Hill Haven Nursing Home

F-F609

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50878

Residents Affected - Few Based on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans,

the facility failed to develop a comprehensive, person-centered care plan for two of eight residents (R) Resident R10 and Resident R13 receiving respiratory care. Specifically, the facility failed to develop a care plan for nebulizer therapy for Resident R10 and oxygen therapy for Resident R13. The deficient practice had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life.

Findings include:

Review of the facility's policy titled Care Plans, Comprehensive Person-Centered with revision date of March 2022, under the Policy Statement revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under the Policy Interpretation and Implementation section revealed, .7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being including: (1) services that would be otherwise provided for the above but are not provided due to resident exercising his or her rights, including the right to refuse treatment.

1. A review of Resident R10's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2024 revealed Section I (Active Diagnoses) revealed, diagnoses that included pneumonia and respiratory failure; Section O (Special Treatments, Procedures and Programs) indicated no respiratory treatments were received.

A review of the Physicians Orders for Resident R10 dated 1/2/2025 revealed a plan of treatment which included budesonide [NAME] 0.25 mg (milligram)/2 in one vial via nebulizer as needed for shortness of breath/wheezing every twelve hours and Ipratropium/ SOL Albuterol one vial via nebulizer as needed for shortness of breath/wheezing four times daily, PRN (as needed).

A review of Resident R10's care plan updated 8/7/2024 revealed Resident R10 has a potential for impaired gas exchange r/t (related to) CHF (Congested Heart Failure). She receives oxygen therapy as needed for SOB (shortness of breath). However, there was no care plan areas that included nebulizer therapy.

2. A review of Resident R13's Quarterly MDS with an ARD of 11/8/2024 revealed Section I (Active Diagnoses) revealed, diagnoses that included anemia, coronary artery disease, and heart failure; Section O (Special Treatments, Procedures and Programs) indicated no respiratory treatments were received.

A review of Physicians Orders for Resident R13 dated 11/18/2024 revealed albuterol neb 0.083% one vial via nebulizer every six hours PRN. However, there were no orders for oxygen therapy.

A review of Resident R13's care plan updated on 8/19/2024 revealed, Resident R13 is at risk for impaired gas exchange related to episodes of shortness of breath. He is prescribed oxygen therapy as needed. However, there was no care plan areas that included nebulizer therapy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 0656 During an interview on 2/19/2024 at 3:35 pm, Unit Nurse EE confirmed Resident R10 did not have a care plan developed for nebulizer therapy. She stated, she was unaware that the care plans were not developed. Level of Harm - Minimal harm or potential for actual harm In an interview on 2/20/2024 at 4:10 pm with the Director of Nursing (DON) confirmed Resident R10's physicians orders for PRN nebulizer treatments and stated the care plan was not developed. The DON further stated all Residents Affected - Few care areas, including medications, diagnosis, and treatments, should be care planned.

Cross Reference

F-F610

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49673 potential for actual harm Based on staff interviews, record review, and review of the facility's policy Abuse, Neglect, and Exploitation Residents Affected - Few or Misappropriation-Reporting and Investigating, the facility failed to ensure a thorough investigation was completed for sexual abuse allegations for one out of 34 sampled residents (R) (Resident R59).

Findings include:

A review of the facility's policy Abuse, Neglect, and Exploitation or Misappropriation-Reporting and Investigating with revision date of September 2022, revealed 1. All allegations are thoroughly investigated.

The administrator initiates investigations. 8.d. Witness statements are obtained in writing, signed, and dated.

The witness may write his/her statement, or the investigator may obtain a statement.

A review of the clinical record revealed, Resident R59 was admitted to the facility with diagnoses that included, but were not limited to cerebral palsy, hyperkalemia, autistic disorder, myoclonus, epilepsy, and contracture right hip/left hip.

A review of Resident R59's Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] for Section C (Cognitive Pattern) revealed, a Brief Interview for Mental Status (BIMS) score was coded as 0, which indicated severe cognitive impairment. Section E (Behaviors) revealed that the resident has other behavioral symptoms not directed towards others.

A review of the Facility Incident Report Form dated 1/9/2025 under the section titled Details of Incident revealed, I received a note under my door from a Certified Nursing Assistant (CNA) stating that she was told that another CNA was involved with a male resident in a sexual way.

A review of a list of Interview for Staff forms revealed, nine of the 20 interviews collected from staff did not include a name and/or date.

A review of CNA MM's statement on 1/3/2025 revealed, a request to have the accusing CNA stop disseminating vicious and false rumors about her in the facility regarding unusual relationship with resident Resident R59.

A review Resident R59's nurse's note dated 1/9/2025 written by the Director of Nursing (DON) revealed, it was reported to the DON a CNA may have been sexually inappropriate with this resident. The administrator, Ombudsman, Medical Director (MD), and Representative (RP) were all notified. Report submitted to the state, a skin assessment was completed by the DON and male CNA. No rashes or other skin issues were noted- genitalia (within normal limits) WNL.

During an interview on 2/19/2025 at 11:09 am with the Human Resource Director (HRD) revealed, when searching for an investigation for a sexual abuse incident for Resident R59, she confirmed that CNA MM was suspended for one day with pay pending investigation. HRD explained that she did not participate in investigations and that she only places reports/findings in employee files. The HRD confirmed nothing was in employee files at the moment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 During an interview on 2/19/2025 at 11:22 am with the DON revealed, she sent the accused CNA MM home for the rest of that day and moved the reporting CNA II to a different hall because it was all rumors. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/20/2025 at 1:15 pm with CNA MM revealed, she was told by two different CNAs that another CNA was stating bad things about her regarding Resident R59. CNA revealed, she dismissed the first CNA Residents Affected - Few report, but the second CNA report was concerning due to the mere fact she did not work full-time for the facility. CNA MM mentioned she wrote a statement to DON but was later questioned by DON, the previous Administrator, and previous owners as if she was in the wrong.

During an interview on 2/20/2025 at 1:58 pm, the DON revealed when reporting an investigation, she would retrieve witness statements, notify family and doctor, and send the resident to the emergency room . DON confirmed she did not complete the skin assessment as indicated in the nurse's notes and could not locate

the fax log sent notifying the MD. DON mentioned she thought she called the MD but was not sure what method she used to contact the MD. DON confirmed she did not call local police officials. DON emphasized that she did not observe any injuries and thought the concerns were not true and just rumors.

During an interview on 2/20/2025 at 2:44 pm with the Administrator revealed, he expects his staff to inform him right away specifically abuse to see if it is reportable. The Administrator emphasized that if it is abuse, neglect, or exploitation and something severe his reporting expectation was one hour and all others two hours. The administrator shared the previous Administrator was not having staff to contact law enforcement and has since had to do inservice with DON.

Cross Reference

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49674

Residents Affected - Many Based on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage,

the facility failed to ensure food items stored in the main kitchen was labeled, dated, and properly stored. The deficient practice had the potential to affect 55 out of 59 residents receiving an oral diet.

Findings include:

Review of the facility's policy entitled, Food Receiving and Storage dated November 2022 under the Policy Statement revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. Under the section titled Refrigerated/Frozen Storage revealed, 1. All foods stored in the refrigerator or freezer are covered, labeled and dated, (use by date) 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded.

During a tour of the kitchen on 2/18/2025 that began at 9:15 a.m., the following concerns were identified: 1) a sleeve of Waffles was located on shelf in walk in freezer undated, 2) half bag of onion rings was left open in

a box unlabeled or dated. 3) a five-pound box of frozen fish sticks, that had been opened and not resealed was present in the freezer and 4) two open containers that contained sausage in one of them and frozen eggs in the other.

During a second observation on 2/19/2025 at 9:30 am of the walk-in freezer and refrigerator it appeared the unlabeled and improperly stored food items were removed, and the box of fish sticks was discarded due to

the unknown use by date.

During an interview conducted on 2/20/2025 at 10:45 am with the Dietary Kitchen Manager (DKM) revealed that the kitchen staff were expected to label and date each food item that was received for the facility. She revealed it was her expectation for each staff member to properly store food items after opening it. The DKM stated going forward she was going to implement a system to double check behind her staff daily to ensure food safety in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 47947 potential for actual harm Based on staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Residents Affected - Many Control Program, the facility failed to establish a water management program as part of the overall infection prevention and control program. The deficient practice had the potential to affect all residents in the facility.

The facility had a census of 59 residents.

Findings include:

Review of the facility policy's titled, Infection Prevention and Control Program revised 10/28/2022 under Policy Explanation and Compliance Guidelines revealed, 16. Water Management: A water management program has been established as part of the overall infection prevention and control program.

Review of the facility's records revealed the facility did not have an established Water Management Plan.

Interview with the Administrator on 2/20/2025 at 1:40 pm confirmed the facility did not have an established Water Management Plan. The Administrator revealed, when he started working at the facility two week ago,

he identified this issue and added it to the agenda for the next Quality Assurance Performance Improvement (QAPI) meeting in March. He reported that daily hot water temperature checks would be a part of the Water Management Plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 115710

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47947

Residents Affected - Few Based on observations, staff interviews, record review and review of the facility's policy titled, Water Temperatures, Safety of, the facility failed to keep the residents free of accident hazards related to water temperatures above 110 degrees Fahrenheit (F) in five out of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Room29, and room [ROOM NUMBER]). The sample size was 34 residents.

Findings include:

Review of the facility undated policy titled Water Temperatures, Safety of, under the Policy Interpretation and Implementation revealed, 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit (F), or the maximum allowable temperature per state regulation. 2.Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log.

Observations on 2/18/2025 from 11:30 am to 11:38 am of water temperature checks on two out of three halls within the facility with Maintenance Director (MD) using the facility's digital thermometer revealed, water temperature measurements in room [ROOM NUMBER] at 108 degrees F, room [ROOM NUMBER] at 132 degrees F, room [ROOM NUMBER] at 136 degrees F and room [ROOM NUMBER] at 135 degrees F, and room [ROOM NUMBER] at 137 degrees F. No other residents' rooms were affected.

Interview on 2/18/2025 at 11:40 am with the MD revealed that he conducted monthly water temperatures in residents' rooms.

Review of the facility's water temperature log revealed that water temperature checks were completed on 11/6/2024, 12/19/2024, and 1/16/2025 with temperatures ranges between 94 degrees F and 120 degrees F.

Review of the facility's records revealed, no residents sustained burns injuries related to hot water temperatures.

Follow-up observation on 2/18/2025 from 3:45 pm to 3:54 pm of water temperature checks with the MD revealed, room [ROOM NUMBER] at 106 degrees F, room [ROOM NUMBER] at 109 degrees F, room [ROOM NUMBER] at 101.9 degrees F, room [ROOM NUMBER] at 101.5 degrees F, and room [ROOM NUMBER] at 100.8 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 115710 Department of Health & Human Services Printed: 09/08/2025 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 115710 B. Wing 02/20/2025

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

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50878 potential for actual harm Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Residents Affected - Few Administration, the facility failed to provide respiratory care consistent with professional standards of practice for one of eight residents (R) (Resident R10) receiving respiratory care. Specifically, the facility failed to properly store

the nebulizer mouthpiece, when not in use, for Resident R10. The deficient practices had the potential to cause respiratory infection for Resident R10.

Findings include:

A review of the facility's undated policy titled Oxygen Administration under the section titled Steps in the Procedure revealed, 16. Discard used supplies into designated containers.

A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Section C (Cognitive Patterns) a Brief Interview for Mental Status Score (BIMS) of 4, which indicated severe cognitive impairment; Section I (Active Diagnoses) revealed, diagnoses that included pneumonia and respiratory failure; Section O (Special Treatments, Procedures and Programs) indicated no respiratory treatments were received.

A review of the Physicians Orders for Resident R10 dated 1/2/2025 revealed a plan of treatment which included budesonide [NAME] 0.25 mg (milligram)/2 in one vial via nebulizer as needed for shortness of breath/wheezing every twelve hours and Ipratropium/ SOL Albuterol one vial via nebulizer as needed for shortness of breath/wheezing four times daily, PRN (as needed).

Observation and interview on 2/18/2025 at 3:16 pm in Resident R10's room revealed the nebulizer jar and mouthpiece was lying on the resident's bed, unbagged and exposed to the environment. Resident R10 revealed, it was not used routinely and that she required supervision when used.

Observation on 2/19/2025 at 11:21 am of nebulizer mouthpiece sitting at bedside uncovered.

Interview on 2/19/2025 at 10:18 am with Certified Nursing Assistant (CNA) DD revealed, she was aware that respiratory tubing should be stored in a clear plastic bag if the resident was not using it. She further stated storing respiratory supplies cuts down on infections and germs and all staff were responsible for ensuring the tubing and mouthpieces were stored while not in use.

Interview on 2/19/2025 at 11:35 am with the Director of Nursing (DON) revealed, staff that worked on Sunday night shift were responsible for ensuring that all respiratory care equipment was properly stored and checked for clean filters, and routine maintenance. The DON revealed, there was no logging system in place for the maintenance task.

Interview on 2/20/2025 at 3:45 pm with the Director of Nursing (DON) confirmed Resident R10's nebulizer mouthpiece was unbagged and exposed to the environment.

Cross Reference