Gold City Health And Rehab

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

staff member assisted Resident R10 away from the area at this time. No apparent injuries or distress noted at this time. Placed on 30-minute checks for Resident R10's safety.Review of a Facility Incident Report Form provided by

the facility dated 8/22/2025 indicated an incident on 8/21/2025 involving Resident R9 touching Resident R10's arm and kissing his hand while Resident R10 was attempting to pull away. During an interview on 8/29/2025 at 3:26 PM, LPN1 stated that the incident occurred at shift change. LPN1 stated that she had just left her office and as she entered

the area around the nurses' station, she saw Resident R9 and Resident R10. Resident R9 was holding Resident R10's arm and Resident R9 attempted to pull away but was unable. Resident R9 was seated in a wheelchair facing Resident R10 who was standing. Resident R9 attempted to pull on Resident R10's arm which created a back-and-forth motion as Resident R10 attempted to pull his arm back. LPN1 stated that Resident R9 attempted to kiss Resident R10's hand but was unsuccessful. LPN1 stated the certified nurse aides (CNAs) were making rounds and no staff member was at the nurses' station. Resident R9 became upset when Resident R10 was escorted to his room and attempted to follow Resident R10. LPN1 stated that she stood between Resident R9 and the entrance to Resident R10's hallway at the double doors so that Resident R9 could not follow Resident R10.During an interview on 8/29/2025 at 5:30 PM, the Administrator stated that her expectations of staff were to meet the basic needs of residents, know their characteristics and behaviors, strategize their interventions, and talk to family members to glean more clues about resident interventions. The Administrator stated she would educate staff, hold impromptu care plan meetings, and provide an individualized supervision approach in the care and protection of the residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gold City Health and Rehab

222 Moore Drive Dahlonega, GA 30533

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

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

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan that included specific interventions to ensure psychosocial well-being and safety for one of three residents (Resident (R) 4) reviewed in a sample of 20 residents.Findings include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 4/1/2025 indicated under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Review of Resident R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed an admission date to the facility on [DATE REDACTED] with diagnoses of cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, paraplegia, Review of Resident R4's admission Minimum Data Set (MDS) located in the MDS tab

in the EMR with an Assessment Reference Date (ARD) of 11/25/2024 indicated a Brief Interview for Mental Status (BIM) score of 15, which indicated Resident R4 was cognitively intact.Review of Resident R4's Care Plan revised on 06/15/25 and located in the EMR under the Care Plan tab revealed a plan for a behavior problem related to having auditory and visual hallucinations at time and has a history of suicidal ideations and suicidal attempts. Interventions initiated on06/16/2025 were to perform 15-minute resident safety checks, resident to have only plastic silverware, resident moved to a room with a roommate, and the room was cleared of items that are potentially harmful.Review of Progress Note dated 5/20/2025 indicated the Resident R4 called out to the nurse tearfully and stated that she was suicidal and drank hand sanitizer.Review of a Progress Note, dated 6/3/2025, authored by Licensed Practical Nurse (LPN)3 indicated that LPN3 found Resident R4 with a plastic bag over her head loosely and stated she was trying to kill herself. Observation on 8/26/2025 at 4:05 PM revealed Resident R4 in her electric wheelchair attempting to get an item from inside the personal refrigerator that was on the floor. Observed clear trash liners in Resident R4's roommate's trash can and in Resident R4's trash can.In an

interview on 8/26/2025 at 4:45 PM Certified Nurse Aide (CNA)1 stated that it would be ok to have a trash liner in the trash can if it was not in reach of the resident. In an interview on 8/26/2025 at 4:49 PM CNA2 stated that it would be ok the have a trash liner in the trash can.In an interview on 8/29/2025 at 5:30 PM, when asked about specific care plan interventions and how to communicate those interventions to staff, the Administrator stated it didn't matter what the changes were, they should document the specific interventions that relate to the situation, and then ensure they monitor for effectiveness. The Administrator stated going forward, all care plans would have to be reviewed and triaged regarding negative potential impact on residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Gold City Health and Rehab

222 Moore Drive Dahlonega, GA 30533

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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure

a resident was evaluated for appropriate bed rail use and that alternative measures were attempted prior to installation of bed rails for one of one resident (Resident (R) 4) reviewed for bed rails out of a total sample of 20. The lack of alternate bed rail measures had the potential to lead to safety concerns related to bed rail use. Findings include:Review of the facility's policy titled Bed Safety and Bed Rails, provided by the facility, with a revision date of August 2022 indicated, Use of Bed Rails.The use of bed rails or side rails (including temporarily) raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.Review of Resident R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed diagnoses of cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, and paraplegia, Review of Resident R4's admission Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/25/2024 indicated a Brief Interview for Mental Status (BIM) score of 15, which indicated Resident R4 was cognitively intact.Review of Resident R4's Care Plan dated 11/14/2024 and located in the EMR under the Care Plan tab revealed an Activity of Daily Living self-care performance deficit related to cerebral palsy care plan with a side rail intervention initiated on 1/28/2025. Quarter rails up on both sides to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. Review of Resident R4's medical record did not reveal an initial bed rail assessment; documented alternatives tried prior to consideration of bed rail or a consent for bed rails.Observation on 8/25/2025 at 5:30 PM revealed a bedrail in the lowered position on the right side of the bed and the bed pushed against the wall

on the left side.During an interview on 8/26/2015 at 2:15 PM, Licensed Practical Nurse (LPN)2 acknowledged that there was a bed rail on Resident R4's bed and stated that she had not seen Resident R4 use it.In an

interview on 8/29/2025 at 10:00 AM, the Administrator confirmed that Resident R4's bed rail evaluation, consent for use, and alternatives tried before installing the bed rail were not done.In an interview on 8/29/2025 at 5:30 PM, the Administrator and Director of Nursing (DON) stated that they did not know how the alternatives tried documentation, assessment by nurses and interdisciplinary (IDT) review and documentation were missed. The Administrator stated that her expectations going forward would be for more communication between nurses, IDT members and herself prior to installing bed rails to ensure that they were appropriate for resident use and safety.

Event ID:

Facility ID:

If continuation sheet