) score was assessed as 14, which indicated Resident R1 was cognitively intact.

Review of Resident R1's Electronic Medical Record (EMR) Order Summary Report revealed a physician order for Coumadin oral tablet 7.5 milligrams (mg) (warfarin sodium) Give 7.5 mg orally in the evening for blood thinner.

Review of the Clinical Physician Orders PT/INR on 2/6/2024 for Resident R1 revealed no documented results were located in Resident R1's EMR.

Review of the Clinical Physician Orders obtain PT/INR (prothrombin time test (PT) measures the time it takes for a clot to form in a blood sample, while an INR is a calculation based on the results of a PT test) on 2/9/2024 for Resident R1 revealed no documented results were located in Resident R1's EMR.

Review of the Clinical Physician Orders PT/INR on 2/16/2024 for Resident R1 revealed no documented results were located in Resident R1's EMR.

Review of the Clinical Physician Orders PT/INR stat (immediately) on 2/19/2024 for Resident R1 revealed no documented results were located in Resident R1's EMR.

Review of the Clinical Physician Orders PT/INR on 3/1/2024 for Resident R1 revealed no documented results were located in Resident R1's EMR.

Review of the Clinical Physician Orders for Resident R1 dated 3/27/2024 INR every Friday. No documented results for 4/5/2024, 4/12/2024, 5/3/2024, 5/10/2024 were located in Resident R1's EMR.

Review of the Clinical Physician Orders PT/INR on 4/8/2024 for Resident R1 revealed no documented results were located in Resident R1's EMR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0684 Review of the Nurse Practitioner Progress Note dated 4/5/2024 revealed: I came to see and evaluate Resident R1 for chronic co-morbidities that includes nonrheumatic aortic valve insufficiency, chronic systolic congestive heart Level of Harm - Minimal harm or failure, to avoid rehospitalization , and to monitor patient's overall condition. The facility lab has been potential for actual harm slacking with INR draws, I had a conversation with their nurse manager regarding INR every week, she called the lab and reiterated that this should be done every Friday, and since they missed her Friday draw, Residents Affected - Few they will do it on Monday, we will continue to monitor.

2. Review of the Admission Record for Resident R29 revealed she was admitted to the facility with diagnoses of but not limited to bipolar disorder, depression, and diabetes mellitus.

Review of the resident's most recent quarterly MDS assessment dated [DATE REDACTED] revealed a BIMS score was assessed as 15, which indicated Resident R29 was cognitively intact.

Review of the Clinical Physician Orders dated 1/15/2025 UA/CS (urine analysis/culture and sensitivity), CBC (complete blood count), CMP (comprehensive metabolic panel) for new onset of confusion. No documented results were located in Resident R29's EMR.

Review of the Clinical Physician Orders dated 1/24/2025 routine labs: CBC, CMP, thyroid stimulating hormone, glycated hemoglobin, lipid panel, vitamin D 25, Hydroxyprogesterone (is a form of progestin), type 2 diabetes mellitus screening, Hyperlipidemia (high cholesterol) on 1/27/2025 for Resident R29. No documented results were located in Resident R29's EMR.

An interview on 2/25/2025 at 10:22 am with the Unit Manager (UM) XX stated the phlebotomist came Monday through Friday and drew the blood work for residents with a physician order. She stated the Physician or Nurse Practitioner would give an order for the test to be performed. The order was entered into

the resident's EMR. The person entering the order must also enter the order into the laboratory's electronic system that would generate the requisition with the order. The requisition was placed in the lab book under

the tab of the date the lab was to be drawn. UM XX stated each unit had their own lab book. When the phlebotomist arrived, they would check the Specimen Log for that day, obtain tests accordingly, and sign off

on the Specimen Log. UM XX stated if the requisition was in the book, the residents' name did not have to be

on the Specimen Log.

An interview on 2/25/2025 at 10:45 am with License Practical Nurse (LPN) YY stated she does remember Resident R1's PT/INR tests were not being drawn.

An interview on 2/25/2025 at 12:40 pm with the Interim DON (IDON) FF revealed she was aware of the issues with the physician orders for laboratory testing not being carried out. She stated because she was new to the facility she needed an opportunity to meet with the laboratory manager and get a clear understanding of the processes and re-educate the staff. She stated the facility does have a meeting with the laboratory manager within the next couple of days. The IDON stated the facility does not have a written policy/process for obtaining laboratory test.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0684 An interview on 2/28/2025 at 9:46 am with the Assistant Manager AAA of __ Laboratory stated the manager has been communicating with the IDON and the ADON regarding the issues with testing not being performed Level of Harm - Minimal harm or as ordered by the physician. She stated one of the problems was the facility was not using the Specimen Log potential for actual harm correctly when a lab test was ordered by the physician. She stated the log must be completed with the resident's name, room number and the test to be completed. She stated the phlebotomists have been Residents Affected - Few instructed to make a copy of the log for record keeping. She stated the logs were not completed with the information.

An interview on 3/4/2025 at 4:00 pm, the IDON confirmed the physician order for laboratory test for Resident R1's and Resident R29's blood work was not obtained. She stated the facility did meet with the laboratory manager regarding

the lab process. She stated the staff were being re-educated on the lab process to ensure that the physician orders were being completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0729 Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Level of Harm - Minimal harm or potential for actual harm 38997

Residents Affected - Few Based on record review, staff interviews, and review of the facility's policy titled, Abuse, Neglect and Exploitation of Residents and the Human Resource Director Job description, the facility failed to ensure that one of six employee files selected for review had evidence they were verified with the State of Georgia's Nurse Aide Registry.

Findings include:

Review of the facility's policy titled Abuse, Neglect and Exploitation of Residents with a review date of 10/24/2022 revealed under IV. Procedure: A. Seven Components of Prevention and Detection: 1. Screening:

The facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs: CNA Registry is contacted to confirm the aides' enrollment and status on the registry.

Review of the facility's Human Resource Director Job description revealed: Pre-Employment Functions: Conduct reference checking, abuse registry checks, and certification/ licensure checks (if applicable), prior to giving job offer.

During a record review of the employee files revealed the facility could not locate an employee file for CMAT (Certified Medication Administration Tech) LL.

An interview on 2/19/2025 at 3:30 pm with the Human Resource Director (HRD) while reviewing the selected employee files revealed that the HRD stated she could not locate an employee file for CMAT LL. The Human Resource Director stated she could not locate an identification, hire date, timecard, separation notice, a certification for a CNA (Certified Nursing Assistant), or CMAT that was requested by the surveyor. The HRD stated a search was done on the Georgia CNA registry and CMAT LL had no certifications in the name she provided to the facility.

An interview on 2/25/2025 at 4:44 pm with the Regional Human Resource/Payroll Director II confirmed that CMAT LL did not have an employee file and could not be located on the CNA registry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 38997 minimal harm Based on observation and staff interviews, the facility failed to have up-to-date facility staffing information Residents Affected - Some posted on 2/11/2025. On 2/12/2025, the staffing information posted was unreadable. In addition, the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months.

Findings include:

An observation on 2/11/2025 at 10:50 am upon the surveyor entering the facility revealed staffing information was not posted in a prominent place readily accessible to residents and visitors.

An observation on 2/12/25 at 9:47 am staffing information was not posted in a prominent place readily accessible to residents and visitors.

An observation and interview on 2/12/2025 at 12:25 pm with the Staffing Coordinator stated she was responsible for posting the staffing information. The staffing Coordinator stated the staffing information was posted at the Receptionist desk. An observation with the Staffing Coordinator of an 8-inch x 11-inch white piece of paper, in landscape view, with dark print was posted at the receptionist area. The Staffing Coordinator confirmed the print was so small that she was unable to read the writing.

An observation and interview on 2/12/2025 at 12:30 pm with an Employee VV in the receptionist area. Employee VV confirmed that the writing on the 8-inch x 11-inch white piece of paper in landscape view with dark print posted at the receptionist area was too small to read.

An observation and interview on 2/12/2025 at 12:35 pm with the Staffing Coordinator revealed she did not keep the posted staffing information. She stated she removed the posted staffing information and discarded

the sheet. The Staffing Coordinator stated she was not aware that the posted staffing information should be available for surveyor's review for eighteen months.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997 potential for actual harm Based on staff interviews and review of the facility's policies titled, Nursing Care Center Pharmacy Policy and Residents Affected - Many Procedure Manual, Facility Assessment and Rules and Regulations of the State Of Georgia, the facility failed to provide evidence of implementation and maintenance of an effective training program for three of thirty Certified Medication Aide Techs (CMAT LL, CMAT MM, and CMAT NN) selected for review of their medication administration skills competency check off. The deficient practice had potential to adversely affect

the care given to all residents in the facility. The facility census was 208 residents.

Review of the facility's Nursing Care Center Pharmacy Policy and Procedure Manual dated January 2024 revealed under Consultant Pharmacist Services Provider Requirements: Observe medication administration pass as outlined in the contract to assist in the assessment and improvement in nursing staff medication administration and submit a report to nursing administration.

Review of the Facility assessment dated [DATE REDACTED] revealed a listed acuity - diseases, conditions and treatments, cognitive, mental, and behavioral status, cultural, ethnic, and religious factors which the facility is equipped to care for. Staffing plan: 3.2. staffs the facility to meet the needs of its resident population. Listed below is the facility's general approach to staging to ensure they have sufficient staff to meet the needs of

the residents at any given time. The following tables provide a snapshot of the staffing needed to meet this expectation and resident acuity: Certified Nursing Assistants & Medication Technicians 20 per day/average. Staff training/education, competencies, and required skill sets: 3.4. The facility has a variety of training/educational requirements and opportunities for staff. The facility maintains and reviews no less than annually a listing of required training for all staff, as well as department-specific training requirements. Medication administration - injectable, oral, subcutaneous, topical.

Review of the Rules and Regulations of the State Of Georgia Subject 111-8-56 Nursing Homes Rule 111-8-56-.01 Definitions (bb) Certified Medication Aide is a person who is a Georgia certified nurse aide and

in good standing with the department who has successfully completed a state-approved medication aide training program, successfully passed a written competency examination and has demonstrated the requisite clinical skills to serve as a medication aide and who is registered on the Georgia Certified Medication Aide Registry. Rule 111-8-56-.04 Nursing Services: (f) A nursing home that employs one or more certified medication aides to administer medications in accordance with this code section shall ensure that each certified medication aide receives ongoing medication training as prescribed by the department. A registered professional nurse or pharmacist shall conduct quarterly unannounced medication administration

observations and report any issues to the nursing home administrator. (g) A nursing home that employs certified medication aides the nursing home shall annually conduct a comprehensive clinical skills competency review of each certified medication aide employed by such nursing home.

The surveyor requested completed clinical staff skill competency check offs for CMAT LL, CMAT MM, and CMAT NN from the facility. They were not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 115129 Department of Health & Human Services Printed: 09/07/2025 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 03/04/2025

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 0940 An interview on 2/19/2025 at 3:30 pm with the Human Resource Director (HRD) while reviewing the selected employee files revealed the HRD stated CMAT LL's employee file could not be located. She stated there was Level of Harm - Minimal harm or not a skill competency check off for CMAT MM and CMAT NN in the employee's file. potential for actual harm

An interview on 2/20/2025 at 9:56 am with CMAT BBB stated she has worked as a CMAT for the past year. Residents Affected - Many The CMAT stated she does not recall signing a skill competency check off.

An interview on 2/25/2025 at 4:44 pm with the Regional Director of Human Resource and Payroll confirmed that CMAT LL's employee file could not be located. She also confirmed there were no skills competency check offs in CMAT MM's or CMAT NN's employee file.

An interview on 2/28/2025 at 11:05 am with the Consultant Pharmacist CCC revealed she did not observe medication pass with the CMATs. She stated if the facility wanted her to observe a medication pass, it was done upon request with a fee. She stated an observation of a medication pass would be something the Nurse Consultant would conduct. The Consultant Pharmacist stated she would have the Nurse Consultant call the surveyor. There was no follow up from the nurse consultant.

Administrator CC was unavailable for an interview.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 115129