Brian Center Health & Rehabilitation/canton

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 115508 Department of Health & Human Services Printed: 09/04/2025 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 115508 B. Wing 03/14/2025

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

Cherokee Center for Nursing and Healing LLC 150 Hospital Circle NW Canton, GA 30114

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26054 potential for actual harm Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure Residents Affected - Few staff: sanitized or washed hands before donning and after doffing gloves, did not stack a medication cup containing liquid medication on top of a medication cup containing pills, and applied gloves before removing

a germicidal wipe to clean the glucometer (device that reads blood glugose) after checking a resident's blood sugar. This affected two (2) of five (5) residents, Resident (R)#34 and R#18, observed during medication pass.

Findings include:

A review of the facility's policy titled, Personal Protective Equipment with a Date Reviewed/Revised of January 2025, revealed the following: Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Definitions: Personal protective equipment, or PPE, . It includes gloves, . Policy Explanation and Compliance Guidelines 4. Indications/considerations for PPE (Personal Protective Equipment) use: a. Gloves: . ii. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene . iv. Change gloves and perform hand hygiene between clean and dirty tasks .

A review of the facility's policy titled, Blood Glucose Monitoring with a Date Reviewed/Revised of February 2025, revealed the following: .Policy Explanation and Compliance Guidelines: . 3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. 4 .the nurse is responsible for cleaning and disinfection of the machine between residents following the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy .

A review of the facility's policy titled Medication Administration, undated, revealed the following: . Purpose To provide a safe, effective medication administration process .

A review of the facility's Infection Prevention and Control Program Description undated, revealed the following as a major activity of the program: .3. Implementation of Control Measures and Precautions which includes basics such as hand hygiene, Standard and Transmission Based Precautions (including the use of personal protective equipment (PPE), cleaning/disinfecting equipment and measures to protect persons . from communicable disease or infections .

A review of R#34's Admission Record, revealed the resident was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

A review of R#34's diagnoses included, but were not limited to: chronic obstructive pulmonary disease, congestive heart failure, muscle weakness, chest pain, atherosclerotic heart disease, malignant neoplasm of prostate, orthostatic hypotension, gastro-esophageal reflux disease without esophagitis, bilateral primary osteoarthritis of hip and essential hypertension.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 115508 Department of Health & Human Services Printed: 09/04/2025 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 115508 B. Wing 03/14/2025

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

Cherokee Center for Nursing and Healing LLC 150 Hospital Circle NW Canton, GA 30114

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 A review of R#34's current Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/13/25, revealed R#34's Brief Interview for Mental Status (BIMS) score was 15, which indicated Level of Harm - Minimal harm or the resident's cognition was intact. potential for actual harm

On 3/12/25 at 9:40 a.m., during medication pass, the following was observed: Licensed Practical Nurse Residents Affected - Few (LPN) BB sanitized her hands and obtained R#34's vital signs. LPN BB exited the resident's room, sanitized her hands, and dispensed R#34's medication. LPN BB poured 90 milliliters (ml) of chocolate supplement into

a cup. LPN BB then dispensed the following medications into a medication cup: Breztri-Aerosphere inhaler, aspirin 81 milligrams (mg), azithromycin 500 mg, Bumex 2 mg, cetirizine 10 mg, cholecalciferol 125 mcg (microgram), clopidogrel bisulfate 75 mg, divalproex sodium 500 mg, iron 325 mg, midodrine hcl (hydrochloride) 5 mg, montelukast sodium 10 mg, omega 3 1000 mg, pantoprazole sodium 40 mg, prednisone 10 mg, roflumilast 500 micrograms (mcg), spiralactone 25 mg, and hydrocodone 5/325 mg. LPN BB poured Enulose 15 ml into a separate medication cup. LPN BB sanitized her hands, poured water into an empty cup and sat the cup containing the water on top of the medication cart. LPN BB stacked the medication cup containing the Enulose on top of the medication cup containing the pills. LPN BB picked up

the stacked medication cups, the inhaler, the cup containing the water and the cup containing the supplement and entered R#34's room. LPN BB administered the medications to R#34.

On 3/12/25 at 10:12 a.m., the surveyor asked LPN BB should medication cups that contained medications be stacked. LPN BB replied she did not think they should, but that was what she had done. LPN BB also stated that it could be a contamination issue regarding stacked medication cups.

A review of R#18's Admission Record revealed the resident was admitted on [DATE REDACTED].

A review of R#18's diagnoses included: Type 2 diabetes, acute kidney failure, hyperkalemia, and essential (primary) hypertension,

A review of R#18's current MDS with an ARD of 3/4/25, revealed R#34's BIMS score was 12, which indicated the resident's cognition was intact.

On 3/13/25 at 11:05 a.m., during medication pass, the following was observed: LPN CC sanitized her hands and dispensed the following medications: Arginaid one packet, acarbose 50 mg, and humalog injection 100 unit/ml. LPN CC mixed the Arginaid packet with six (6) ounces of water. LPN CC sanitized her hands, gathered supplies to obtained R#18's blood sugar, alcohol prep, tissue, and entered R#18's room. LPN CC applied gloves and proceeded to obtain R#18's blood sugar. LPN CC did not sanitize or wash her hands

before applying gloves. After obtaining R#18's blood sugar, LPN CC removed her gloves and exited the resident's room. LPN CC did not sanitize or wash her hands after removing her gloves. LPN proceeded to discard the trash removed from R#18's room, obtained a germicidal wipe and cleaned the glucometer. LPN CC did not apply gloves before obtaining the germicidal wipe used to clean the glucometer.

On 3/13/25 at 11:30 a.m., the surveyor asked what should be done before applying gloves and after gloves are removed. LPN CC replied that she should sanitize or wash hands. The surveyor asked what should be applied prior to obtaining a germicidal wipe to clean the glucometer. LPN CC replied to wear gloves, but that was not what she had done. Also, LPN CC stated she did not sanitize or wash hands prior to putting her gloves on or after removing her gloves when she checked R#18's blood sugar.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 115508 Department of Health & Human Services Printed: 09/04/2025 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 115508 B. Wing 03/14/2025

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

Cherokee Center for Nursing and Healing LLC 150 Hospital Circle NW Canton, GA 30114

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 On 3/14/2025 at 9:12 a.m., during an interview with the Director of Nursing (DON), the surveyor asked what

the expectations of staff regarding hand hygiene were before donning (putting on) and after doffing (taking Level of Harm - Minimal harm or off) gloves. The DON stated to sanitize hands if not visibly soiled and if visibly soiled, staff should wash their potential for actual harm hands. The surveyor asked what the expectations were for staff regarding stacking medication cups on top of one another containing medications. The DON stated medication cups should not be stacked, and staff Residents Affected - Few should use Styrofoam trays that are in the medication cart. The surveyor asked what the expectations were for staff regarding hand hygiene when using a germicidal wipe to clean a glucometer. The DON stated staff should sanitize hands, apply gloves, clean the machine, allow the machine to dry, remove gloves, and sanitize hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 115508