Perimeter Rehabilitation Suites By Harborview

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

email was sent due to it was not sent from her email address.During an interview on 12/17/2025 at 11:03 am, the Administrator stated, Nursing has a consent to treat form that should be signed upon admission in

the physical chart.During an interview on 12/17/2025 at 1:01 pm, the [NAME] President of Operations (VPO) stated, The resident's consent for treatment and admission packet was not signed at admission. The packet was created on 11/6/2025. The admissions person, who was responsible, resigned from the position at the time of admission. There is no paper consent to treat form signed. There is no documentation that the resident/representative was informed of the resident's rights or benefits and costs.

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perimeter Rehabilitation Suites by Harborview

5470 Meridian Mark Road, Bldg E Atlanta, GA 30342

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

resident interviews, and further investigation showed no additional residents had been affected by FT1. The Administrator stated it was against facility policy for staff to request money or gifts from residents, and it was considered exploitation/abuse.

Residents Affected - Few

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

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perimeter Rehabilitation Suites by Harborview

5470 Meridian Mark Road, Bldg E Atlanta, GA 30342

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 0606

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Level of Harm - Minimal harm or potential for actual harm

Based on interviews, document review, and review of the policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three staff, Floor Technician (FT) (FT1), completed and documented a criminal background history, including a history of abuse, neglect, or exploitation, before employment. This failure had the potential to contribute to a substantiated allegation of exploitation for a facility resident (R) (Resident R6). Findings included:A review of the facility's Abuse, Neglect and Exploitation policy dated 7/15/2025 revealed, The components of the facility abuse prohibition plan are discussed herein:I. ScreeningA.

Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.1. Background, reference, and credentials checks shall be conducted on potential employees,contracted temporary staff, students affiliated with academic institutions, volunteers, andconsultants.2. Screenings may be conducted by the facility itself, a third-party agency, or an academic institution.3. The facility will maintain documentation of proof that the screening occurred.A review of the Final Report dated 5/15/2025 regarding the investigation of an allegation of exploitation by Resident R6, provided in

the incident folder, revealed that Resident R6 alleged that FT1 sent text messages to her asking for money. The investigation also included screenshots of Resident R6's text messages confirming that FT1 requested money. The allegation of exploitation was substantiated, and FT1 was terminated.A review of the personnel file for FT1 provided by the Administrator revealed a hire date of 3/27/2024. There was no evidence of a criminal background check or reference checks before employment. The file indicated that two reference checks were attempted on 3/19/2024; however, not completed.During an interview on 12/17/2025 at 1:04 pm with

the Administrator, who served as the facility's Abuse Prevention Coordinator, confirmed that he was unable to locate a background check on FT1, and the only evidence of reference checks was the two that were not completed.Cross-reference F-F602: Free from Misappropriation/exploitation

Residents Affected - Few

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

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perimeter Rehabilitation Suites by Harborview

5470 Meridian Mark Road, Bldg E Atlanta, GA 30342

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

During an interview on 12/18/2025 at 4:02 pm, Assistant Director of Nursing (ADON) 2 stated that he was not at the facility but was informed by LPN9 that Resident R28 was found in the day room, foaming at the mouth.

ADON2 said that he communicated with LPN9 during the incident. He said the resident was given oxygen, and his neuros were taken. ADON2 said that paramedics came quickly. He said they did a follow-up and found out Resident R28 had a cervical fracture. ADON2 said that he had talked to other residents, but no one could explain what had happened. He said that the facility did not know. ADON2 stated that the Administrator would follow up with any reported events to the SA.

During an interview on 12/18/2025 at 4:45 pm, the Director of Nursing (DON) stated that the facility staff called and told her what happened with Resident R28. She stated that the facility reviewed the incident the next day.

She said that it was determined that Resident R28 had been in the day room when it happened. She confirmed he was a frequent faller. She said that it looked like Resident R28 might have had seizure activity, but there was no way to know if he had the fall or the seizure first before the injury.

During an interview on 12/18/2025 at 5:00 pm, the Administrator stated that when he was notified of a resident going to the hospital, he submitted a Facility Incident Report Form to the SA. The Administrator said that he would use the resident's record and then document what happened in the report. Upon reviewing the resident's record of the incident and the subsequent Facility Incident Report Form submitted to the SA, the Administrator confirmed that they did not correspond. He said he was not sure why he documented the date of the fall as 10/7/2025, and that it was witnessed. He stated that if he had known it was unwitnessed, he would have done an investigation as an injury of unknown origin.

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

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perimeter Rehabilitation Suites by Harborview

5470 Meridian Mark Road, Bldg E Atlanta, GA 30342

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

did not code the UTI on the quarterly MDS assessment for Resident R20. The MDS Coordinator stated he was trained to code a UTI if the resident had a UTI while in the facility. The MDS Coordinator stated that he used

the RAI Manual when coding the assessments and received training on calls monthly held by the Regional MDS Coordinator. During an interview on 12/18/2025 at 2:34 pm, the [NAME] President (VP) of Clinical Reimbursement stated the MDS Coordinators were trained to code a UTI when the resident was diagnosed and treated for a UTI in the hospital within the last 30 days. The VP of Clinical Reimbursement stated she expected the staff to follow the RAI Manual and accurately code the MDS assessments. The VP of Clinical Reimbursement indicated she had regional MDS coordinators over the facilities, and they had not started auditing MDS assessments for accurately coding the UTIs yet. During an interview on 12/18/2025 at 1:29 pm, the Administrator stated he expected staff to code the MDS assessments correctly according to the RAI Manual.

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perimeter Rehabilitation Suites by Harborview

5470 Meridian Mark Road, Bldg E Atlanta, GA 30342

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

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

confirmed the radiologist faxed the X-ray result at 9:02 pm on 9/2/2025. During a telephone interview on 12/18/2025 at 1:04 pm, LPN4 stated the expectation was that the nurse on the night shift would retrieve faxes from the fax machine, as there was one on each floor, and follow up immediately by calling the physician for any critical results. LPN4 stated that sometimes, however, she was unable to get to the faxes

on the night shift because she was so busy taking care of the residents, and in that case, the ADON would look at the faxes when she came in the next day. LPN4 stated she had not worked at the facility in months and did not recall this specific resident or situation. During an interview on 12/19/2025 at 12:05 pm, the Director of Nursing (DON) stated her expectation was that the nurse on duty receive a fax and notify the physician of the results at the time. During a follow-up interview on 12/19/2025 at 12:30 pm, the DON stated she was unable to find any evidence of physician notification of Resident R4's hip arthroplasty dislocation from

the time of the fax on 9/2/2025 at 9:02 pm to the time of documented physician notification at 2:01 pm. The DON stated she had noticed there was a delay in notification and subsequently sending Resident R4 to the hospital.

The DON stated there was no incident report or investigation into this incident.

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

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Perimeter Rehabilitation Suites by Harborview

5470 Meridian Mark Road, Bldg E Atlanta, GA 30342

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

above the stairway door, but the door was locked with a special locking arrangement and did not open or sound an alarm. The exit door near 225, leading to a stairway, opened in 15 seconds with pressure, as did

the exit door near 249. The cross corridor exits access doors near 205 also opened in 15 seconds (no sign,) each with special locking arrangements. These two doors were also accessed by using special knowledge or a code. The two elevator doors used for residents also lock when a wander guard sensor is near and alarm when the doors open, as well as the service elevator near bedroom [ROOM NUMBER]. A code pad was also at each elevator.Further interview with [NAME] on 11/19/2025 at 9:30 am revealed that

a contractor unlocked the exit discharge door about two weeks ago to work on an exterior wooden fence in

the area. He must not have relocked the door when he was finished. When asked by the [NAME] if the contractor had a key, he stated, No, he would have to get the key from the facility and relock through a key with the facility.

Event ID:

Facility ID:

If continuation sheet