Sadie G. Mays Health & Rehabilitation Center

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997

Residents Affected - Few Based on observation, record review, interviews, and facility policies, the facility failed to ensure two of 19 residents (R) (Resident R6 and Resident R15) weren't provided with nursing care and services to ensure their medical needs were met related to pain management for Resident R6 and Resident R15; administering medication without a physicians order for Resident R15; and a pest infestation of gnats that were on the Resident R6 left leg wound. Further, harm was identified to have occurred when Resident R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate.

Findings included:

A review of the facility policy titled Administering Medications dated April 2019 that medications are administered in a safe and timely manner, and as prescribed; only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions; medications are administered in accordance with prescriber orders, including any required time frame; if a dosage is believed to be inappropriate or excessive for a resident, or medication has been identified as having potentially adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns; and the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

A review of the facility policy titled Pain Assessment and Pain Management dated October 2022 revealed that the purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; d. Addressing the underlying causes of the pain.

Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: a. musculoskeletal conditions: (1) degenerative joint disease; (2) rheumatoid arthritis. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.

A review of the facility policy titled Pressure Ulcer/Skin Breakdown, with a revision date of April 2018, revealed that the physician will assist the staff in identifying the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. The physician will help identify and define any complications.

A review of the facility policy titled Pest Control dated May 2008 revealed that the facility shall maintain an effective pest control program. Policy Interpretation and Implementation. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 1. A review of the Admission Record for Resident R15 revealed she was admitted to the facility on [DATE REDACTED] and diagnoses of, but not limited to major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified Level of Harm - Actual harm dementia, severe, with other behavioral disturbances.

Residents Affected - Few A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) was assessed as 00 which indicated severe cognitive impairment; no mood or behavior exhibited; that Resident R15 required supervision/touching assistance with Activities of Daily Living (ADL) care; was independent with mobility requiring no mobility device; was receiving a scheduled pain medication; and not receiving any PRN (as needed) pain medication.

A review of the care plan updated 6/4/2024 revealed that Resident R15 is care planned for pain related to left knee diagnosis of osteoarthritis and low back pain. Interventions to be implemented included administering medications for the lower back and left knee as ordered. Monitor and document effectiveness every shift.

An observation on 6/18/2024 at 11:25 am revealed Resident R15 lying in bed with the covers bunched up around her waist. The resident was gripping the covers and grimacing. The resident's bilateral knees were observed to be swollen and the resident appeared to be in pain and discomfort. During the observation, the Licensed Practical Nurse (LPN) NN and a family member entered the room. The family member stated that both of Resident R15's knees were swollen on the previous day as well (6/17/2024) and that Resident R15 would not allow the family to touch her knees. The family was observed to ask Resident R15 if she could touch her knees and promised to be gentle and Resident R15 gave permission. The family stated that Resident R15's left knee was warm to the touch. The LPN asked Resident R15 if she would like something for pain and the resident nodded her head up and down. The LPN stated that Resident R15 did not have an as-needed oral pain medication and would call the Nurse Practitioner (NP) regarding Resident R15's pain.

During an interview on 6/18/2024 at 11:40 am, LPN NN stated the NP gave an order for Tylenol for Resident R15. The LPN explained to Resident R15 that she had something for the pain. LPN NN was observed to administer two tablets of Tylenol 325 mg (milligrams) to Resident R15 by mouth (PO). The resident took the medication without any problems.

During the reconciliation of the medication pass, there was no physician order for Tylenol 325 mg, two tablets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 A phone interview on 6/18/2024 at 10:33 am with the family of Resident R15 stated they have filed several grievances with the facility regarding Resident R15's care and services. The family expressed that their most recent concern when Level of Harm - Actual harm they visited Resident R15 on 6/17/2024 was that Resident R15 looked weak, sick, and was moaning and crying. The family stated something was going on with Resident R15 because Resident R15 was usually up walking without any type of assistive Residents Affected - Few device and was usually attending activities. The family stated that Resident R15 had been complaining of knee pain and this was reported to the charge nurse. The family stated the nurse applied Diclofenac Sodium ointment to both knees. The family stated the ointment is routine, the pain in the knees is different and no one bothered to notify the physician asking for something else for pain. The family stated the facility is quick to notify the family when Resident R15 is combative and refusing medication, but no one notified the family that Resident R15 had been in the bed lethargic, with a low-grade temperature (99.0 Fahrenheit), unable to stand or walk, and not her usual self. The family stated the nurse or Certified Nursing Assistant (CNA) should have taken notes, assessed Resident R15, and notified the physician, NP, and/or psychiatrist of Resident R15's change. The family stated there was a meeting with the Social Worker, Unit Manager (UM), and the Psychiatrist but could not give the exact date of the meeting. She stated that the Psychiatrist explained that he would discontinue the Citalopram (Celexa) and start Escitalopram (Lexapro). The family stated he gave the UM instructions during the phone conference to have the nurses document and notify him of any adverse reactions (i.e. overly sedated). The family stated they noticed a change in Resident R15 after the most recent medication change was made by the psychiatrist. She stated that on 6/17/2024 the family visited and Resident R15 appeared to be overly sedated, but the psychiatrist was not notified. The family stated she understood that Resident R15 has dementia but what was going on with her was different and not related to the diagnosis of dementia.

An interview on 6/18/2024 at 11:20 am with CNA DDD stated that Resident R15 was usually up, dressed, and attending the facility's activities. She stated that today, Resident R15 was limping when assisted with ADL care. She stated that Resident R15 complained of knee pain. The CNA stated that she did let the charge nurse know that Resident R15 complained of pain but did not give a reason why she did not inform the nurse.

An observation of Resident R15's medication administration on 6/20/2024 at 10:19 am with LPN NN the following medications were administered to Resident R15:

Amlodipine Besylate (Norvasc) 5 mg 1

Aspirin 81 mg 1 over-the-counter (OTC)

Depakote sprinkle 125 mg 1 (placed in water)

Diclofenac Sodium External Gel (applied to the right and left knee)

Escitalopram (Lexapro) 5mg/5 milliliters (ml)

Fluoxetine (Prozac) 10 mg 1

Metformin 500 mg 1

Methimazole 5 mg 1

Metoprolol Succinate Extended Release (ER) 50 mg 1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 Multiple Vitamins 1 OTC

Level of Harm - Actual harm Omeprazole 20 mg 1

Residents Affected - Few Potassium Chloride ER 10 milliequivalent 1

Prednisone 10 mg 1

The resident looked inside the medication cup before taking the medications and shook her head to the left and right. The nurse explained what was in the cup and with multiple prompts the resident took the medication and drank two 8-ounce glasses of water.

During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg.

A review of the care plan updated 6/4/2024 revealed that Resident R15 is care planned for depression and insomnia with intervention to administer antidepressant medications as ordered; monitor for a decline in ADL self-care and gait changes; and to notify the physician of the findings.

A review of the Physician Order dated 6/29/2023 revealed discontinuation of Fluoxetine (Prozac) 10 mg. Discontinue Order ePrescription sent successfully 6/29/2023 3:25 pm to pharmacy. Ordered signed by the Medical Director.

An interview on 6/20/2024 at 2:35 pm with LPN NN confirmed that the Fluoxetine (Prozac) 10 mg capsule is

a medication that is in Resident R15's strip pack. The LPN stated on the days that she works Fluoxetine (Prozac) is administered to Resident R15. The LPN, with the assistance of the Assistant Director of Health Services, could not locate a physician order for the medication. The LPN checked the remaining strip packs on the cart and the Fluoxetine (Prozac) is one of the medications in the individual strip packs. The LPN stated she would talk to her Director of Health Services (DHS) immediately.

A phone interview on 6/20/2024 at 3:35 pm with the Psychiatrist EEE regarding Resident R15's medication. The Psychiatrist stated it is dangerous to give a person two selective serotonin reuptake inhibitors (SSRIs) due to

it causing serotonin syndrome. He stated it can cause insomnia, poor appetite, agitation, or restlessness. He stated that he was called in on consult 6/28/2023 to see Resident R15. He stated that Prozac was discontinued due to being a potentially harmful drug in the elderly. He stated that Resident R15 was started on Escitalopram (Lexapro) on 6/28/2023. He stated because the resident continued to have a decline, he discontinued Escitalopram (Lexapro) and started Citalopram (Celexa). He stated a few weeks ago he had a conference call with the UM and family. He stated the family expressed that Resident R15 was continuing to decline. He stated he discontinued the Citalopram (Celexa) and restarted the Escitalopram (Lexapro). He stated the UM was instructed at that time to notify him of any changes or behaviors Resident R15 may have. The Psychiatrist stated if the Prozac was never stopped that would explain the resident's continued decline. He stated that receiving two SSRIs (Fluoxetine (Prozac) and Escitalopram (Lexapro) is not good.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 6/21/2024 at 12:36 pm with the Pharmacist stated pharmacy has been dispensing a daily dose of Fluoxetine (Prozac) 10 mg from 7/28/2023-6/20/2024. The Pharmacist stated the first time they Level of Harm - Actual harm received an order to discontinue the medicine was on 6/20/2024. The pharmacist confirmed that the Fluoxetine (Prozac) was not on the resident's profile although it is being dispensed. She stated that the Residents Affected - Few pharmacy has started pulling the resident's medication profile and comparing it with the framework of the APP machine that automatically dispenses the medications. She stated that currently, the pharmacy reconciles each patient's profile in the Electronic Medical Record system. She stated the pharmacy department is willing to go to the facility and do a complete cart audit. She stated what happened was not purposely done, it was an accident.

An interview on 6/25/2024 at 4:58 pm with UM JJ stated the pharmacy delivers a strip pack of medications approximately every seven days. She stated the medications arrive on the 11: 00 pm to 7:00 am shift. The UM stated it is the responsibility of the nurse to verify the medications in the strip packs with the resident's Medication Administration Record (MAR) before the strip packs of medication are placed on the cart. She stated the physician should be notified for clarification if there are any discrepancies. The UM stated if a medication is in the strip pack and not on the resident's MAR the medication should not be given. She stated

the physician should be notified for clarification.

An interview on 6/25/2024 with the DHS stated that she expects the nurses to administer medication safely as prescribed by the physician. She stated she has started a skills check-off on medication administration for all the nurses. She stated the nursing staff has also started a facility-wide cart audit.

2. An observation and interview on 5/2/2024 at 11:30 am of Resident R6 who was lying flat in the bed (B), the room was dark. The resident's mood was blunted, affect was sad. An observation of Resident R6's right hand, left hand and fingers has a deformity. The resident had a white sheet covering his waist down to the upper part of his left leg. An observation of black gnats flying around and lying on the left leg. The Resident had a dressing on the left leg from the knee to the ankle dated 5/1/2024. The dressing was covered with a large amount of reddish-brown drainage. The resident was pleasant and agreed to speak with the surveyor. The resident stated he has bad Rheumatoid Arthritis in his fingers and shoulders that are painful. The resident stated he has never been seen by therapy for any type of braces on his hands or fingers. The resident stated he must ask for his pain medication because it is not a regularly scheduled medication. The resident stated the physician or nurse practitioner had never asked if he needed his oral pain medicine scheduled. During the interview, Resident R6 stated he has had a vascular wound on his left leg for a long time. The resident stated gnats have always been a problem in the room.

An observation on 5/3/2024, 5/7/2024, and 5/8/2024 of black gnats flying around and lying on Resident R6's left leg.

The Resident had a dressing on the left leg from the knee to the ankle the dressing was saturated with a large amount of reddish-brown drainage.

A review of Resident R6 Admission Record revealed an admitted [DATE REDACTED] with multiple diagnoses of, but not limited to, chronic pain, gout, and rheumatoid arthritis (RA).

A review of the quarterly MDS assessment dated [DATE REDACTED] revealed Resident R6 presented with a BIMS score of fifteen, which indicated Resident R6 was cognitively intact. The assessment further indicated the resident had a regularly scheduled pain medication and an as-needed pain medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 A review of the care plan updated 10/31/2024 revealed that Resident R6 was care planned for rheumatoid arthritis. Interventions to be implemented included monitoring, documenting, and reporting to the physician as needed Level of Harm - Actual harm signs and symptoms or complications related to arthritis: joint pain, joint stiffness, contracture formation, and joint shape changes. Residents Affected - Few

A review of the Order Summary Report revealed an order for Oxycodone 10 mg every six hours as needed for pain related to chronic pain on 8/1/2023.

A review of the Order Summary Report revealed an order for Tylenol 325 mg two every six hours as needed for chronic pain syndrome on 8/1/2023.

A review of the Order Summary Report revealed an order for Diclofenac Sodium External Gel 1%. Apply half inch to shoulders topically four times a day, for seropositive rheumatoid arthritis on 3/27/2024.

A review of the MAR for 4/1/2024 to 4/30/2024 revealed that Resident R6 had a documented pain level of seven to nine on fifteen occasions. The resident requested and was given Oxycodone 10 mg 57 times. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication.

A review of the MAR for 5/1/2024 to 5/3/2024 revealed that Resident R6 had a documented pain level of five to eight.

The resident requested and was given Oxycodone 10 mg five times out of three days. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication.

During an interview on 5/7/2024 at 10:48 am, the Occupational Therapist (OT) stated the therapy department has never had Resident R6 on caseload for hand braces. The OT explained that Resident R6's right hand metacarpophalangeal (MCP) joint, also known as the knuckle, hyper flex, the proximal interphalangeal joint (PIP) that bends and extends the fingers is hyperextended, the distal interphalangeal (DIP) close to the fingernail is hyper flexed.

The left-hand MCP is hyper-flexed, the PIP is flexed, and the DIP is hyper-flexed. The Therapist stated that Resident R6 hands/fingers have a lot of inflammation that can be painful and cause discomfort.

During an interview and observation on 5/8/2024 at 10:20 am of Resident R6's wound, the Wound Care Physician confirmed the gnats on the resident's left leg dressing and the drainage. He stated the wound had a lot of moisture and that was attracting the gnats to the left leg. The Wound Care Physician stated he had seen gnats in the room on previous visits.

During an interview on 5/9/2024 at 11:50 am, LPN OO stated that for the last two years, the facility had been having problems with gnats. LPN OO stated she had never reported the gnats to anyone, and she did not realize they were in Resident R6's room that bad until the surveyor brought it to her attention.

During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to

the Maintenance Department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed. She stated that Resident R6 was more relaxed since his pain medication had been Level of Harm - Actual harm adjusted.

Residents Affected - Few A review of the MAR for 4/1/2024 to 4/30/2024 revealed that Resident R6 had a documented pain level of seven to nine on fifteen occasions. The resident requested and was given Oxycodone 10 mg 57 times. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication.

A review of the MAR for 5/1/2024 to 5/3/2024 revealed that Resident R6 had a documented pain level of five to eight.

The resident requested and was given Oxycodone 10 mg five times out of three days. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication.

During an interview on 5/7/2024 at 10:48 am, the Occupational Therapist (OT) stated the therapy department has never had Resident R6 on caseload for hand braces. The OT explained that Resident R6's right hand metacarpophalangeal (MCP) joint, also known as the knuckle, hyper flex, the proximal interphalangeal joint (PIP) that bends and extends the fingers is hyperextended, the distal interphalangeal (DIP) close to the fingernail is hyper flexed.

The left-hand MCP is hyper-flexed, the PIP is flexed, and the DIP is hyper-flexed. The Therapist stated that Resident R6 hands/fingers have a lot of inflammation that can be painful and cause discomfort.

During an interview and observation on 5/8/2024 at 10:20 am of Resident R6's wound, the Wound Care Physician confirmed the gnats on the resident's left leg dressing and the drainage. He stated the wound had a lot of moisture and that was attracting the gnats to the left leg. The Wound Care Physician stated he had seen gnats in the room on previous visits.

During an interview on 5/9/2024 at 11:50 am, LPN OO stated that for the last two years, the facility had been having problems with gnats. LPN OO stated she had never reported the gnats to anyone, and she did not realize they were in Resident R6's room that bad until the surveyor brought it to her attention.

During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to

the Maintenance Department.

During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed. She stated that Resident R6 was more relaxed since his pain medication had been adjusted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997

Residents Affected - Many Based on record review, staff interviews, and the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal the facility failed to ensure that two Certified Nursing Assistance (CNA) certifications were renewed out of ten employee files selected for review. One CNA TT worked six months with an expired certification and CNA UU worked thirty days with an expired certification. The facility's census was one hundred and fifty-five residents.

Findings included:

A review of the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal revealed that to remain on the Registry and to be eligible to work in a licensed Medicaid & Medicare facility, you must meet

the requirements for Re-Certification. Failure to return the Application for Renewal as a Certified Nurse Aide will result in your name being removed from the Georgia Nurse Aide Registry and will not be eligible to work as a nurse aide by a licensed Medicaid facility.

1. A review of CNA TT's employee file revealed the original certification date of [DATE REDACTED]. The employee certification expired on [DATE REDACTED]. The employee worked twenty-two weeks before the facility identified that the employee's certification had lapsed. The employee certification was not renewed until [DATE REDACTED].

During an interview on [DATE REDACTED] at 10:27 am, CNA TT stated that the facility has a person who usually reminds the staff when certification needs to be renewed. The CNA stated she was not sure what happened last year and why she did not receive a reminder. She stated she worked for several months without her certification being renewed and as soon as the facility realized the certification needed to be renewed, it was taken care of.

2. A review of CNA UU's employee file revealed an original certification date of [DATE REDACTED]. The employee certification expired on [DATE REDACTED]. The employee worked four weeks before the facility identified that the employee's certification had lapsed. The employee certification was not renewed until [DATE REDACTED].

During an interview on [DATE REDACTED] at 12:30 pm, CNU UU confirmed that she did work for about a month without her certification being renewed. She stated as soon as it was discovered the facility assisted her with getting

the certification renewed.

During an interview on [DATE REDACTED] at 10:47 am, the Human Resources Director (HRD) confirmed that CNA TT worked for six months without her certification being renewed. She stated CNA UU worked for approximately one month without her certification being renewed. The facility identified that both employees' certifications had lapsed on [DATE REDACTED]. She stated when the issue was identified, both CNAs were pulled from resident care until their certification was updated. The HRD stated previous Education Coordinator was responsible for ensuring the license and certifications were updated and was not performing their job duties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997 Residents Affected - Few Based on observation, record review, staff interviews, and the facility policy Administering Medications the facility failed to ensure one of forty-three sampled residents (R) (Resident R15) was receiving medications as prescribed by the psychiatrist. The pharmacy continued to dispense Fluoxetine (Prozac) to Resident R15 after it was discontinued on 6/29/2023 by the psychiatrist. Harm was identified to have occurred when Resident R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate.

Findings included:

A review of the facility policy titled Administering Medications dated April 2019 revealed that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services (DNS) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

During an observation of Resident R15's medication administration on 6/20/2024 at 10:19 am with a Licensed Practical Nurse (LPN) NN, the following medications were observed to be administered to Resident R15:

Amlodipine Besylate (Norvasc) 5 milligrams (mg) 1

Aspirin 81 mg 1 over-the-counter (OTC)

Depakote sprinkle 125 mg 1 (placed in water)

Diclofenac Sodium External Gel (applied to the right and left knee)

Escitalopram (Lexapro) 5mg/5 milliliters (ml)

Fluoxetine (Prozac) 10 mg 1

Metformin 500 mg 1

Methimazole 5 mg 1

Metoprolol Succinate Extended Release (ER) 50 mg 1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0755 Multiple Vitamins 1 (OTC)

Level of Harm - Actual harm Omeprazole 20 mg 1

Residents Affected - Few Potassium Chloride ER 10 milliequivalent 1

Prednisone 10 mg 1

During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg.

A review of the Admission Record for Resident R15 revealed she was admitted to the facility on [DATE REDACTED] with diagnoses of, but not limited to, major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances.

A review of the Psychiatrist Progress Note dated 6/28/2023 revealed that Resident R15 was seen for initial psych evaluation and ongoing management of symptoms related to cognitive impairment/behaviors. Coordination of Care: Discussed with nursing, discussed with social services, reviewed medications, reviewed chart, discussion of medication side effects. Psychotropic medication (include dosage, frequency): Prozac 10mg by mouth (PO) every am for depression, Trazodone 50mg PO every night for sleep, Melatonin 3 mg PO every night for sleep, Depakote DR 125mg PO twice a day for mood/agitation. Recommendations for Primary Care Physician/Facility Staff: will stop Prozac and start Resident R15 on Lexapro solution 10 mg PO every morning for agitated dysphoria.

A review of the Physician Order dated 6/29/2023 revealed discontinuation of Fluoxetine (Prozac) 10 mg. Discontinue Order ePrescription Sent Successfully 6/29/2023 3:25 pm to the pharmacy. The order was signed by the Medical Director.

A review of the Pharmacy Medication Regimen Review for July 2023 through May 2024 revealed the pharmacist conducted monthly reviews. There were no pharmacy recommendations for Resident R15 and/or Fluoxetine (Prozac).

A review of the Pharmacy Med Room, Med Cart & Nursing Station Inspection Report conducted by the Pharmacy Nurse Consultant from 9/8/2023 to 6/3/2024 revealed the nurse consultant conducted monthly medication cart audits twice a month. There was no documentation of a medication cart audit for Resident R15.

During an interview on 6/25/2024 at 1:00 pm, the Executive Director stated in August 2023 the facility was transitioning from one pharmacy to the current pharmacy. She stated that the current pharmacy physically picked up all the resident physician orders on or around 6/23/2023. She stated that the nursing staff were educated to fax all orders after 6/23/2023 to both pharmacies. She stated that Resident R15 order to discontinue the Fluoxetine (Prozac) was on 6/29/2024 and should have been faxed to both pharmacies. The Executive Director stated the pharmacy did not reconcile Resident R15's medication orders. She stated that the facility has started a medication cart audit, and the pharmacy is in the process of also completing a facility-wide medication cart audit. The medication cart audit is to ensure that residents are getting the medications as ordered by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0755 A post-survey telephone interview on 6/27/2024 at 1:00 pm with the Pharmacy Nurse Consultant stated onsite visits to the facility are conducted twice a month. She stated she is responsible for medication cart Level of Harm - Actual harm audits. The Nurse Consultant stated during her visits to the facility she does not audit every resident medication cart. She stated the medication cart audit is randomly selected. She is aware that the pharmacy Residents Affected - Few continued to dispense a medication for Resident R15 that had been discontinued. The Nurse Consultant stated she has not completed a medication cart audit on Resident R15. She stated that the pharmacy has planned to come in on Friday 6/28/2024 and complete a facility-wide medication cart audit on the residents that are currently in the facility.

Cross-refer to F-Tag 684 and 757

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997

Residents Affected - Few Based on interviews, record review, and review of facility policy titled Administering Medications, the facility failed to ensure one of two residents (R) (Resident R15) was free from unnecessary psychotropic medications. Resident (Resident R15) was administered Fluoxetine (Prozac) during a medication observation. Harm was identified to have occurred when Resident R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate.

Findings included:

A review of the Admission Record for Resident R15 revealed she was admitted to the facility on [DATE REDACTED] with diagnoses of, but not limited to, major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances.

A review of the resident's most recent quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed a Brief

Interview for Mental Status (BIMS) was assessed as 00 which indicated severe cognitive impairment. Section N Resident R15 was assessed as receiving antidepressants in this assessment period.

An observation of Resident R15's medication administration on 6/20/2024 at 10:19 am with Licensed Practical Nurse (LPN) NN the following medications were administered to Resident R15:

Amlodipine Besylate (Norvasc) 5 milligrams (mg) 1

Aspirin 81 mg 1 (over the counter OTC)

Depakote sprinkle 125 mg 1 (placed in water)

Diclofenac Sodium External Gel (applied to the right and left knee)

Escitalopram (Lexapro) 5mg/5 milliliters (ml)

Fluoxetine (Prozac) 10 mg 1

Metformin 500 mg 1

Methimazole 5 mg 1

Metoprolol Succinate Extended Release (ER) 50 mg 1

Multiple Vitamins 1 (OTC)

Omeprazole 20 mg 1

Potassium Chloride ER 10 milliequivalent 1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0757 Prednisone 10 mg 1

Level of Harm - Actual harm During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg.

Residents Affected - Few A review of the Order Summary Report revealed a physician order dated 1/17/2024 Observe closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of

the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings.

An interview on 6/20/2024 at 2:35 pm with LPN NN confirmed that the Fluoxetine (Prozac) 10 mg capsule is

a medication that is in Resident R15's strip pack. The LPN stated on the days that she works Fluoxetine (Prozac) is administered to Resident R15. She confirmed that the Fluoxetine (Prozac) was not listed on Resident R15's Medication Administration Record (MAR).

An interview on 6/25/2024 at 10:40 am with LPN NN stated she just started in the role as a nurse in February 2024. The LPN stated all her education/in-services have been provided by the staff in the facility. The LPN stated the facility does provide resources (i.e. Drug Handbooks) on each medication cart. She stated in the future she will make sure she is checking the MAR and the medication in the strip packs for accuracy. She stated if it is a question about the residents medication, she will notify the physician or Nurse Practitioner.

The LPN expressed she is open and willing to learn.

An interview on 6/25/2024 at 11:00 am with the Director of Health Services (DHS) stated that LPN NN was hired in 2/2024 and has not had a Medication Pass completed. She stated she would schedule a medication pass with the Pharmacy Nurse Consultant for LPN NN. She stated she would also do random medication passes with the nurses in the facility. She stated the staff will be in-service on medication passes and assess residents who are administered psychotropic medication. She stated the facility is in does not have a Staff Educator and is in the process of hiring someone.

A post-survey telephone interview on 6/27/2024 at 1:00 pm with the Pharmacy Nurse Consultant stated onsite visits to the facility are conducted twice a month. She stated she is responsible for medication passes with the nursing staff. She stated She will conduct a medication pass with the nursing staff that are working

during the time she is in the facility. The Pharmacy Nurse Consultant stated she has not done a medication pass with LPN NN. She stated she and the DHS would arrange to conduct a medication pass with LPN NN.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0757 A review of the facility policy titled Administering Medications dated April 2019 revealed that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this Level of Harm - Actual harm state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related Residents Affected - Few functions. Medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

Cross Refer to F-tag 684 and 755

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws.

Level of Harm - Minimal harm or 38997 potential for actual harm Based on staff interviews, record review, and review of the facility's policies titled Background Screening Residents Affected - Few Investigations and Hiring Process, the facility failed to ensure that one of three staff members (Registered Nurse (RN) HH) had the required licensure to provide nursing care to the residents. The facility census was 150 residents.

Findings included:

A review of the facility policy titled Background Screening Investigations dated April 2021, revealed that any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license.

A review of the facility policy titled Hiring Process dated 1/21/2024 revealed that this policy provides guidance for the hiring of team members. The Human Resources Director is responsible for overseeing all aspects of the hiring process, which includes: Human Resources will obtain copy of two forms of identification and will verify license or certification prior to an offer being made.

A review of the employee files revealed RN HH was hired on 11/3/2023. However, a review of her personnel file revealed the Professional Licensing status of the RN license had lapsed. The lapsed Georgia license was not identified prior to hire by Human Resources staff.

A review of RN HH's Team Member Information revealed she was hired as an RN Supervisor.

A review of RN HH's Time-Card revealed she worked in the facility on 11/2/2023 for 7.67 hours.

In an interview on 5/17/2024 at 10:47 am, the Executive Director, Assistant Executive Director, and Human Resources Director (HRD) revealed the facility was unaware that RN HH's RN license had lapsed at the time of the interview and hire date. The HRD stated the employee only worked one day and did not return. The HRD stated RN HH quit without providing the facility with a notice. The HRD further stated it was her responsibility to conduct the final check of the potential employee's application. She stated she was responsible for checking the applications for completeness, which included initiating the Team Member Information, completing the Employment Eligibility Verification and the I-9 information, verifying professional license and certifications, and ensuring that the criminal background checks and fingerprint records check were completed before the employee began work. The Executive Director stated there were very few controls in place and that the staff that were employed was circumventing the system. She stated that is why

the current HRD was hired to put policies and procedures in place to ensure the facility was following State and Federal requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 38997 potential for actual harm Based on observation, staff interviews, and review of the facility policies titled Cleaning and Disinfection of Residents Affected - Many Resident-Care Items and Equipment, and Administering Medications, the facility failed to maintain infection control standards by not cleaning and disinfecting reusable items between residents, and not performing hand hygiene after assisting a resident and picking paper up off the floor during a medication observation.

The facility census was 150 residents.

Findings included:

A review of the policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of September 2022, revealed that resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. It is further noted that reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, and durable medical equipment).

A review of the policy titled Administering Medications with a revised date of April 2019, revealed that medication is administered in a safe and timely manner, and as prescribed. It is further noted that staff is required to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) during the administration of medications.

During a medication administration observation on 6/20/2024 at 9:52 am, Registered Nurse (RN) SS obtained Resident R19's blood pressure with a wrist blood pressure monitor. RN SS then used the same wrist blood pressure monitor and obtained Resident R6 blood pressure. The wrist blood pressure machine was not cleaned and disinfected after use between residents. As the observation continued, RN SS assisted a resident out of the way by touching the wheelchair. The RN did not perform hand hygiene after this encounter and proceeded to pick up Resident R6's medication and enter the room. While in the room, an item fell off the resident's overbed table onto the floor. RN SS picked the item up off the floor, took Resident R6's blood pressure, and administered the resident's medication. The RN did not perform hand hygiene at all during this observation.

During an interview on 6/20/2024 at 10:00 am, RN SS stated the wrist blood pressure monitor should have been clean after obtaining Resident R19's blood pressure and confirmed that she did not use appropriate hand hygiene during the medication observation.

During an interview on 6/20/2024 at 10:05 am, the Director of Health Services (DHS) stated that the staff should always clean and disinfect resident equipment after use between residents. The DHS stated hand hygiene should be conducted to prevent the spread of germs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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** 38997

Residents Affected - Few Based on record review, staff interviews, and the facility policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents, the facility failed to obtain vaccination consent before administering COVID-19 vaccines on two of five Residents (R) (Resident R1 and Resident R10) reviewed for vaccination status.

Findings included:

A review of the policy titled Coronavirus Disease (COVID-19) - Vaccination of Residents with a revised date of May 2023 revealed the following: Each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated.

The resident's medical record includes documentation that indicates, at a minimum, the following:

a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine including (1) samples of the educational materials used; (2) the date the education took place; and (3) the name of the individual who received the education.

b. Signed consent.

1. A review of Resident R1 Electronic Medical Record (EMR) revealed an admitted [DATE REDACTED] with multiple diagnoses of, but not limited to, chronic diastolic (congestive) heart failure and chronic systolic (congestive) heart failure.

A further review of Resident R1's EMR revealed a Physician Order Report dated 2/3/2021 noting First and Second dose of COVID vaccine to be given.

A review of the Physician Order Report dated 2/24/2021 revealed a second (COVID-19 vaccine) 0.3 milliliters times one dose.

A review of the Physician Order Report dated 4/1/2022 revealed (COVID-19 vaccine) 0.3 milliliters intramuscular once.

A review of the Immunization Report revealed that Resident R1 received a COVID-19 vaccine on 2/3/2021, 2/24/2021, and 4/1/2022. There was no documentation in Resident R1's EMR that vaccination consent before administering COVID-19 vaccines was obtained.

2. A review of Resident R10 EMR revealed an admitted [DATE REDACTED] with multiple diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.

Further Review of Resident R10 EMR revealed a Physician Order Report on 2/3/2021 (COVID-19 vaccine) 0.3 milliliters administered today.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 A review of Resident R10 EMR revealed a Physician Order Report on 12/22/2021 (COVID-19 vaccine) 0.3 milliliters intramuscular once. Level of Harm - Minimal harm or potential for actual harm A review of Resident R10 EMR revealed a Physician Order Report on 12/9/2022 (COVID-19 vaccine) 0.3 milliliters intramuscular once. Residents Affected - Few

A review of the Preventive Health Care document revealed that Resident R10 received a COVID-19 vaccine on 2/3/2021, 12/22/2021, and 12/9/2022. There was no documentation in the EMR that vaccination consent

before administering COVID-19 vaccines was obtained.

During an interview on 6/5/2024 at 11:08 am, the Director of Health Services (DHS) stated education should be provided before a resident receives any vaccine. She further stated that after the education is completed, consent should be obtained before administering the vaccine. The DHS confirmed that Resident R1 and Resident R10 did not have a signed consent form for the COVID-19 vaccines that were administered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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** 38997 potential for actual harm Based on observations, interviews, and a review of the facility's policies titled Pest Control and Maintenance Residents Affected - Some Service, the facility failed to maintain an effective pest control program on one of four units (Unit B) related to

an infestation of black gnats.

Findings included:

A review of the facility policy titled Pest Control dated May 2008 revealed that it is the facility's policy that it shall maintain an effective pest control program. It is noted that the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services.

A review of the facility policy titled Maintenance Service with a revised date of December 2009 states that maintenance service shall be provided to all areas of the building, grounds, and equipment and that the maintenance department will monitor and oversee the pest control program.

1. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed that Resident R6 was admitted to the facility on [DATE REDACTED] and presented with a Brief Interview for Mental Status (BIMS) score of fifteen, indicating that the resident is cognitively intact.

During an observation on 5/2/2024 at 11:30 am, a swarm of live black gnats was observed flying around Resident R6's room. The gnats were observed lying on and flying around his left leg. An outlet with a gnat trapper was observed next to Resident R6's bedside dressers. During an interview with Resident R6 at this time, he stated the gnats had been an ongoing problem and that the Maintenance Department installed a gnat trapper. The resident stated

he was not sure if the gnat trapper was working properly because the gnats were still a concern.

2. An observation on 5/3/2024 at 2:30 pm revealed a massive amount of live black gnats swarming in room B18.

3. An observation on 5/3/2024 at 3:30 pm revealed a massive amount of live black gnats swarming in room B20.

4. An observation on 5/7/2024 at 10:15 am revealed a massive amount of live black gnats swarming in room B10.

5. During an observation on 5/9/2024 at 12:05 pm of the bathroom shared by Room B14 and B16, a massive amount of live black gnats was observed.

During an interview and observation on 5/2/2024 at 2:39 pm with the Executive Director, Assistant Executive Director, and the Environmental Service Director, they all confirmed the plethora of live black gnats on Unit B.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 and observation on 5/3/2024 at 2:35 pm with Unit Manager JJ confirmed that she was aware of the enormous number of live black gnats in room B18. She stated she would notify the Director of Level of Harm - Minimal harm or Health Service and the Maintenance Director immediately. potential for actual harm

During an interview on 5/8/2024 at 1:57 pm, Maintenance Director QQ stated he oversees the pest control Residents Affected - Some program. He stated the pest control company provides service to the building weekly (Wednesday). The Maintenance Director explained the process of how the staff report pests. He stated each unit has a pest control logbook at the nursing station and the staff are required to place the type of pest and where the problem is in the log. He stated the receptionist also has a book that can be used by staff. He stated that he checks the pest control log books daily and treats problem areas as needed in between technician visits. He stated that when the technician arrives, he will check each book, treats the problem areas, and communicates which areas were treated prior to leaving the building. He stated the facility has no issues with pests and the only pests he has seen in the facility are dead roaches. He stated he was unaware that the facility has gnats and that 5/2/2024 was the very first time he was made aware of the gnats in the facility. He stated the pest control company came out today (5/8/2024) and serviced the building.

During an interview on 5/8/2024 at 2:55 pm, Licensed Practical Nurse (LPN) LL stated that she has never heard of a pest control logbook and that she reports all maintenance concerns through the electronic maintenance system.

During an interview on 5/9/2024 at 11:50 am, LPN OO stated that the facility had been having problems with gnats for the last two years, but she did not realize it was as bad as it was in Resident R6's room. The LPN also confirmed the live black gnats in the bathroom shared by rooms B14 and B16.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 115542

F-F677

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 34 115542 Department of Health & Human Services Printed: 09/22/2025 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 115542 B. Wing 06/26/2024

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

Sadie G. Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38997 potential for actual harm Based on observations, staff interviews, record reviews, and a review of the facility policy titled Activities of Residents Affected - Few Daily Living (ADL), Supporting, the facility failed to provide ADL assistance to one of eight residents (R) (Resident R9) reviewed. This failure had the potential to cause Resident R9 to be unclean and feel self-conscious of his appearance.

Findings included:

A review of the facility policy titled Activities of Daily Living (ADL), Supporting, with a revised date of March 2018 revealed that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL care independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).

A review of the Admission Record for Resident R9 revealed he was readmitted to the facility on [DATE REDACTED] with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of muscle right upper arm, contracture of right ankle, and vascular dementia.

A review of Resident R9's most recent comprehensive Minimum Data Set (MDS) dated [DATE REDACTED] revealed a Brief

Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. It was further documented that Resident R9 required partial/moderate assistance for upper body dressing and substantial/maximal assistance for lower body dressing. Functional Abilities (Self-Care and Mobility) triggered as an area of concern on the Care Area Assessment Summary (CAAS).

An observation on 5/3/2024 at 2:19 pm revealed Resident R9 propelling himself down Unit A.

The resident stopped the surveyor and pointed to his clothing. His speech was not understood. Observation revealed the resident had remnants of food on his pants and shirt. The resident nodded his head up and down when asked if he needed help with changing his clothes. Charge Nurse KK and Charge Nurse MM were notified that the resident needed assistance with changing his clothes.

An observation on 5/3/2024 at 3:25 pm revealed Resident R9 sitting in a wheelchair in his room. Further observation revealed that Resident R9 stopped Certified Nursing Assistant (CNA) CCC and asked for assistance with changing his clothes and getting in the bed. He was still observed with remnants of food on his pants and shirt.

In an interview on 5/3/2024 at 3:30 pm, Unit Manager (UM) JJ confirmed that Resident R9 had food on his shirt and pants and that the charge nurses should have assisted Resident R9 with changing his clothes. She stated the resident should not have had to wait over an hour for assistance.

Cross-Reference