Fayetteville Center For Nursing & Healing Llc

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record reviews, family and staff interviews, and review of the facility policy titled Notification of Changes, the facility failed to notify the physician and Responsible Party (RP)/family of a fall of one of seven Residents (R) (Resident R7) reviewed for notification of change.Findings include:Review of the facility policy titled Notification of Changes, reviewed/revised date of January 2024, revealed: Policy: The purpose of this policy is to ensure

the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative (consistent with their authority) when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents. Review of the admission Record for Resident R7 revealed he was admitted to the facility on [DATE REDACTED] with diagnoses of, but not limited to, bilateral rotator cuff injuries, cerebral infarction, and nontraumatic intracerebral hemorrhage.

Review of the admission Minimum Data Set (MDS) for Resident R7, dated 6/24/2025, revealed a Brief Interview for Mental Status (BIMS) was not assessed. Review of the Employee Punch Report revealed LPN III worked

the following hours on 7/14/2025 8:01 pm to 7/15/2025 7:24 am. Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 7/15/2025, created on 7/16/2025 at 3:41 am, revealed that Resident R7 had a fall. The SBAR documented that the family was notified on 7/15/2025 at 6:50 am, and the primary care physician was notified on 7/15/2025 at 11:00 am. A telephone

interview on August 27, 2025, at 2:13 pm with Resident R7's family member, who is the RP, revealed that the family stated they did not receive a call at 6:50 am on July 15, 2025, from the facility stating that Resident R7 had a fall. A telephone interview on 9/3/2025 at 12:40 pm with Licensed Practical Nurse (LPN) III stated she did not call

the family prior to leaving work regarding Resident R7's fall on 7/15/2025. She stated she notified __ (the medical service that takes calls from the facility after 5 pm or weekends) of Resident R7's fall prior to leaving work on the morning of 7/15/2025. An interview on 9/23/2025 at 1:44 pm with LPN JJJ stated she received report from LPN III on 7/15/2025. She stated LPN III never mentioned that Resident R7 had a fall on the 7 pm to 7 am shift. LPN JJJ stated the family was visiting and asked if their dad had a fall last night. LPN JJJ immediately called LPN III and was initially told that Resident R7 did not fall. LPN JJJ stated that after having a further conversation with LPN III, she admitted that Resident R7 had a fall. Licensed Practical Nurse JJJ stated she assessed the resident and notified the Nurse Practitioner of the fall and received an order for x-rays. An interview on 9/24/2025 at 9:23 am with the Director of Nursing stated she was not able to verify that the physician/medical service was notified of Resident R7's fall on the morning of 7/15/2025.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayetteville Center for Nursing & Healing LLC

110 Brandywine Boulevard Fayetteville, GA 30214

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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

9/4/2025 at 2:45 pm, Resident R8's family member, who is the RP, stated that on 8/1/2025, it was reported to the ADON and a Certified Nursing Assistant (CNA) that Resident R8's shorts and eyeglasses were missing. The family member stated the CNA returned with Resident R8's shorts, but the glasses could not be located. She stated she reported the missing items again in a formal email on 8/3/2025. In an interview on 9/9/2025 at 11:10 am,

the ADON stated she never had any communication with the family of Resident R8 regarding lost eyeglasses or clothes. She stated that if a resident or family reported lost items, she would report it to the Social Worker.

The ADON stated the Social Worker was responsible for logging the resident/family grievances into the __ system. The ADON stated she would also report the lost items to the laundry department so that they could look for the missing items. In an interview on 9/16/2025 at 10:57 am, the ADON confirmed that she did receive an email from Resident R8's family. She stated she does not remember reading the email. She stated, Those things are handled by the DON.

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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayetteville Center for Nursing & Healing LLC

110 Brandywine Boulevard Fayetteville, GA 30214

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

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

pillow. An observation of swelling in the right knee, laceration on the right great toe open to air with red drainage, and an observation of an open area on the left second toe. Review of the admission Record for Resident R16 revealed she was admitted to the facility on [DATE REDACTED] and a diagnosis of, but not limited to, dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy. Review of the resident's admission MDS dated [DATE REDACTED] revealed a BIMS assessed at eight, indicating moderately impaired. Section GG revealed that Resident R16 requires partial/moderate assistance with transfer. Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS. Review of the care plan initiated 7/25/2025 revealed that Resident R16 has an ADL self-care performance deficit related to limited mobility. Intervention to be implemented included a mechanical lift with two staff for assistance with transfers.Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred Resident R16 from bed to wheelchair causing a laceration on right leg. The investigation revealed that as a result of CNA EEEE failure to follow the facility policy of using a mechanical lift when transferring Resident R16 causing a small laceration to Resident R16's great right toe.

Review of the CNA EEEE employee file in the presence of the Human Resource Director revealed: a Disciplinary Action Form description of violation and events leading to personnel action: employee fail to use lift to transfer resident from bed to the wheelchair. Work improvement plan: Employee must perform all job duties outlined in the description as requested by manager/supervisor. Signed by the employee, UM, and the DON dated 9/8/2025. Further review revealed a Separation Notice with a hire date of 9/1/2019 and

a termination date of 9/9/2025 for violating company policies; poor performance; transferred resident without using lift as educated, signed by Human Resources on 9/10/2025. A telephone interview on 9/17/2025 at 10:24 am with CNA EEEE stated she was educated on reviewing the kiosk for the residents' plan of care for transfers. The CNA stated Resident R16 was assigned to her on 9/8/2025. She also stated she was aware that Resident R16 required a transfer with two people using the mechanical lift. The CNA stated Resident R16 had been crying and complained of general hurting and refused to get out of bed for the day. She stated Resident R16 did not want to get up using the mechanical lift to be transferred from the bed to the chair. The CNA stated she asked Resident R16 was it okay for her (CNA) to be transferred from the bed into the chair. The CNA stated the resident agreed and was transferred from the bed to the wheelchair. The CNA stated she did not report to

the charge nurse or the UM that the resident was in pain and did not want to get up. The CNA stated she was not aware that Resident R16 sustained an injury to the right knee and toe during the transfer. An interview on 9/17/2025 at 10:32 with UM LLL stated she has daily huddles with the staff on 100-700 hall. She stated that because of the incident with Resident R7, she educates the staff to review the resident's plan of care. All mechanical lifts must be done with two staff; in the event there is not a second person available she (UM) will assist with the transfer. The UM stated on 9/8/2025, Resident R16's family approached her and asked, Why was my mom transferred out of bed today without using the mechanical lift? The family went on to inform the UM that Resident R16 was in pain, and her knee had been injured during the transfer. She stated the resident was assessed and sent to the hospital. The UM stated she asked the CNA assigned to Resident R16 did you transfer Resident R16 without using

the mechanical lift. The CNA confirmed she had transferred the resident from the bed to the wheelchair alone without the lift. She stated she reported the incident to the Administrator immediately, and the CNA was sent home by the Assistant Director of Nursing.

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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayetteville Center for Nursing & Healing LLC

110 Brandywine Boulevard Fayetteville, GA 30214

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 0627 Level of Harm - Minimal harm or potential for actual harm

family did meet with the Administrator, DON, and the Clinical Marketing Director on 8/1/2025. The family stated that the Clinical Marketing Director informed the family that it was her decision that Resident R7 was not allowed to return.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayetteville Center for Nursing & Healing LLC

110 Brandywine Boulevard Fayetteville, GA 30214

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

chair. The resident agreed and was transferred from the bed to the wheelchair. The CNA stated she was not aware Resident R16 sustained an injury to the right toe due to the transfer. An interview on 9/9/2025 at 9:30 am with

the Administrator stated his expectations that all documentation is completed after a fall and or incident. He stated that documentation includes updating the residents' care plan. Cross reference F-F689

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayetteville Center for Nursing & Healing LLC

110 Brandywine Boulevard Fayetteville, GA 30214

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

family regarding a fall. 2. Review of the admission Record for Resident R16 revealed a diagnosis of, but not limited to, dementia, quadriplegia, and type 2 diabetes mellitus with diabetic neuropathy. Review of the resident's admission MDS dated [DATE REDACTED] revealed a BIMS assessed at eight, indicating moderately impaired. Section GG revealed Resident R16 is partial/moderate assistance with transfer. Functional Abilities (Self-Care and Mobility) triggered as an area of concern in the CAAS. Review of the care plan initiated 7/25/2025 revealed that Resident R16 has an ADL self-care performance deficit related to limited mobility. Intervention to be implemented included a mechanical lift with two staff assistance for transfers. Review of the Facility Reportable Incident dated 9/8/2025 revealed: Employee transferred Resident R16 from bed to wheelchair causing laceration on the right leg. The investigation revealed that as a result of CNA EEEE's failure to follow the facility policy of using a mechanical lift when transferring Resident R16, a small laceration to Resident R16's great right toe. A telephone interview on 9/21/2025 at 4:37 pm with Resident R16's family stated that on 9/8/2025, while visiting mom, she (Resident R16) verbalized that her knee was hurting. She stated she was informed by B that a CNA had transferred mom without using the mechanical lift. She stated she was told that her mom's right leg/foot was injured. She stated she immediately reported the incident to the Unit Manager. A phone interview on 9/19/2025 at 2:58 pm with the facility's Medical Director (MD) stated he was part of the Quality Assurance and Performance Improvement Meeting and discussed and reviewed the safe transfers policies. He stated that during the meeting, the team discussed educating the staff to report incidents as they happen and accurately. The MD stated he was not aware that another incident with failing to use the mechanical lift had occurred. The MD was informed on 9/8/2025 that Resident R16 was transferred without the mechanical lift and sustained an injury to her right great toe. The MD stated he would follow up with the Administrator and the other Health Care Providers regarding Resident R16's unsafe transfer on 9/8/2025. Cross-reference to F-F600

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

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayetteville Center for Nursing & Healing LLC

110 Brandywine Boulevard Fayetteville, GA 30214

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

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

(NP) in the clinical meeting as the orders were reviewed and adjustments could be made by the NP at that time. She stated that after hours and on weekends, the nurse reviewed the hospital orders with the after-hours medical service. The DON stated she was not aware that Resident R8's CPAP and oxygen were not part of the order summary. The DON stated she would review the resident's chart.In an interview on 9/10/2025 at 9:50 am, the DON stated Resident R8 did use oxygen and had a CPAP machine, and there was no order. She stated that the nurses would be educated to ensure that the hospital orders were accurately transcribed.

Event ID:

Facility ID:

If continuation sheet