Orchard Health And Rehabilitation

F-F600 the policy for abuse education was reviewed to include response to sexual abuse, Non-Pharmacological Interventions to manage behaviors, Patient interviews completed on 3/31/2025 by social service director to interviewIO residents to ensure they feel safe and IO associates interviews to ensure they know process for reporting and can identify abuse to include sexual and physical aggression. Audit will continued until IJ removed.

F-F740, ensuring that patients were safe and that staff understood

the education on non pharmacological interventions for inappropriate sexual/physical behavior, and QAPI

review completed as indicate on reportable for trends. Any noncompliance noted will be addressed through written education by the Divisional [NAME] President.

The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:

1. On 4/3/2025 at 12:55 pm verified by record review of a 5-way tool was used during QAPI meeting that held on

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 115522 Department of Health & Human Services Printed: 08/31/2025 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 115522 B. Wing 04/03/2025

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

Orchard Health and Rehabilitation 1321 Pulaski School Road Pulaski, GA 30451

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 0867 3/31/2025 at 2:30 pm. The tool determined that root causes were a result Gradual Dose Reduction (GDR)s of some behaviors. They established a communication tool with titled {Named} Visits Communication dated Level of Harm - Immediate 4/1/2025. The tool is broken into 4 identified components routine visits, acute episode, GDR and Added to jeopardy to resident health or PAR. {Named} visit. On 4/3/2025 verified by interview with facilities Management Supervisor who revealed safety that he attended the QAPI meeting on 3/31/2025 at 2:30pm. On 4/3/2025 at 1:48 pm DON revealed that she was in the QAPI meeting that was held on 3/31/2025 and a discussion of all IJ tags and they discussed Residents Affected - Few behaviors and GDR reviews. On 4/3/2025 at 3:45 pm verified by record review of QAPI minutes were reviewed along with attendees sign in sheets all QAPI committee was present except for Administrator. On 4/3/2025 at 3:45 pm verified by record review revealed that on March 28,2025, the governing body held in service education to the Administrator, the divisional vice president, educated her on the process to follow when reporting abuse, the QAPI role, responsibilities, and her duties as the Administrator to ensure the safety of the patients. On 4/3/2025 at 2:27 pm LPN GG confirmed that she attended QAPI meeting during

the meeting they discussed the IJ tags. On 4/3/2025 at 2:27 pm LPN HH confirmed that she attended QAPI meeting they discussed the communication tool that they will be utilizing with {Named} Behavioral Health monitor residents with sexual behaviors and behaviors.

2. On 4/3/2025 at 2:02 pm verified by record review of an education titled, Behavior Health Process dated 3/31/2025, presented by Senior Director of Clinical Standards. On 4/3/2025 at 2:08 pm Licensed Practical Nurse (LPN) GG confirmed that she was educated on the process of an audit that will be conducted as the {Named} Behavioral Health enters and exits the facility. In further interview she revealed that they will identify residents that are acute episode and routine visits. The communication between {Named} Behavioral Health and nursing staff will increase to ensure that residents are being identified if medications are changed or if interventions are added for sexual behaviors or behaviors. On 4/3/2025 at 2:27 pm LPN HH confirmed that

she attended QAPI meeting and she was educated on 3/31/2025 titled, Behavior Health Process presented by Senior Director of Clinical. In further interviews she revealed that this audit has been conducted since 4/1/2025 the indicators: 1.Were there any self-reportable for sexually inappropriately behaviors submitted? 2. If so, was there an RCA completed to identify trends? LPN GG revealed that no reports were reported to nursing leadership on 4/1/2025, 4/2/2025, or 4/3/2025. A record review conducted on 4/3/2025 at 2:47 pm of

the Quality improvement Data Collection Grid was implemented by nursing staff submitting information to assistant Administrator and reviewed by Senior Director for 4/1/2025, 4/2/2025 and 4/3/2025.The results self-reportable for sexually inappropriate behaviors were submitted no reports. On 4/3/2025 Certified Nursing Assistant (CNA) BB revealed that she is aware that they must report any sexual abuse behaviors for all residents she works on the memory unit. An observation was conducted on 4/3/2025 at 3:33 pm on memory unit residents were singing and calm in TV room no sexual behaviors were seen or heard. Staff were involved with residents and CNAs and Nursing staff are monitoring residents. Residents were observed in TV room CNAs were in room observing residents. On Hall C residents were seen in halls chatting with one another no sexual abuse seen or heard on halls. Residents are communicating with each other no issues found. Nursing staff are visible and monitoring and interacting with residents. On 4/3/2025 at 3:53 pm an audit of reportable in the last 30 days has been identified on 3/31/2025 of 6 residents that were identified with

the date of incident and nature of incident.

All corrective actions were completed on 3/31/2025.

The Facility alleges IJ Removal 4/1/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 115522

F-F835 a daily review for oversight will be completed by the Divisional [NAME] president and/or Senior Director of Clinical Standards to ensure that audits were completed for

F-F867 - QAPI education was provided to include trending RCA to analyze resources needed to decrease or prevent reoccurrence. Communication tool was developed and implemented on 3/31/2025 by DON to improve the communication between the behavior provider and center to provide notification of any recommendations timely. The behavior provider will meet with the DON, ADON, and/or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events. Nurse Managers will update the patient care plan with any non-pharmacological interventions to the patient care plan. For