Chatuge Regional Nursing Home

F-F600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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

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

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36917 jeopardy to resident health or safety Based on record review, interviews, and review of the policy titled Abuse Reporting and Investigation, the facility failed to ensure that allegations of abuse, allegations of exploitation, and an injury of unknown origin, Residents Affected - Few were thoroughly investigated for three residents (R) (Resident R78, Resident R71, and Resident R107) reviewed out of a total sample of 27 residents. Specifically, the facility failed to investigate allegations of employee to resident abuse for Resident R78 and Resident R107, perpetrated by Certified Nurse Aide (CNA) 2. In addition, the facility failed to investigate an injury of unknown origin that resulted in a hip fracture and failed to investigate allegations of exploitation for Resident R71 perpetrated by CNA 1. The failure of the Administrator to investigate these incidents have the likelihood to lead to future unreported allegations of abuse and exploitation as well as injuries of unknown origin.

On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 7/12/2023 when the facility became aware CNA 1 was in a personal relationship with Resident R71 and potentially exploited is money.

A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.

Findings include:

Review of the facility policy titled Abuse Reporting and Investigation, revised March 2017, indicated the Statement Of Purpose is that all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by the facility. Implementation: Number 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator and/or the Director of Nursing (DON), will appoint a member of management to investigate the alleged incident. Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state and local laws, within five working days of the reported incident.

1. Review of Resident R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admitted [DATE REDACTED] with diagnoses of dementia and delusions.

Review of Resident R71's quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed a BIMS score of 11 out of 15 which indicated Resident R71 was moderately cognitively impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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

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

F 0610 The Administrator submitted a written document dated 7/12/2023 that documented a suspected situation with CNA 1 and Resident R71 being involved in a relationship with each other. The document continued to indicate that Level of Harm - Immediate CNA 1 would neglect the other residents on her assignment, while she would be spending time in Resident R71's jeopardy to resident health or room. CNA 1 was reassigned to another hall, and she was no longer allowed to go to Resident R71's hall. There was safety no evidence this incident was thoroughly investigated by the facility.

Residents Affected - Few Review of the Adult Protective Services (APS) report dated 5/30/2024 filed by the Business Office Manager revealed Resident R71 left facility Against Medical Advice (AMA). Review of additional information in the report revealed Resident R71 attempted to pay his bill and he presented three debit cards that were all declined. Resident stated, I don't know who is spending all my money. There was no evidence this incident was reported to the SA.

Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024. Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip. This note further revealed Resident R71 was not able to move his leg on that side and knee and foot appeared very swollen. Resident R71 was immediately sent to the emergency room . On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery. There was no evidence that the injury of unknown origin was investigated by the facility.

During an interview with the Administrator on 6/6/2024 at 10:48 pm, he confirmed the above incidents involving Resident R71 were not thoroughly investigated.

3. Review of Resident R78's Record of Admission located under the Clinical tab of the EMR revealed an admitted [DATE REDACTED] with a diagnosis of dementia.

Review of Resident R78's significant change MDS dated of 3/21/2024 revealed a BIMS score of a zero out of 15 which indicated Resident R78 was severely cognitively impaired.

Review of the Facility Reported Incident (FRl) dated 3/22/2024, completed by the administrator/abuse coordinator, revealed a report of verbal abuse to Resident R78 by CNA 2. Further review of this FRI revealed no documentation of an investigation.

During an interview on 6/6/2024 at 9:20 am, the Administrator revealed he had investigated the issue but misplaced all documentation related to this incident. He was unable to provide or report the outcome of the investigation and confirmed CNA 2 continued to provide care to Resident R78 and other residents.

4. Review of Resident R107's Record of Admission, located under the Clinical tab of the EMR revealed Resident R107 was admitted to the facility on [DATE REDACTED] with a diagnosis of Hemiparesis.

Review of Resident R107's discharge MDS dated [DATE REDACTED] revealed a BIMS score of 15 out of 15 which indicated Resident R107 was cognitively intact. The resident required supervision for lower body and toileting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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

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

F 0610 Review of the Grievance Form dated 4/22/2024 revealed that Resident R107 submitted a grievance when the facility received a message from resident's granddaughter stating that the resident was not allowed to use the Level of Harm - Immediate bathroom over the weekend. When Social Services spoke with Resident R107 he advised that that CNA 2 would not jeopardy to resident health or assist him to the bathroom and told him to go in his pull up. He further stated she did not get him up all safety weekend. There was no evidence the incident was investigated by the facility.

Residents Affected - Few During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed there was an allegation of abuse reported by Resident R107 against CNA 2 and the facility did not complete a thorough investigation of the abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28154 potential for actual harm Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) manual, the Residents Affected - Few facility failed to ensure an annual Minimum Data Set (MDS) assessment was submitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for one resident (R) (Resident R58) reviewed out of a total sample of 27. This failure had the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.

Findings include:

Review of the October 2023 RAI Manual page 2-24 showed:

The ARD . must be set within 366 days after the ARD of the previous . comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous . Quarterly . (ARD of previous . Quarterly assessment + 92 calendar days).

Review of Resident R58's electronic medical record (EMR) Face Sheet from the Face Sheet tab showed a facility admitted [DATE REDACTED].

Review of the MDS assessments received by Centers for Medicare and Medicaid Services (CMS) showed

the last MDS received had an assessment reference date (ARD) of 1/15/2024.

The MDS Coordinator (MDSC) provided documentation for Resident R58 of . Final Validation Report dated 5/30/2024 that the ARD of 4/11/2024 annual (comprehensive) MDS was not submitted until 5/30/2024 and, on page 4 of 52, showed Message: Record Submitted Late: The submission date is more than 14 days after V0200C2

on this new comprehensive assessment.

During an interview on 6/6/2024 at 10:50 am, the MDSC confirmed Resident R58's assessment was submitted late, stating, The assessment was closed, and the care plan signature was in there, but the last audit was not done to actually close it and I didn't notice it.

In a follow-up interview on 6/6/2024 at 6:12 pm, the MDSC stated the facility did not have a policy regarding timely submission of assessments. She stated, We use the RAI Manual and follow that.

During an interview on 6/7/2024 at 7:00 pm, the Director of Nursing (DON) stated the expectation is that MDS assessments would be submitted within the RAI guidelines and confirmed the facility did not have a policy and used the RAI Manual.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35690

Residents Affected - Few Based on record review, interviews, and review of the policy titled Care Plan Meetings, the facility failed to ensure that three residents (R) (Resident R56, Resident R44, and Resident R17) of 27 sampled residents had scheduled care plan conferences after each assessment. In addition, the facility failed to ensure updated interventions were included on the comprehensive care plan for one resident (Resident R3). This failure had the potential for residents not to be involved with their care decisions and potential unmet care needs.

Findings include:

Review of the undated policy titled Care Plan Meetings, revealed the policy is that each resident will have an individualized interdisciplinary care plan in place. The care plan will be ongoing, focusing on each individual resident as a unitary unit. Resident and their representative will play an active role in the development of goals and implementation of the residents Comprehensive care plan. Procedure: Number 5. The resident, resident representative, and IDT team members will sign attendance sheet at each comprehensive care plan meeting and this form will be scanned into the residents EMR. Number 7. The comprehensive care plan will be revised as needed and goals updated as appropriate.

1. Review of Resident R56's Record of Admission, located under the Clinical tab of the electronic medical record (EMR), revealed Resident R56 was admitted to the facility on [DATE REDACTED] with a diagnosis of hemiparesis.

Review of Resident R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident R56 was cognitively intact.

Review of the Care Plan Attendance Sheet provided by the MDS Coordinator (MDSC) dated 11/8/2023 revealed that Resident R56 and a friend attended. The form did not indicate the type of assessment. This was the only care plan conference that was held since Resident R56's admission.

Interview on 6/4/2024 at 11:42 am, Resident R56 said he was never involved in planning his care but would like to be.

2. Review of Resident R44's Record of Admission, located under the Clinical tab of the EMR revealed Resident R44 was admitted to the facility on [DATE REDACTED] with a diagnosis of dementia and seizure disorder.

Review of Resident R44's quarterly MDS with an ARD of 2/26/2024 and located under the Clinical tab of the EMR, revealed a BIMS of 15 which indicated Resident R44 was cognitively intact.

Review of the Care Plan Attendance Sheets dated 5/4/2023 and 8/31/2023 revealed that Resident R44 attended. The form indicated the type of assessment was a quarterly assessment. These were the only care plan conferences that were held for Resident R44 since admission.

3. Review of Resident R17's Record of Admission, located under the Clinical tab of the EMR revealed Resident R17 was admitted to the facility on [DATE REDACTED] with a diagnosis of Alzheimer's Disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0657 Review of Resident R17's significant change MDS with an ARD of 2/16/2024 and located under the Clinical tab of the EMR, revealed a BIMS score of 11 which indicated Resident R17 was moderately impaired. Level of Harm - Minimal harm or potential for actual harm Review of the Care Plan Attendance Sheet dated 2/10/2023 revealed that Resident R17 and two other unknown individuals attended. The form did not indicate the type of assessment. This was the only care plan Residents Affected - Few conference that was held for Resident R17 since admission.

During a group interview on 6/6/2024 at 10:00 am, members of the Resident Council (Resident R88, Resident R15, Resident R17, Resident R2, Resident R44, Resident R94 and Resident R8), all seven residents revealed they had never been invited to a care plan conference and did not know that care plan conferences existed. Resident R44 and Resident R17 stated it would be important to them to be involved in planning their care.

30622

4. Review of Resident R3's Record of Admission, located under the Clinical tab of the EMR), revealed Resident R3 was admitted on [DATE REDACTED] with diagnosis of cerebral palsy.

Review of Resident R3's quarterly MDS with an ARD of 3/12/2024 located under the MDS tab revealed the resident did not have a BIMS score.

Review of Resident R3's June 2024 Physician Orders, revealed the following order dated 9/21/2023: Bilateral body pillows to be in place under fitted sheet when resident in bed for torso support Resident having no upper body core strength and having gastric feeding tube in place resident needs for support in attempt to keep resident upright and aide in possible prevention of aspiration.

Review of the care plan dated 12/23/2020 revealed Resident R3 had impaired bed mobility. Interventions to care include assess for changes quarterly and as needed. The care plan did not address the resident's order for body pillows under the fitted sheet.

Observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, revealed Resident R3 was observed in bed without pillows under the fitted sheet.

During an interview on 6/6/2024 at 12:25 pm, MDS Coordinator (MDSC) stated she was currently working on

the care plan conference process. She revealed since COVID the facility has not had care plan conferences.

She said their new process would start today and they would be starting a Performance Improvement Plan (PIP) on this date. The MDSC said usually when it is time for Resident R56's care conference, they do not invite him, only his responsible party.

During an interview on 6/7/2024 at 2:15 pm, Resident R97's Family Members (FM)1 and FM 2 stated they are rarely informed about the status of Resident R97 and were uncertain about the process. The family members indicated they would appreciate a care plan conference, so they would know more about what was going on with Resident R97.

During an interview on 6/7/2024 at 3:35 pm, the Director of Nursing (DON) stated she was not aware that care plan conferences were not being conducted until Resident R56 was discussed the day before. She said moving forward care conferences will happen because they are important.

Cross Refer

F-F602

2. On 3/8/2024, the Administrator was made aware of an injury of unknown origin for Resident R71 and failed to investigate and report this incident.

Cross Refer

F-F610

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0835 During an interview on 6/6/2024 at 9:20 am, the Administrator confirmed the incidents listed above were indicative of abuse to the residents, and were either not reported timely, and/or investigated thoroughly. He Level of Harm - Immediate indicated he had misplaced the documentation related to the incidents. jeopardy to resident health or safety

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm 28154

Residents Affected - Some Based on interviews, review of facility's Nursing Home Inspection Report Upon Receipt of Equipment, review of the Food and Drug Administration (FDA) guidelines, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure bed rails were inspected for safety to minimize the risks of possible entrapment or resident injury for 90 resident beds out of 104. This failure had the potential to cause serious injury to all 90 residents in the facility using a bed with bed rails attached.

Findings include:

Review of the policy titled Proper Use of Side Rails, revised in December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids. General Guidelines: Number 13. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress used).

Review of the Nursing Home Inspection Report Upon Receipt of Equipment provided by the facility and completed annually, documented items inspected included electrical and bed function. There was nothing noted regarding the review of the bed rails for secure attachment and/or gaps that the US Department of Health and Human Services: FDA guidelines dated 3/10/2006 that showed the measurements for the bed rails to reduce the chance of resident entrapment when using bed rails.

During an interview on 6/7/2024 at 9:55 am, Maintenance Worker (MW) confirmed that they did not perform safety checks on resident beds with side rails.

Review of a resident list compiled by Restorative Nurse Aide (RNA) on 6/7/2024 at 8:05 pm revealed that 90 of 104 residents in the facility have one or two side rails on their beds.

During an interview on 6/7/2024 at 7:14 pm, the Director of Nursing (DON) stated the expectation was that maintenance would inspect the beds, including bedrails for safety and security.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 115701

F-F684

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30622 potential for actual harm Based on observations, record review, staff interviews, and review of the policy titled Physician Orders Policy Residents Affected - Few and Procedure, the facility failed to follow the physician orders for one resident (R) (Resident R3) related to using body pillows for positioning. This failure had the potential to put the resident at risk of aspirating. The sample size was 27.

Findings include:

Review of the policy titled Physician Orders Policy and Procedure revised 6/2024, revealed the nurse will carry out all physician orders within a timely manner. The nurse will notify the physician with any delay.

Review of Resident R3's Record of Admission, located under the clinical tab of the electronic medical record (EMR), revealed Resident R3 was admitted to the facility on [DATE REDACTED] with a diagnosis of cerebral palsy.

Review of Resident R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2024 revealed the Brief Interview for Mental Status (BIMS) was not completed. The section to enter the BIMS was blank. It was documented the resident was rarely/never understood.

Review of Resident R3's Physician Orders, revealed an order dated 9/21/2023 for bilateral body pillows to be in place under fitted sheet when resident in bed for torso support, resident having no upper body core strength, and having gastric feeding tube in place. Resident needs support in attempt to keep resident upright and aide in possible prevention of aspiration.

Review of the Kardex Summary located in the EMR under the Clinical tab revealed for fall interventions bilateral body pillows in place under fitted sheet for torso support.

During observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, the resident was observed in bed without body pillows under the fitted sheet.

During an interview on 6/5/2024 at 5:16 pm, Certified Nurse Aide (CNA) 5 stated, he did not use pillows under the fitted bed sheet. He revealed he was not aware of the physician order to have pillows under the resident's fitted sheet.

During an interview on 6/5/2024 at 5:38 pm, Licensed Practical Nurse (LPN) 3 stated, she was not aware of

the physician order for pillows under the fitted sheet and, she had never placed them under Resident R3's sheet.

During an interview on 6/6/2024 at 11:10 am, LPN 5 confirmed she was aware of the physician orders for Resident R3 to have pillows under his fitted sheet. She stated she did not know why the pillows were not in place or when

they were removed. The LPN verified the pillows were not in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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** 30622 potential for actual harm Based on observations, record review, interviews, and review of the policy titled Departmental (Respiratory Residents Affected - Few Therapy) - Prevention of Infection, the facility failed to provide respiratory care in accordance with professional standards for one resident (R) (Resident R48) of two residents reviewed for respiratory care out of a total sample of 27 residents. Specifically, respiratory equipment was not stored in a sanitary manner. This had the potential for the resident to have possible respiratory infections.

Findings include:

Review of the policy titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 2001, revealed the policy is to guide prevention of infection associated with Respiratory tasks and equipment. Infection Control Considerations . Medications: Number 3. After completion of therapy: a. remove the nebulizer container; b. rinse the container with fresh tap water; c. dry on a clean paper towel or gauze sponge. Number 4. Reconnect to the administration set-up when air dried. Number 5. Take care not to contaminate internal nebulizer tubes. Number 6. Wipe the mouthpiece with damp paper towel or gauze sponge. Number 7. Store the circuit in plastic bag, marked with date and resident's name, between uses.

Review of Resident R48's Record of Admission revealed Resident R48 was admitted to the facility on [DATE REDACTED] with diagnosis of chronic obstructive pulmonary disease (COPD).

Review of the quarterly Minimum Data Set (MDS) for Resident R48 with an Assessment Reference Date (ARD) of 4/25/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating resident was cognitively intact.

Review of June 2024 Physician Orders revealed the following order dated 2/14/2024 for ipratropium bromide-albuterol sulfa (Albuterol Sulfate/Ipratropium Bromide 3 milligrams/milliter-0.5 MG/3 ML solution) 1 vial inhalation twice daily for COPD.

Observation on 6/5/2024 at 1:17 pm, revealed Resident R48's nebulizer medication chamber still had medication in it.

It had not been rinsed and was not stored in the plastic storage bag.

Interview on 6/5/2024 at 2:44 pm, Resident R48 stated staff placed the medication chamber and tubing in the basket behind her bed and did not rinse it out. She revealed when she first received the device, the instructions indicated to boil the mouthpiece and medication chamber for five minutes after use.

Interview on 6/5/2024 at 2:52 pm, Registered Nurse (RN) 1 verified that medication was still in the medication chamber and, the medication chamber, mask and tubing were not bagged. She stated she should have rinsed the medication chamber after the medication was administered, and the equipment should have been rinsed, dried, and placed in the plastic bag.

Interview on 6/5/2024 at 3:29 pm, the Director of Nursing (DON) stated the nurses administering the nebulized breathing treatments should wash the equipment after each use with soap and water, dry it with a paper towel, and then place the items in the storage bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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

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

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28154 Residents Affected - Some Based on observations, record review, interviews, and review of the policy titled Proper Use of Side Rails,

the facility failed to ensure that informed consents were signed prior to the use of bedrails for four of 27 sampled residents (R) (Resident R1, Resident R45, Resident R72, and Resident R78) reviewed for bed rail use. The failure had the potential for risks of injury, entrapment, and/or death.

Findings include:

Review of the policy titled Proper Use of Side Rails, revised December 2016, revealed the policy is to ensure

the safe use of side rails as resident mobility aids. General Guidelines: Number 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks.

1. Review of Resident R1's Face Sheet from the electronic medical record (EMR) Face Sheet report tab showed a facility admitted [DATE REDACTED].

The residents quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact.

Review of the care plan for Resident R1 dated 12/17/2021 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility, turning, and repositioning. Interventions to care include monitor for safety, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.

Review of the 8/22/2020 (first) and 4/10/2024 (most recent) bed rail assessments showed bed rail precautions and alternatives to siderails had been discussed with Resident R1 for the first assessment and the family/resident representative for the most recent.

Review of the 12/14/2020 quarterly restorative Interdisciplinary Progress Notes (IPN) written by Registered Nurse (RN) RN3 documented Resident has order for one bed rail but has requested two bed rails with turning and repositioning in bed, risks and benefits of bed rail use discussed with resident and resident wife. However, there wasn't an informed consent signed located in the EMR.

During an observation and interview on 6/5/2024 at 10:40 am, Resident R1 was noted to have bilateral upper quarter rails on his bed. When asked if he used them, Resident R1 responded I hate these damn things, they antagonize me. When asked if he had been advised of the risks/benefits of the rails, he stated, No risk/benefits - I hate them damn things.

2. Review of Resident R45's Face Sheet from EMR Face Sheet report tab showed a facility admitted [DATE REDACTED].

The residents quarterly MDS with an ARD of 3/11/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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

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

F 0700 Review of the care plan for Resident R45 dated 12/16/2020 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility, turning and repositioning, and to access his Level of Harm - Minimal harm or bed controls. Interventions to care include monitor for safety while in bed, provide frequent visual checks, potential for actual harm assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.

Residents Affected - Some Review of the 12/28/2020 (first) and 2/14/2024 (most recent) bed rail assessments for Resident R45 showed siderail precautions and alternatives to siderails had been discussed with family/representative. However, there was no signed consent form found in the EMR.

Review of the 12/28/2020 restorative IPN written by RN3 documented resident has bilateral upper bedrails and risks/benefits had been discussed with the resident and wife. However, there was no signed consent form found in the EMR.

During an interview and observation on 6/420/24 at 2:14 pm, it was observed that Resident R45 had one upper quarter bed rail on the window side of the bed. When asked if anyone had reviewed the risks and/or benefits of the bed rail, Resident R45 stated, No, not said anything to me.

3. Review of Resident R72's Face Sheet from the EMR Face Sheet report tab showed a facility admitted [DATE REDACTED].

The residents quarterly MDS with an ARD of 3/19/2024 revealed no BIMS score and the resident was rarely or never understood.

Review of the care plan for Resident R72 dated 9/30/2022 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility and turning and repositioning. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.

Review of the 9/30/2022 (first) and 3/5/2024 (most recent) bed rail assessments for Resident R72 showed siderail precautions and alternatives to siderails had been discussed with family/representative. However, there was no informed consent found with the family and/or representative in the EMR.

During an observation on 6/4/2024 at 12:09 pm, Resident R72 was out of the room but the bed had one upper quarter rail in the up position on the window side of the bed.

During an observation of Resident R72's bed on 6/7/2024 at 10:54 am, bilateral upper quarter rails now wrapped in pipe insulation padding. Registered Nurse (RN)1 was outside the door and said, The padding was added yesterday because she fell out of bed and hit her cheek on the siderail. When asked if Resident R72 used the rails, RN1 replied Yes - to turn and reposition, that's how she fell out of the bed.

4. Review of Resident R78's Face Sheet from the EMR Face Sheet report tab showed a facility admitted [DATE REDACTED].

Review of the significant change of status MDS with an ARD of 3/21/2024 revealed a BIMS score could not be obtained and the resident was rarely or never understood.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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

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

F 0700 Review of the care plan for Resident R78 dated 2/14/2024 documented resident has impaired bed mobility and uses 1-2 upper quarter-length side rail(s) to assist with bed mobility, turning and repositioning, and bed controls. Level of Harm - Minimal harm or Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, potential for actual harm repositioning, pulling up in bed as needed, and assess for changes quarterly.

Residents Affected - Some Review of the 2/2/2023 (first) and 3/4/2024 (most recent) bed rail assessments for Resident R78 showed siderail precautions and alternatives to siderails had been discussed with family or representative.

Review of the 4/20/2023 restorative IPN written by RN4 documented resident demonstrates proper use of upper bilateral quarter length side rails for turning, and repositioning. There was no signed consent form found in the EMR.

During an observation of Resident R78's room on 6/4/2024 at 10:15 am, the bed had bilateral upper quarter rails in the up position.

During an interview on 6/7/2024 at 7:19 pm, the Director of Nursing (DON) stated the expectation was that

the facility would attempt alternatives before side rails were used and that they do assess the resident; that risk/benefits would be advised, and it is documented who is being advised.

No signed consents were provided for any of the four residents above by the time of the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0732 Post nurse staffing information every day.

Level of Harm - Potential for 28154 minimal harm Based on observation and staff interviews, the facility failed to ensure that the daily nurse staffing posted Residents Affected - Many included the name of the facility, the facility census, and the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. display contained the required information for residents, visitors, and/or staff. This failure could affect the knowledge of the family members or representatives of the 104 residents in the facility.

Findings include:

During an observation on 6/4/2024 at 9:15 am of the nursing staff posting on the wall in the lobby of the facility revealed a grid chart with all 30 days of June with the first three days filled out with the numbers of staff for each of the following staffing categories for each of three eight-hour shifts (days, evenings, nights - no ward clerk):

*Registered Nurse (RN)

*Licensed Practical Nurse (LPN)

*Certified Nurse Aide (CNA)

*Ward Clerk (WC)

The staff posting did not show the name of the facility, the census for each shift, or the total number of hours for each category.

Review of the April and May 2024 staff posting documents provided by the facility showed the entire months and the number of staff for each category, but not the facility name, census, or total number of hours worked for each staffing category.

During an interview on 6/7/2024 at 9:33 am Human Resources (HR) staff stated she was responsible for the staff posting, and stated it may not be every day, the numbers are not the day of, but usually the day after. At 4:12 pm, the HR staff stated there was no policy regarding the nurse staff posting.

During an interview on 6/7/2024 at 7:03 pm, the Director of Nursing (DON) stated the expectation was that

the staff posting would contain all the required elements. The DON confirmed the posting did not contain all

the required elements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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** 30622

Residents Affected - Few Based on record review, staff interviews, and review of the policy titled 10.b Medication Regimen Review, the consultant pharmacist failed to identify and report irregularities regarding an order for PRN (as needed) lorazepam (antianxiety medication) beyond 14 days and to include a written rationale and duration for continuing its use, for one resident (R) (Resident R24) reviewed for psychotropic medications from a total of 27 sampled residents.

Findings include:

Review of the policy titled 10.b Medication Regimen Review revised 5/2020 revealed Procedure: A. The consultant pharmacist will conduct medication regimen reviews (MRRs) if required under a pharmacy consultant agreement and will make recommendations based on the information available in the residents health record.

Review of the clinical record revealed was admitted to the facility on [DATE REDACTED] with diagnosis of dementia.

The resident's annual Minimum Data Set (MDS) dated [DATE REDACTED] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section N revealed that the resident received antianxiety medications.

Review of the June 2024 Physician Orders revealed an order dated 5/9/2023 for lorazepam 0.5 milligrams (mg) tablet, one tablet by mouth as needed [PRN] TID [three times a day] for anxiety.

Review of Resident R24's Medication Regimen Review (MRR) from 5/2023 through 5/2024 provided by the Director of Nursing (DON) did not reveal any recommendations from the pharmacist to address the lack of a 14-day stop date or for the physician to provide a rationale to continue the lorazepam.

Review of Resident R24's EMR revealed no documentation by the resident's physician regarding the clinical rationale for continued use of lorazepam.

During a phone interview on 6/7/2024 at 10:47 am, Physician (PHY) 1 was contacted regarding the lorazepam order. He confirmed he did not document the rationale for the continued use of lorazepam.

During an interview on 6/7/2024 at 11:35 am, Licensed Practical Nurse (LPN) 1 stated they did not have any documentation showing pharmacy recommendations regarding the resident's lorazepam.

During an interview on 6/7/2024 at 11:47 am, the Pharmacist verified the monthly MRRs did not address the lorazepam and no recommendations were made.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 30622 Residents Affected - Some Based on observations, interviews, and review of the policy Titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure expired medications were removed from one of two medication carts, failed to remove expired phlebotomy supplies for one of two phlebotomy carts, and one of two medication rooms. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The census was 104.

Findings include:

Review of the undated policy titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles revealed Procedure: C.9. Nursing staff will monitor for expired drugs and cleanliness of medication room/medication carts once weekly. Procedure: D. Facility should ensure that medications and biologicals: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

1. Observation on 6/6/2024 at 9:27 am in the Blue Hall medication room, the following expired items were found:

One bottle Pro- Stat (protein) expired 4/2024

One bottle Pro-Stat expired 3/2024

One bottle Co-Q-10 100 milligrams (mg) tabs expired 5/2024

One bottle Zinc Sulfate 220 mg expired 4/2024

One bottle Zinc Sulfate 220 mg expired 3/2024

One box L-Methylfolate Calcium Tablets expired 4/2024

One box L-Methylfolate Calcium Tablets expired 10/2023

Seven boxes of Omeprazole 20 mg tablets expired 5/2024

One box Omeprazole 20 mg tablets expired 12/2023

One box Omeprazole 20 mg tablets expired 2/2024

One box Pink Bismuth anti-diarrheal 30 chewable tablets expired 5/2024

Four boxes of Omeprazole acid reducer 20 mg tablets expired 5/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0761 One box Saccharomyces Boulardii (probiotic) 250 mg capsules expired 5/2024

Level of Harm - Minimal harm or One bottle Iron supplement liquid expired 2/2023 potential for actual harm One bottle Centrum Adults expired 2/2024 Residents Affected - Some

Interview on 6/6/2024 at 9:27 am, Registered Nurse (RN) 2 verified the expiration dates and, confirmed that

the medications were still available for resident use. She stated the expired medications should be given to

the Director of Nursing (DON) for destruction.

Interview on 6/6/2024 at 9:50 am, Licensed Practical Nurse (LPN) 4 stated the expiration dates should be checked upon receiving the medications from the pharmacy. The LPN stated the night shift nurses were responsible for checking the medication room for expired medications.

2. Observation and interview on 6/6/2024 at 2:07 pm, the phlebotomy cart located at the nurses' station between the pink and green halls revealed one black top vacutainer tube that expired on 6/2/2024; one container (85 tubes) of light blue top vacutainer tubes expired on 12/31/2023. RN 1 verified the expiration dates and confirmed they were still available to be used.

3. Observation on 6/6/2024 at 2:10 pm, the [NAME] Hall medication cart was inspected with LPN 5 and revealed one card of discontinued oxycodone (narcotic pain medication) 15 mg with 78 tablets was on the cart. The LPN stated that discontinued narcotics should be removed from the cart the day they are discontinued. LPN 5 verified the oxycodone medication was discontinued.

Interview on 6/6/2024 at 2:20 pm, the DON stated expired medications should not be available for use on medication carts or in the medication room. She stated they should be removed immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 35690 Residents Affected - Some Based on observations and resident and staff interviews, the facility failed to ensure that meals were served according to resident preferences and designated meal times for 50 residents on the green and pink halls.

Findings include:

Interview on 6/4/2024 at 9:30 am, the Registered Dietician (RD) and the Dietary Manager (DM) stated the designated meal times were: Breakfast was to be served at 8:00 am, Lunch to be served at 12:00 pm, and Dinner was to be served at 5:00 pm.

Interview on 6/4/2024 at 1:39 pm, Resident R48 stated she had not received her lunch yet. At that moment, a staff member entered the room with her tray. Resident R48 stated the trays should be there at noon or 12:30 pm. Her roommate also did not have a tray and revealed it was supposed to be noon.

Interview on 6/4/2024 at 2:08 pm, Resident R45 stated he had not received his lunch tray. The interview ended at 2:25 PM and the lunch tray had still not arrived.

During a group interview on 6/6/2024 at 10:00 am with members of the Resident Council (Resident R88, Resident R15, Resident R17, Resident R2, Resident R44, Resident R94 and Resident R8), residents confirmed meal delivery was consistently late. Resident R88 and Resident R15 said dinner was sometimes so late it affected their acid reflux. Resident R17 and Resident R55 expressed concerns about having lunch so late because they were diabetics and received insulin. Resident R17 stated sometimes lunch is served as late as 2:15 pm.

Observation on 6/6/2024 at 1:31 pm (an hour and a half after the scheduled time), lunch trays for 24 residents were observed to arrive on the pink hall. Continued observation revealed the last tray on the hall was served at 1:51 pm.

Interview on 6/6/2024 at 1:57 pm, Certified Nurse Aide (CNA) 9 revealed room trays always come late. She said she has seen them come as late as 3:00 pm.

Interview on 6/6/2024 at 2:00 pm, CNA10 confirmed that room trays always come late. She said they are supposed to make round on their residents between 2:00 pm - 4:00 pm daily and it is difficult when lunch is served so late.

Interview on 6/6/2024 at 2:12 pm, CNA 11 said lunch trays always come around this time or later. She said when trays come so late it makes it difficult to complete other work because residents are eating. She said residents frequently complain about how long it takes to get their meals.

Interview on 6/7/2024 at 1:30 pm, Resident R45 stated he had not yet received his lunch tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0809 Observation on 6/7/2024 at 1:45 pm (an hour and 45 minutes after the scheduled time), lunch trays for 26 residents were observed to arrive on the green hall. Continued observation revealed the last tray on the hall Level of Harm - Minimal harm or was served at 2:19 pm. potential for actual harm

Observation on 6/7/2024 at 1:50 pm, eight residents were observed on the green hall, sitting outside their Residents Affected - Some rooms, waiting for their lunch. Resident R81 said we always eat lunch late. Resident R52 agreed saying, usually we don't get lunch earlier than 2:00 pm. Resident R52 stated she was hungry since breakfast was served earlier this morning.

Observation and interview on 6/7/2024 at 2:15 pm, family members (FM) 1 and FM 2 for Resident R97 were observed giving him a protein shake. FM 2 revealed the lunch trays were always served late and they were not sure why. They said that's too late for lunch, and Resident R97 agreed.

Interview on 6/7/2024 at 6:54 pm, the DM said room trays are late because of the lack of communication between nursing and dietary staff. He said having a list of who is coming into the dining room would help with room trays being served earlier.

Interview on 6/7/2024 at 7:06 pm, the Director of Nursing (DON) stated the expectation is that meal service would be timely, all day should be timely.

Interview on 6/8/2024 at 11:27 am, License Practical Nurse (LPN) 4, the Unit Manager for Pink Hall and LPN 2, the Unit Manager for [NAME] Hall, stated they were not aware that meals were served as late as 2:00 pm at times. They both agreed that receiving meals at 2:00 pm was too late and said serving a meal late impacts other resident care that staff need to complete.

A policy for meal service and/or mealtimes was requested. The policy was never provided.

28154

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate 36917 jeopardy to resident health or safety Based on record review, interviews, review of the Administrator Job Description, and review of the policy titled Abuse Reporting and Investigation, the facility Administration failed to provide protective oversight to Residents Affected - Many attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident abuse, exploitation, and injury of unknown origin, which were reported to him. The failure of the Administrator to take appropriate action which was reported to him has the likelihood to lead to future allegations of abuse, exploitation, and injury of unknown origin that are not identified, reported, or investigated.

On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.

The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the Immediate Jeopardy's was identified to have existed

on 3/22/2024 when the facility failed to protect two residents (R) (Resident R78 and Resident R107) from physical, mental, and verbal abuse. A second Immediate Jeopardy was identified to have existed on 3/22/2024 when Certified Nurse Aide (CNA)1 began a personal relationship with Resident R71.

A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.

Findings include:

Review of the undated document titled Nursing Home Administration Job Description/Performance Evaluation documented the Administrator of the Nursing Home shall be responsible for the planning, controlling, and directing the overall program and shall be responsible for direct supervision of all departments of the Nursing Home. The Administrator of the Nursing Home is an experienced professional who ensures that the facility meets the age specific needs of adults and geriatrics as well the physical, psychosocial, and cultural needs of the residents. Functions and duties include:

Assist with planning, organizing, controlling, and directing a viable program of services at Nursing Home.

Manage a program of patient services that allows resident the opportunity for input into the facility's operation

and to promote an environment that is conducive to the social, physical, psychological, and cultural health of

the patient population.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 115701 Department of Health & Human Services Printed: 09/23/2025 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 115701 B. Wing 06/08/2024

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

Chatuge Regional Nursing Home 386 Belaire Drive Hiawassee, GA 30546

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 0835 Ensure the facility's physical plan is maintained to OSHA guidelines and standards and that the physical

Level of Harm - Immediate environment remains attractive and pleasant to residents and visitors. jeopardy to resident health or safety Ensure compliance with State and Federal guidelines regarding Nursing Home operations.

Residents Affected - Many Monitor in-service training and ensure that it is carried out on an on-going basis and encourage staff

development.

Attend organizational meetings, board meetings, and represent the Nursing Home in all matters.

Review of a policy titled Abuse Reporting and Investigation, last revised March 2017 revealed Implementation: Number 3.c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. and interview the resident's attending physician as needed to determine

the resident's current level of cognitive function and medical condition; g. Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; i. interview other residents to whom the accused employee provides care or services; j. and review all events leading up to the alleged incident, and obtain the interviews in writing by the staff member or the administrator/abuse coordinator, notify the ombudsman, suspend the employee pending the progress/findings of the investigation. Number 5. Witness reports will be obtained in writing. Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency.

1. On 7/12/2023, an allegation of exploitation was reported to the Administrator regarding a staff to resident personal relationship between CNA 1 and Resident R71. The Administrator failed to identify this personal relationship as potential exploitation and did not investigate or report this allegation.

Cross Refer