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Health Inspection

Fort Gaines Health And Rehab

Inspection Date: April 30, 2025
Total Violations 5
Facility ID 115696
Location FORT GAINES, GA

Inspection Findings

F-Tag F677

Harm Level: Minimal harm or bath, I have to wipe up, I haven't refused my bath.
Residents Affected: Few half inch over her fingertips, and brown debris was noted underneath her nails.

F-F677, revised 04/2025, revealed, . Residents who are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene .

1. Review of Resident R49's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed Resident R49 was admitted to the facility on [DATE REDACTED] with diagnoses which included malignant neoplasm of brain, unspecified epilepsy, and repeated falls.

Review of Resident R49's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/25 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed Resident R49 had a Brief

Interview for Mental Status (BIMS) score of 00 out of 15, which indicated Resident R85 had severe impaired cognition.

Review of Resident R49's Care Plan, located in the EMR under the Care Plan tab and last revised 02/27/25, revealed Resident R49 . Requires mod-max [moderate to maximum] assist from staff with baths, prefer showers on Tuesdays and Thursdays, bed bath on alt. [alternate] days .

During an observation and interview on 04/27/25 at 10:50 AM, Resident R49 was observed sitting in her room. Resident R49's fingernails were noted to be greater than a quarter an inch over her fingertips. [NAME] debris was noted under the nails. When asked if she preferred her fingernails to be this long and unclean, Resident R49 stated, No I really want them trimmed.

During an observation on 04/28/25 at 9:30 AM, Resident R49's nails remained greater than a quarter of an inch over her fingertips with brown debris under her nails.

2. Review of Resident R24's Face Sheet, located under the Profile tab of the EMR, revealed Resident R24 was admitted to the facility on [DATE REDACTED] with diagnoses which included hypertension, paroxysmal atrial fibrillation, and legal blindness.

Review of Resident R24's significant change MDS, with an ARD of 04/02/25 and located under the RAI tab of the EMR, revealed Resident R24 had a BIMS score of eight out of 15, which indicated Resident R24 had moderate impaired cognition.

Review of Resident R24's Care Plan, located in the EMR under the Care Plan tab and last revised 03/27/25, revealed, . Resident has difficulty in performing tasks of daily living such as feeding self, dressing, bathing, toileting .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 During an observation and interview on 04/27/25 at 10:40 AM, Resident R24 had fingernails that were greater than one half inch over her fingertips. [NAME] debris was noted under her nails. Resident R24 stated, I don't get a regular Level of Harm - Minimal harm or bath, I have to wipe up, I haven't refused my bath. potential for actual harm

During an observation 04/28/25 at 12:24 PM, Resident R24 continued to have fingernails that were greater than one Residents Affected - Few half inch over her fingertips, and brown debris was noted underneath her nails.

3. Review of Resident R37's Face Sheet, located under the Profile tab of the EMR, revealed Resident R37 was admitted to the facility on [DATE REDACTED] with diagnoses which included type 2 diabetes, venous insufficiency, and hypertension.

Review of Resident R37's quarterly MDS, with an ARD of 03/30/25 and located under the RAI tab of the EMR, revealed Resident R37 had a BIMS score of 14 out of 15, which indicated Resident R37 had intact cognition.

Review of Resident R37's Care Plan, located in the EMR under the Care Plan tab and last revised 03/07/23, revealed, . Resident requires assist with adl's, non-compliant with allowing staff to assist, believes he is more capable of doing more for himself than he is able . Prefers to have showers on Mondays and Thursdays on 7a-7p (7:00 am to 7:00 pm) shift, bed bath on other days on 7a-7p shift . date initiated: 06/29/2023, no revision .

During an observation on 04/27/25 at 12:19 PM, Resident R37 stated, I'm lucky to get one shower a week. Resident R37 stated, I have not refused a shower or bath.

During an observation 04/28/25 at 1:00 PM, Resident R37 stated, I still haven't had a shower.

During an interview on 04/29/25 at 3:30 PM, Certified Nursing Assistant (CNA) 9 was asked who was responsible for trimming residents' fingernails and toenails. She stated CNA's during the residents' shower and anytime it is needed. She stated Resident R49's daughters trim and clean her nails. She was asked who was responsible if the family was not there to provide the care. CNA 9 stated, I guess we are. She stated, CNAs are supposed to make sure each resident was bathed/showered unless they refuse and then the nurse would be notified CNA9 was asked if Resident R37 had refused. She stated, Not that I know of. CNA9 stated she did not assist Resident R37 with showers. She stated the resident bathed himself at the sink.

During an interview on 04/29/25 at 3:45 PM, CNA4 was asked who was responsible for trimming and cleaning residents' fingernails. She stated, CNAs during their [the residents] shower and anytime it's needed, unless the resident is diabetic then the nurse would trim the resident's nails. CNA4 stated, CNAs are supposed to make sure each resident is bathed/showered unless they refuse and then the nurse would be notified. CNA4 was asked if Resident R37 had refused showers. She stated, Not that I know of. CNA4 stated she did not assist Resident R37 with showers. She stated the resident bathed himself at the sink.

During an interview on 04/29/25 at 4:15 PM, CNA3 was asked who was responsible for trimming residents' fingernails and toenails. She stated, CNAs during their shower, and anytime it's needed, unless the resident is diabetic then the nurse would trim the resident's nails. CNA3 stated CNAs were supposed to make sure each resident was bathed/showered unless they refused and then the nurse would be notified. CNA3 was asked if Resident R37 had refused showers. She stated, Not that I know of. We let him wash up.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 During an interview on 04/29/25 at 4:20 PM, CNA2 was asked who was responsible for trimming residents' fingernails and toenails. She stated, CNAs during their shower, and anytime it's needed, unless the resident Level of Harm - Minimal harm or is diabetic and then the nurse would trim the resident's nails. CNA2 stated CNAs were supposed to make potential for actual harm sure each resident was bathed/showered unless they refused, and then the nurse would be notified. CNA2 was asked if Resident R37 had refused showers. She stated, I'm not sure. CNA2 stated she did not assist Resident R37 with Residents Affected - Few showers. She stated the resident bathed himself at the sink.

During an interview on 04/29/25 at 4:25 PM, Licensed Practical Nurse (LPN) 6 was asked who was responsible for trimming and cleaning resident's fingernails, she stated, CNA's during their shower, and anytime it's needed, unless the resident was diabetic then the nurse trims the resident's nails. LPN6 was asked if residents are not bathed/showered are you made aware, she stated yes, the CNAs are supposed to let us know, I don't know of Resident R37 refusing a shower.

During an interview on 04/29/25 at 4:30 PM, Licensed Practical Nurse (LPN) 4 was asked who was responsible for trimming and cleaning resident's fingernails. She stated, CNAs during their shower, and anytime it's needed, unless the resident is diabetic. Then one of nurses would trim the resident's nails. LPN4 was asked if she was made aware if residents were not bathed/showered. She stated, Yes, the CNAs are supposed to let us know. LPN4 was asked if she was aware Resident R37 had not received his showers. She stated, I didn't know he had not gotten a shower, I'll see what I can get done.

During an observation and interview on 04/30/25 at 10:45 AM, the Director of Nursing (DON) observed Resident R49 and Resident R24's nails and confirmed they needed to be cleaned and trimmed. The DON was asked who was responsible for trimming residents' fingernails and toenails. She stated primarily the CNAs during showers, but everyone there should assist the residents with their needs. She was asked what the expectation was regarding baths/showers for residents. She stated, The care plan should be followed and the resident offered and given their showers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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** 28306 potential for actual harm Based on observations, staff interviews, record review, and policy review, the facility failed to store a Trilogy Residents Affected - Few (a noninvasive ventilator device used to assist breathing for patients with respiratory issues) mask in a manner to prevent contamination for one of 23 sampled residents (Resident (R)156) reviewed for respiratory services. This failure increased the risk of respiratory infection.

Findings include:

Review of the facility's policy titled, Administrating Medications through a Small Volume (Handheld) Nebulizer dated 10/2024, revealed, . When equipment is completely dry, store in a plastic bag with the resident's name and date on it .

Review of Resident R156's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated Resident R156 was admitted to the facility on [DATE REDACTED] with diagnoses that included acute and chronic respiratory failure with hypercapnia (elevated carbon dioxide levels in the blood).

Review of Resident R156's admission Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 04/18/25, indicated Resident R156 had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated Resident R156 was severely cognitively impaired. Resident R156 was coded as requiring continuous oxygen therapy and a non-invasive mechanical ventilator.

Review of Resident R156's Care Plan, dated 04/14/25 and located under the Care Plan tab in the EMR, revealed, [Resident R156] is on a non-invasive ventilator during hs [hour of sleep], O2 [oxygen] via [by] n/c [nasal cannula]

during the day. Interventions were, Assess for s/sx [signs/symptoms] of hypoxia: altered level of consciousness, irritability, listlessness, cyanosis [sic]. Keep head of bed elevated above 30 degrees unless providing care or resident request . Maintain ventilator settings as ordered md [sic] for settings .

During observations on 04/27/25 at 10:30 AM and on 04/28/25 at 11:15 AM, the Trilogy non-invasive mechanical ventilator mask was stored on the top of the bedside table and not being stored in a plastic bag when not in use.

During an observation and interview on 04/28/25 at 2:06 PM, Licensed Practical Nurse (LPN)2 accompanied

the surveyor to Resident R156's room, and the resident's mask was not stored in a plastic bag. LPN2 stated, That mask should be in a bag. Let me go get her [Resident R156] a new mask and a plastic bag to put it in.

During an interview on 04/28/25 at 2:09 PM, the Infection Preventionist (IP) stated, It [Trilogy mask] is supposed to be stored in a bag. The IP was asked to provide the facility's policy on the storage of masks when they were not in use. The IP brought a policy and explained this policy did not specifically address Trilogy masks. The IP stated, But it is what we would expect the staff to follow for this mask.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 06401

Residents Affected - Few Based on staff interviews, record review, policy review, and review of the National Library of Medicine, the facility failed to ensure the Consultant Registered Pharmacist (CRPH) identified an irregularity when performing monthly medication regimen reviews regarding the discontinuation of a resident's duloxetine (Cymbalta, antidepressant medication) and/or failed to ensure pharmacist recommendations regarding antipsychotic medications in a timely manner for two of five residents (Resident (R)11 and Resident R25) reviewed for unnecessary medications out of a total sample of 23 residents. Failures to identify irregularities in medication regimens and to act upon pharmacist recommendations placed residents had increased risk of adverse reactions and medication administration errors.

Findings include:

Review of the facility's policy titled, Medication Regimen Review, dated 2/2025, indicated, Procedure The consultant pharmacist will conduct MRRs [medication regimen reviews] if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record . 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR.

Review of the National Library of Medicine article titled, Symptoms following abrupt discontinuation of duloxetine treatment in patients with major depress disorder, located at https://pubmed.ncbi.nlm.nih. gov/16266753/, revealed, . Abrupt discontinuation of duloxetine is associated with a DEAE [discontinuation-emergent adverse events] profile similar to that seen with other selective serotonin reuptake inhibitor (SSRI) and selective serotonin and norepinephrine reuptake inhibitor (SNRI) antidepressants. It is recommended that, whenever possible, clinicians gradually reduce the dose no less than 2 weeks before discontinuation of duloxetine treatment.

1. Review of Resident R11's Admission Record, located under the profile tab in the electronic medical record (EMR), revealed Resident R11 was admitted to the facility on [DATE REDACTED] with diagnoses that included schizoaffective disorder depressive type, epilepsy, anxiety disorder, and delusional disorders.

Review of Resident R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/18/2024 and located in the resident's EMR under the MDS tab, revealed the resident was receiving an antidepressant medication and had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated she was moderately cognitively impaired.

Review of Resident R11's current care plan, located under the Care Plan tab of the EMR, revealed a Focus area, with

a creation date of 3/31/2016, of having behavior problems with a diagnosis of schizoaffective disorder. A care plan intervention indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0756 Review of Resident R11's August 2024 Order Summary Report, located in the Misc [Miscellaneous] tab of the EMR, revealed an order for Duloxetine HCL Capsule Delayed Release Particles 30 MG [milligrams] Give 1 capsule Level of Harm - Minimal harm or by mouth two times per day related to schizoaffective disorder, depressive type. This medication order had a potential for actual harm start date of 5/31/2022.

Residents Affected - Few Review of Resident R11's September 2024 Order Summary Report, located in the Misc tab of the EMR, revealed the order for Duloxetine HCL Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times per day related to schizoaffective disorder, depressive type continued as an active order.

Review of Resident R11's Physician Orders, located under the Orders tab of the EMR, revealed an order was written

on 9/26/2024 to discontinue the resident's order for Duloxetine HCL Capsule Delayed Release Particles 30 MG Give 1 capsule by mouth two times per day. Further review of Resident R11's physician orders revealed there was no new order written for Resident R11 to receive Duloxetine medication after the medication was discontinued on 9/26/2024. There was no order to taper the use of the medication.

Review of Resident R11's September 2024 monthly Medication Administration Record (MAR), provided by the facility, revealed the resident last received duloxetine HCL on 9/26/2024.

Review of Resident R11's monthly October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, and April 2025 MARs, provided by the facility, revealed that Resident R11 had not received duloxetine medication since 9/26/2024.

During an interview on 4/29/2025 at 9:15 am, the Director of Nursing (DON) stated Resident R11's duloxetine was mistakenly discontinued on 9/26/2024 by the facility's prior Medical Director. The DON explained that the error was not discovered until 3/24/2025 when the facility's consultant pharmacist discovered the error during her monthly review of Resident R11's medications. The DON stated the resident did not receive duloxetine from 9/27/2024 until present because a new order was not written to restart the medication.

Review of the monthly pharmacy Consultation Reports, provided by the facility, revealed on 10/23/2024, 11/20/2024, 12/22/2024, 1/31/2025, and 2/24/2025, the CRPH reviewed Resident R11's drug regimen and did not identify any medication irregularities.

During an interview on 4/29/2025 at 9:45 am, the facility's CRPH confirmed that Resident R11's duloxetine medication was discontinued on 9/26/2024. The CRPH stated she performed monthly medication reviews after the physician discontinued Resident R11's duloxetine on 9/26/2024. She confirmed she did not note any irregularities on her monthly reviews until she completed the resident's review in March 2025 and informed the facility of the error.

During an interview on 4/29/2025 at 11:41 am, the Pharmacist Supervisor stated duloxetine should not be stopped abruptly because a resident could experience side effects including nausea, vomiting, dizziness, and other effects as noted on the medication's information insert.

28306

2. Review of Resident R25's Face Sheet, located under the Profile tab in the EMR, revealed Resident R25 was admitted to the facility on [DATE REDACTED] with diagnoses that included chronic obstructive pulmonary disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0756 Review of Resident R25's quarterly MDS, located under the MDS tab in the EMR and with an ARD of 9/07/2024, revealed Resident R25 had a BIMS score of 10 out of 15, which indicated Resident R25 was moderately cognitively impaired. Level of Harm - Minimal harm or Resident R25 was coded as receiving antipsychotic medications while a resident at the facility. potential for actual harm

Review of Resident R25's Care Plan, located under the Care Plan tab in the EMR and dated 09/20/23, revealed a Residents Affected - Few focus of, [Resident R25] is easily angered\annoyed [sic] by others, uses profanity, demanding, inpatient, behaviors not always altered. Has dx [diagnosis] of brief psychotic disorder, vascular dementia with behavioral problems, drug seeking behaviors [sic]. Non compliant [sic] with care/tx [treatment]. Interventions were Allow him [Resident R25] to make decisions in his care, give choices and honor preferences. Explain what you are doing prior to doing it. Analyze [sic] of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's [sic] understanding of the situation. Allow time for the resident to express self and feelings towards the situation .

Review of Resident R25's Physician's Orders, located under the Orders tab in the EMR, revealed an order dated 09/09/24 for ziprasidone [Geodon, an antipsychotic medication] HCL Oral Capsule 20 mg Give one capsule by mouth two times a day for F19.14 [sic] Give one capsule by mouth three times a day related to Other Psychsoactive Substance Abuse With Psychoactive Substance-Induced Mood Disorder (F19.14) [sic].

Review of Resident R25's Medication Administration Record (MAR), located under the Orders tab in the EMR, indicated Resident R25's order for ziprasidone was written in the same manner which the order for 9/9/2024 recorded.

Review of Resident R25's MAR for the months of September through November 2024 indicated Resident R25 was administered ziprasidone two times a day at 8:00 am and 4:00 pm.

Review of Resident R25's Consultation Report, provided by the facility and dated 10/23/2024 and 11/20/2024, revealed, Clinical Priority Recommendation. Prompt Response Requested. [Resident R25's] order for Ziprasidone 20 mg was TID [three times per day] but on 9/9/2024, the directions in , the EMR were changed to Give 1 [sic] capsule by mouth two times a day for F19.14 Give 1 [sic] capsule by mouth three times a day. These reports had the Director of Nursing (DON) name under the signature line. Neither report was signed nor dated by the DON.

Review of Resident R25's Physician Orders, dated 12/02/24 and located under the Orders tab of the EMR, revealed

an order to give ziprasidone 20 mg three times a day.

During an interview on 4/30/2025 at 3:30 pm, the DON stated, This order was clarified with the doctor on 12/2/2024. The DON was asked why the pharmacy recommendations were not acted upon until 12/2/2024.

The DON stated, I cannot answer that. The ADON [Assistant Director of Nursing] was responsible for doing those, and she no longer works here. The DON was asked if she had checked behind the ADON to see that

the pharmacy recommendations were completed and acted upon. The DON stated, No, I didn't check behind her. The DON confirmed the pharmacy recommendations should have been completed when the 10/23/2024 pharmacy request for clarification of the order was received.

During an interview on 4/30/2024 at 4:30 pm, the Regional Director of Clinical Services confirmed the pharmacy recommendations received on 10/23/2024 should have been acted upon by nursing as soon as

they had received the consultation report and staff should not have waited until 12/2/2024 for the order to be clarified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 06401 potential for actual harm Based on observations, resident and staff interviews, record review, and facility policy review, the facility Residents Affected - Many failed to serve food that was palatable and hot to three of 23 sampled residents (Resident (R) 8, Resident R11, and Resident R13) reviewed for food palatability. This failure had the potential to affect all 51 residents who consumed food prepared from the facility's kitchen.

Findings include:

Review of the facility's policy titled, Food Preparation and Appearance, revised 10/2024, specified, . Residents are provided meals that are prepared by methods that conserve value, flavor, and appearance. Residents are provided with food and drink that is palatable, attractive and at a safe and appetizing temperature .

1. Review of Resident R8's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/25 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.

During an interview on 04/27/25 at 1:04 PM, Resident R8 stated the food served at the facility could be improved. Resident R8 specified the food served at meals did not always taste good and was not always hot.

2. Review of Resident R11's quarterly MDS, with an ARD of 03/20/25 and located in the EMR under the MDS tab, revealed a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired.

During an interview on 04/27/25 at 11:12 AM, Resident R11 stated she ate her meals in her room and most of the time her food was not hot when served at mealtime.

3. Review of Resident R13's significant change MDS, with an ARD of 01/18/25 and located in the EMR under the MDS tab, revealed a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired.

During an interview on 04/27/25 at 1:32 PM, Resident R13 stated the food served at meals was not always hot.

4. In response to resident complaints about food, a test tray was requested to be sent to the facility's 300 hallway during the evening meal on 04/29/25. Observation revealed before the meal cart, which contained

the test tray, left the kitchen at 5:27 PM, resident meals were observed being served on unheated plates and food temperatures were at acceptable levels of 140 degrees Fahrenheit (F) and above when being served from the kitchen's tray line. The meal trays were placed on an enclosed tray cart with no heating element and were delivered to the 300 hallway at 5:29 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0804 Observation revealed the last resident's evening meal tray was served on the 300 hallway on 04/29/25 at 5:44 PM. At this time, the foods and beverages were sampled in the presence of the facility's Consultant Level of Harm - Minimal harm or Registered Dietitian (RD). The RD utilized a calibrated facility thermometer to obtain temperatures of the potential for actual harm food served on the test tray. The RD also tasted the food served on the requested test tray with the surveyor. Temperature checks and tasting of the food served on the test tray revealed the following: Residents Affected - Many a. The spaghetti with meat sauce served on the test tray registered 125 degrees F and was warm when tasted. The RD also tasted the spaghetti with meat sauce and confirmed it was warm and needed to be hotter.

b. The peas and carrots served on the test tray registered 126 degrees F and were warm when tasted. The RD also tasted the peas and carrots confirmed it was warm and needed to be hotter.

During an interview on 04/29/25 at 5:44 PM, the RD stated the spaghetti with meat sauce and peas and carrots should be hot when served to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 06401

Residents Affected - Many Based on observations, staff interviews, and facility policy review, the facility failed to discard food with expired use by dates and cover and date food stored in kitchen refrigeration units. The facility failed to ensure the kitchen's electric slicer and knives were clean prior to being stored for use. These failures had the potential to create an environment for food-borne illnesses which could affect 51 residents who consumed food prepared from the facility's kitchen.

Findings Include:

Review of the facility's policy titled, Food Safety Requirements, revised on ,d+[DATE REDACTED], specified, . Food shall be received and stored in a manner that complies with safe food handling practices . 8. All food stored in the refrigerator or freezer will be covered, labeled, and dated .

Review of the facility's policy titled, Sanitation, revised on ,d+[DATE REDACTED], specified, . The food service area shall be maintained in a clean and sanitary manner. Guidelines . 2. Utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair . 3. Equipment, food contact services, and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .

1. Observation during the initial kitchen inspection on [DATE REDACTED] from 8:20 AM to 8:50 AM, with the Dietary Manager (DM) present, revealed the following food stored in the kitchen's reach in refrigerators: six dozen hard boiled eggs with expired use by dates of [DATE REDACTED], one five pound container of cottage cheese with an expired use by date of [DATE REDACTED], one opened and undated 46 ounce container of thickened orange juice, one large uncovered container of shredded cheese, and one large plastic zip lock bag that contained cheese slices was stored open to air.

During an interview on [DATE REDACTED] at 8:50 AM, the DM confirmed the expired, undated, and/or uncovered food stored in the kitchen's reach in refrigerators. The DM stated food should be dated and closed when stored and food with expired use by dates should be discarded by kitchen staff.

2. Observation during the initial kitchen inspection on [DATE REDACTED] from 8:20 AM to 8:50 AM, with the DM present, revealed the following unclean food preparation and service equipment that was stored and ready for use:

the kitchen's electric slicer was unclean with grease and food residues on the front and back of its' slicing blade and control board, and three large knives, stored in a kitchen drawer, were unclean with a greasy residue on their cutting blade.

During an interview on [DATE REDACTED] at 8:50 AM, the DM confirmed the kitchen's stored electric slicer and three knives were not clean. The DM stated the slicer and knives should be cleaned by staff prior to being stored for use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306

Residents Affected - Few Based on record review, staff interviews, and facility document review, the facility failed to have a complete and accurate medical record regarding documentation of a change in condition for one of 23 sample residents (Resident (R)15). This failure had the potential for the following shifts not to be completely informed of the resident's status.

Findings include:

Review of the facility's policy Documentation Guidelines

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F-Tag F760

Harm Level: Minimal harm or Give 1 capsule by mouth two times per day. Further review of R11's physician orders revealed no orders
Residents Affected: Few Review of R11's Progress Notes tab of the EMR revealed no documented evidence staff had attempted to

F-F760, revealed, . The individual administering

the medication must check THREE [sic] (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication .

Review of Preventing Medication Errors in Nursing, located at https://www.nursingcenter. com/clinical-resources/nursing-drug-handbook/medication-errors/prevention, revealed, . Reducing medication errors is critical. In addition to recognizing common medication error risk factors, nurses must implement workplace strategies to prevent adverse drug events . Clarify drug, dosage, frequency and other details with the pharmacist or prescribing healthcare provider if there is any uncertainty .

Review of Resident R11's Admission Record, located under the profile tab in the electronic medical record (EMR) revealed Resident R11 was admitted to the facility on [DATE REDACTED] with diagnoses that included schizoaffective disorder depressive type, epilepsy, anxiety disorder, and delusional disorders.

Review of Resident R11's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/24, located in the resident's EMR under the MDS tab, revealed the resident was receiving an antidepressant medication and had a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated she was moderately cognitively impaired.

Review of Resident R11's current care plan, located under the Care Plan tab of the EMR, revealed a Focus area, with

a creation date of 03/31/16, which identified Resident R11 as having behavior problems with a diagnosis of schizoaffective disorder. A care plan intervention indicated, Administer medications as ordered. Monitor/document for side effects and effectiveness.

Review of Resident R11's September 2024 Order Summary Report, located in the Misc [Miscellaneous] tab of the EMR, revealed an order for Duloxetine HCL [an antidepressant medication] Capsule Delayed Release Particles 30 MG [milligrams] Give 1 capsule by mouth two times per day related to schizoaffective disorder, depressive type. This medication order had a start date of 05/31/22.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0658 Review of Resident R11's Physician orders, located under the Orders tab of the EMR, revealed an order written on 09/26/24 to discontinue the order for Duloxetine HCL Capsule Delayed Release Particles 30 MG [milligrams] Level of Harm - Minimal harm or Give 1 capsule by mouth two times per day. Further review of Resident R11's physician orders revealed no orders potential for actual harm were written for Resident R11 to receive duloxetine after the medication was discontinued on 09/26/24.

Residents Affected - Few Review of Resident R11's Progress Notes tab of the EMR revealed no documented evidence staff had attempted to clarify with the physician why Resident R11's duloxetine had been abruptly discontinued.

During an interview on 04/29/25 at 9:15 AM, the Director of Nursing (DON) stated Resident R11's duloxetine was mistakenly discontinued on 09/26/24 by the facility's prior Medical Director. The DON explained that the error was not discovered until 03/24/25 when the facility's consultant pharmacist discovered the error during her monthly review of Resident R11's medications. The DON stated the resident did not receive duloxetine from 09/27/24 until present because a new order was not written to restart the medication.

During an interview on 04/29/25 at 9:15 AM, the Administrator stated the physician who made the error in discontinuing Resident R11's duloxetine on 09/26/24 was no longer employed by the facility.

During an interview on 04/29/25 at 12:29 PM, the facility's current Medical Director stated that Resident R11's duloxetine should not be discontinued cold turkey because a resident needs to be weaned off the medication because there were side effects that could occur with it being discontinued abruptly.

Review of a facility Medication Related Incident Report, dated 03/24/25, provided by the facility, indicated, Incident Description: Pharmacy consultant questioned why medication [duloxetine] was no longer active on eMAR [electronic Medication Administration Record] . Description: It was founded that the medical director mistakenly discontinued medication and failed to notify facility. Provider was immediately notified of occurrence. No recommendation. Resident was assessed and no abnormalities were observed. Resident was pleasant. Name of provider behavioral services notified of occurrence.

During an interview on 04/29/25 at 11:41 AM, the Pharmacist Supervisor (RPHS) stated duloxetine should not be stopped abruptly because a resident could experience side effects including nausea, vomiting, dizziness, and other effects as noted on the medication's information insert.

Review of Resident R11's behavioral health notes, located in the EMR under the Prog [Progress] Note tab revealed behavioral notes written on 10/24/24, 11/08/24, 11/29/24, 12/05/24, 12/19/24, 01/16/25, 01/30/25, 02/13/25, and 02/28/25 specified Resident R11 continued to receive duloxetine HCL and that it was helping to control her symptoms of despair and sadness even though the medication had been discontinued on 09/26/24. Resident R11's behavioral health note dated 04/25/25 [noted as a late entry] specified, Depression is stable. Her Duloxetine was accidentally discontinued by another staff member and never added back. She tolerated the discontinuation well and we will monitor for any changes in her mood or behavior. No feelings of sadness or dread are noted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0658 During an interview on 04/29/25 at 12:34 PM, the Mental Health Nurse Practitioner (MHNP), stated he had worked with Resident R11 for years and was not aware that Resident R11's Duloxetine medication was discontinued on Level of Harm - Minimal harm or 09/26/24 until March 2025. The MHNP stated after Resident R11's duloxetine medication was discontinued he potential for actual harm continued to erroneously document in the resident's behavior notes that she was receiving this medication and that it was helping to control her symptoms of depression. The MHNP stated it would have been prudent Residents Affected - Few of him to review Resident R11's medications at each of his visits to see what medications the resident was receiving.

The MHNP stated he would have expected staff to inform him that Resident R11's antidepressant medication was discontinued, but it was his responsibility to review the residents' medications as part of his evaluation. The MHNP stated that Resident R11's duloxetine was stopped abruptly, which was not advisable. The MHNP explained that Resident R11 should have been weaned off her duloxetine medication slowly to prevent any potential side effects when discontinuing this medication. The MHNP stated he had not noticed a change in Resident R11's mood or an increase in her depression during the past months.

During an interview on 04/29/25 at 1:15 PM, Resident R11 stated over the past months she had felt a little more tired than normal but had not experienced an increase in depression or sadness.

During an interview on 04/30/25 at 1:40 PM, The DON stated she would expect facility nurses to clarify any questionable physician order, which included when a physician discontinued a resident's antidepressant medication abruptly. The DON stated when an order was questionable the nurse should call the Physician for clarification to ensure the order is what the physician wants to implement. The DON stated since it was discovered that Resident R11's antidepressant medication was discontinued abruptly in error by the physician the nursing staff had received additional training on clarifying physician orders.

During an interview on 04/29/25 at 5:19 PM, Resident R11's Physician stated, If I wanted to decrease Cymbalta [duloxetine] from 30 mg to completely taking her [Resident R11] off of the medication, I would not stop it [duloxetine] abruptly. I would have tapered her [Resident R11] off of it [duloxetine] by decreasing the dosage to 30 mg every other day for a month, then 15 mg every other day for a month and assess how she was doing with the taper and adjust as I would need to so she would not have withdrawals. I was not made aware of this until six months later, that the mistake was made by another doctor that mistakenly discontinued it [duloxetine].

28306

2. Review of Resident R25's Face Sheet, located under the Profile tab in the EMR, indicated Resident R25 was originally admitted to the facility on [DATE REDACTED] with the diagnosis of chronic obstructive pulmonary disease (COPD).

Review of Resident R25's quarterly MDS located under the MDS tab in the EMR and with an ARD of 09/07/24, revealed Resident R25 had a BIMS score of 10 out of 15, which indicated Resident R25 was moderately cognitively impaired. Resident R25 was coded as receiving antipsychotic medications while a resident at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0658 Review of Resident R25's Care Plan, located under the Care Plan tab in the EMR and dated 09/20/23, revealed, . [Resident R25] is easily angered\annoyed [sic] by others, uses profanity, demanding, inpatient, behaviors not always Level of Harm - Minimal harm or altered. Has dx of brief psychotic disorder, vascular dementia with behavioral problems, drug seeking potential for actual harm behaviors [sic]. Non compliant [sic] with care/tx [treatment]. Interventions were, . Allow him [Resident R25] to make decisions in his care, give choices and honor preferences. Explain what you are doing prior to doing it. Residents Affected - Few Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's [sic] understanding of the situation. Allow time for the resident to express self and feelings towards the situation .

Review of Resident R25's Physician's Orders, located under the Orders tab in the EMR, indicated an order dated 09/09/24 for ziprasidone [Geodon, an antipsychotic medication] HCL Oral Capsule 20 mg [milligram] Give one capsule by mouth two times a day for F19.14 [sic] Give one capsule by mouth three times a day related to Other PSYCHSOACTIVE SUBSTANCE ABUSE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD DISORDER (F19.14) [sic].

Review of Resident R25's Medication Administration Records (MARs), dated 09/09/24 through 12/01/24, revealed Resident R25 received ziprasidone twice daily.

Review of Resident R25's Progress Notes and Orders tabs of the EMR revealed no documented evidence staff attempted to clarify the 09/09/24 physician's order until 12/02/24, when a new order was received to give ziprasidone 20 mg three times a day.

During an interview on 04/30/25 at 5:00 PM, the Director of Nursing (DON) stated the resident had the right to receive the right frequency of medication. The DON stated the nursing staff did not ensure this right. The DON stated, They should have called the doctor to clarify the order. There were 2 times listed to give this medication.

During an interview on 04/30/24 at 4:30 PM, the Regional Director of Clinical Services confirmed the nurses administering ziprasidone should have called the doctor to clarify the frequency in which the medication was to be given.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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** 39857 potential for actual harm Based on observations, record review, resident and staff interviews, and facility policy review, the facility Residents Affected - Few failed to ensure nail care and/or showers were provided for three of 23 sampled residents (Resident (R) 49, Resident R24 and Resident R37) reviewed for activities of daily living (ADLs). This failure had the potential to cause Resident R49, Resident R24, and Resident R37 to have unmet care needs.

Findings include:

Review of the facility's policy titled, Quality of Life-Activities of Daily Living

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F-Tag F842

Harm Level: Minimal harm or
Residents Affected: Few

F-F842 dated 04/2024 revealed, . Services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record .

Review of Resident R15's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated Resident R15 was admitted to the facility on [DATE REDACTED] with the diagnosis of cerebral infarction.

Review of Resident R15's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 03/22/24, indicated Resident R15 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated Resident R15 was severely cognitively impaired.

Review of Resident R15's Care Plan, located under the Care Plan tab in the EMR and dated 12/31/17, revealed, . [Resident R15] has dx [diagnosis] and cva [sic] [Cerebral Vascular Accident] with hemiplegia . Interventions were Notify md [Medical Doctor] if blood pressure is outside perimeters. Give cardiac/antihypertensive meds [medications] as ordered, monitor for effectiveness and adverse effects. Monitor blood pressure as scheduled and as needed. Monitor for and document any edema. Notify MD .

Review of Resident R15's Nursing Progress Notes, located under the Progress Note tab in the EMR indicated documentation and dated 06/01/24 at 8:24 AM, revealed, . Received report that resident vomited throughout

the night. [Name of Certified Nursing Assistant (CNA)] reported to [Name of Licensed Practical Nurse (LPN)2] that the resident did not look like herself. Upon further evaluation, we discovered the resident has left sided facial droopiness. She [Resident R15] is also not alert and responding at this time. MD notified of situation and instructed us to send her [Resident R15] out .

During an interview on 04/30/25 at 11:00 AM, LPN1 stated, If I was working on her [Resident R15] hallway and she [Resident R15] had a change in condition that I was aware of, I would document the change and the assessment if I had to perform one. I can't remember back that far if I worked with her [Resident R15] or not.

During an interview on 04/30/25 at 11:15 AM, LPN2 stated, I remember working with another nurse that day. I can't remember who told me about her [Resident R15] not acting like herself but as soon I was told, I went and assessed her [Resident R15] and told the other nurse that I was working with that day, and we worked together getting her [Resident R15] out of the facility. LPN2 was asked if the assessment would be something that LPN2 would have documented. LPN2 stated, Yes, I would have documented it. LPN2 was notified the only documentation on 06/01/24 was from another nurse and not LPN2. LPN2 was asked if she should have documented this assessment. LPN2 stated, Yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0842 During an interview on 04/30/25 at 12:09 PM, Registered Nurse (RN)1 stated, I remember someone said she [Resident R15] had a little vomiting the night before she [Resident R15] was transferred to the hospital the day after that. Level of Harm - Minimal harm or potential for actual harm Further review of Resident R15's Nursing Progress Notes revealed no documentation on 05/31/25 that Resident R15 had been vomiting that shift. Residents Affected - Few

During an interview on 04/30/25 at 3:30 PM, the Director of Nursing (DON) stated, If a resident has a change

in condition, the nurse is to do an assessment and document the findings in PCC [Point Click Care, electronic medical record].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on record review, staff interviews, policy review, and review of McGeer criteria (a tool designed to Residents Affected - Few support facility healthcare-associated infection surveillance), the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for three of 23 sampled residents (Resident (R) 33, Resident R42, and Resident R8) reviewed for antibiotic stewardship. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary.

Findings included:

Review of the facility's policy titled, Infection Control Program - Antibiotic Stewardship

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F-Tag F881

Harm Level: Minimal harm or staff had mentioned some confusion. She agreed to [sic] due to having lower back pain that comes and goes
Residents Affected: Few urgency before the nursing note that was documented on 01/09/25 or having malaise and confusion before

F-F881, dated 10/2024, revealed, . After an order has been received, the Infection Control Coordinator or designee should complete

the surveillance document, utilizing the McGeer criteria, noting evidence for the infection. If the antibiotic does not fit criteria, the physician will be contacted.

Review of the McGeer's Criteria (11/5/24) revealed, Table 1. Constitutional Criteria for Infection Fever, Leukocytosis, Acute Mental Status Change, Acute Functional Decline . Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Syndrome: UTI without indwelling catheter Criteria: 1. At least one of the following sign or symptom: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency If no fever or leukocytosis, then greater than 2 of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency 2. At least one of the following microbiologic criteria greater than or equal to 100,000 Colony Forming Units (CFU) per milliliter (mL) of no more than 2 species of organisms in a voided urine sample greater than or equal to 100 of any organism(s) in a specimen collected by an in-and-out catheter . Selected Comments: The following two comments apply to both UTI with or without catheter: UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection In the absence of a clear alternate source of infection, fever, or rigors with a positive urine culture resulting in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source. Urine specimens for culture should be processed as soon as possible, preferably within 1-2 hours If urine specimens cannot be processed within 30 minutes of collection, they should be refrigerated and used for culture within 24 hours.

1. Review of Resident R33's Face Sheet, located under the Profile tab in the electronic medical record (EMR), revealed Resident R33 was admitted to the facility on [DATE REDACTED] with diagnoses of but not limited to urinary tract infection and dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0881 Review of Resident R33's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed a note dated 01/09/25 at 3:11 PM which indicated, This nurse spoke with resident about getting a urine sample after Level of Harm - Minimal harm or staff had mentioned some confusion. She agreed to [sic] due to having lower back pain that comes and goes potential for actual harm and urinary urgency, Urine will be sent to [name of laboratory] for testing after collection. Further review of

the nursing progress notes indicated no documentation of Resident R33 experiencing low back pain with urinary Residents Affected - Few urgency before the nursing note that was documented on 01/09/25 or having malaise and confusion before 01/09/25.

Review of Resident R33's Physician's Orders, dated 01/09/25 and located under the Orders tab in the EMR, revealed

a physician's order to obtain a urinalysis with culture and sensitivity for malaise and confusion.

Review of Resident R33's Urinalysis lab report, provided by the facility and with a collection date of 01/15/25 and a reported date of 01/18/25, revealed the urinalysis was for microscopic only and not a complete urinalysis.

Review of Resident R33's Urine Culture lab report, provided by the facility and dated 01/18/25, revealed results of the organism being Escherichia coli greater than 100,000 colonies.

Review of Resident R33's Physician's Orders, located under the Orders tab in the EMR, revealed an order dated 01/21/25 for Levaquin (an antibiotic) 500 mg (milligram) Give one tablet by mouth one time a day for UTI (Urinary Tract Infection) for 10 days.

Review of Resident R33's Infection Screening Evaluation, provided by the facility and dated 01/21/25, indicated Resident R33 did not have a fever, and the symptom being experienced by Resident R33 was urinary incontinence. Under the Infection Analysis section of the screening, it was indicated, McGeer's Criteria: Suspected UTI without indwelling catheter.

During an interview on 04/30/25 at 11:27 AM, the Infection Preventionist (IP) stated, We were told in an in-service with the lab we could only order UA [urinalysis] microscopic. The IP confirmed that a complete urinalysis should have been obtained from the lab instead of the microscopic only. The IP confirmed that the order for the antibiotic did not meet McGeer's Criteria due to the resident having confusion and malaise and there were no urine results that showed the presence of leukocytes (organisms that can indicate infection).

2. Review of Resident R42's Face Sheet, located under the Profile tab in the EMR, revealed Resident R42 was admitted to the facility on [DATE REDACTED] with the diagnosis of cerebral infarction and diabetes mellitus.

Review of Resident R42's Physician's Orders, located under the Orders tab in the EMR, indicated an order dated 08/18/24 for Urinalysis one time only for lethargic, change in mental status.

Review of Resident R42's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed no documented evidence that the resident was experiencing lethargic or altered mental changes.

Review of Resident R42's Urinalysis lab report, provided by the facility and with a collection date of 08/21/24 and a resulted date of 08/22/24, revealed a urinalysis-microscopic only was performed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0881 Review of Resident R42's Urine Culture lab report, provided by the facility and dated 08/24/24, indicated the organism

in the urine was Providencia stuartii, greater than 100,000 colonies. Level of Harm - Minimal harm or potential for actual harm Review of Resident R42's Physician Orders, dated 08/29/24 and located under the Orders tab of the EMR, revealed

an order dated 08/29/24 for Cipro (an antibiotic) 500 mg Give one tablet by mouth two times a day for UTI for Residents Affected - Few 10 days.

Review of the Infection Screening Evaluation, dated 08/30/24 and provided by the facility, revealed Resident R33 did not have a fever, had acute pain, swelling, or tenderness of the testes, epididymis or prostate, was experiencing abdominal pain/tenderness, and urinary urgency. Resident R33 was a female. Under the Infection Analysis section of the screening, it was indicated McGeer's Criteria Met: Gastroenteritis.

During an interview on 04/30/25 at 11:27 AM, the IP stated, The RN [Registered Nurse] would round with the doctors and write these orders. She did not document anything on this resident except to order the urinalysis with culture and sensitivity. There was no documentation from nursing on any of these symptoms. The IP also confirmed the urinalysis performed should have been for a complete urinalysis and this did not meet McGeer's Criteria for a UTI. The IP stated, I will put in the information into the EMR but not necessarily what is in the nurses' notes, but from what I know from what they have reported to me about this antibiotic order.

3. Review of Resident R8's Face Sheet, located under the Profile tab in the EMR, revealed Resident R8 was admitted to the facility on [DATE REDACTED] with the diagnosis of seizures.

Review of Resident R8's Physician Orders, located under the Orders tab in the EMR, indicated an order dated 01/12/24 for Macrobid (an antibiotic) 100 mg one tab twice a day for seven days. There was also an order dated 01/12/24 to collect urine due to recent behaviors.

Review of Resident R8's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed no documentation of Resident R8 having any behaviors.

Review of Resident R8's Urinalysis Results lab report, provided by the facility and dated 01/12/24, revealed the abnormal results for Leukocytes 75 High and [NAME] Blood Cells 5-10 High. There was no culture results noted prior to the start of the antibiotic Macrobid.

Review of the Infection Screening Evaluation, dated 01/12/24 and provided by the facility, revealed Resident R8 did not have a fever, had acute dysuria, delirium, new onset of confusion, and supra (around) pubic tenderness. Under the Infection Analysis section of the screening indicated McGeer's Criteria: Suspected UTI without indwelling catheter.

During an interview on 04/30/25 at 11:27 AM, the IP confirmed after reviewing the nursing progress notes and the behavioral monitoring for Resident R8, that there was no documentation of symptoms or behaviors to support what was recorded on the 01/12/24 screening. The IP also confirmed after reviewing the documentation with

the surveyor that this did not meet McGeer's Criteria due to the doctor prescribing an antibiotic prior obtaining the urine culture on Resident R8.

During an interview on 04/30/25 at 12:10 PM, the Regional Director of Clinical Services confirmed that Resident R33, Resident R42, and Resident R8 did not meet McGeer's Criteria for antibiotic usage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28306 potential for actual harm Based on record review, staff interviews, facility policy review, and review of the Centers for Disease Control Residents Affected - Few and Prevention (CDC) guidelines, the facility failed to provide a pneumococcal vaccine once the resident's responsible (RP) had signed the consent form for one of 23 sampled residents (Resident (R) 24) reviewed for immunizations. This failure had the potential to increase the resident's risk of developing pneumonia.

Findings include:

Review of the facility's policy Pneumococcal Vaccine

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F-Tag F883

Harm Level: Minimal harm or
Residents Affected: Few marked the section You are being offered the following vaccine. The section I have received information

F-F883, dated 02/2025 and provided by the facility, revealed, . Residents will be offered the pneumococcal vaccine to aid in preventing pneumococcal infections (e.g., pneumonia) . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine unless medically contraindicated or

the resident has already been vaccinated. Assessments of the pneumococcal vaccination unless medically contraindicated within five (5) days of the resident's admission if not conducted prior to admission .

Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 or PCV21 is used, Give a dose of PCV15 at least one year later . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give one dose of PCV20 or PCV21 . The PCV20 or PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13, Give one dose of PCV20 or PCV21 or PPSV23 to be administered at least a year later. If PCV20 and PCV21 are used, their pneumococcal vaccinations are complete .

Review of Resident R24's Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated Resident R24 was admitted to the facility on [DATE REDACTED] with diagnoses that included heart failure and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Resident R24 was currently over [AGE] years old.

Review of Resident R24's Immunizations, located under the Immunizations tab in the EMR, revealed Resident R24 had not received a pneumococcal vaccine since being admitted to the facility on [DATE REDACTED]. There was no documentation of historical administration or refusal of any pneumococcal vaccine for Resident R49.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 115696 Department of Health & Human Services Printed: 08/28/2025 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 115696 B. Wing 04/30/2025

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

Fort Gaines Health and Rehab 101 Hartford Road, West Fort Gaines, GA 39851

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 0883 During an interview on 04/30/25 at 4:30 PM, the Infection Preventionist (IP) stated, The resident's RP signed her consents for [Resident R24] to receive the pneumococcal vaccine, but I have not ordered the vaccine for her yet. Level of Harm - Minimal harm or potential for actual harm Review of Resident R24'sInformed Consent for Pneumococcal Vaccine PCV-15 or PCV-20 (Pneumococcal Conjugate) and PPSV23 (Pneumococcal Polysaccharide), provided by the facility, revealed PCV-20 was Residents Affected - Few marked the section You are being offered the following vaccine. The section I have received information about the vaccine and understand the risk and benefits of receiving this vaccine. I CONSENT to receiving

the vaccine by signing below was signed by the resident's RP, dated 10/08/24, and was witnessed by the IP.

During an interview on 04/30/24 at 4:40 PM, the DON confirmed Resident R24 should had been given the pneumococcal vaccine when the consent was signed by the RP in 2024 or soon after.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 115696

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