Pruitthealth - Bethany

F-F600

2. The facility failed to develop a comprehensive person-centered care plan that specified the need for two-person assistance with ADL care.

Cross refer

F-F656

3. The facility failed to protect Resident R1 from a fall during ADL care, resulting in her death at the hospital.

Cross refer

F-F689

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 115700 Department of Health & Human Services Printed: 09/17/2025 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 115700 B. Wing 07/11/2024

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

Pruitthealth - Bethany 466 South Gray Street Millen, GA 30442

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 An interview on 7/2/2024 at 3:00 pm with Administrator HH revealed she was not at the facility at the time of

the incident but was informed of the incident by the weekend supervisor, Registered Nurse (RN) AA. Level of Harm - Immediate Administrator HH further revealed Certified Nursing Assistant (CNA) CC was sent home and suspended jeopardy to resident health or pending the outcome of the investigation to determine what happened with Resident R1. Administrator HH stated that safety some staff could do Resident R1's ADL care by themselves. She stated that the facility had initiated a self-imposed Immediate Jeopardy and immediately began educating the staff. Residents Affected - Few

An interview on 7/2/2024 at 4:09 pm with the DHS revealed the weekend supervisor RN AA met with CNA CC and obtained a statement. She stated CNA CC was sent home on Sunday, 6/30/2024. She further stated CNA CC was off Monday but was called in and spoke with Administrator HH and the DHS. She stated CNA CC was suspended pending the investigation. The DHS stated that Resident R1 could assist with turning, and she held on to the mattress while turning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 115700