Pruitthealth - Toccoa

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, record review, and resident and staff interviews, the facility failed to ensure call lights were within reach for one of 31 sample residents (Residents (R) 58) reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the residents in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible.Findings include:Review of Resident R58's admission Record found in the Profile tab of the electronic medical record (EMR), revealed she was admitted with diagnoses including but not limited to dementia, cervical disc disorder with myelopathy, muscle weakness, and difficulty in walking.Review of Resident R85's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 8/4/2025, revealed a Brief Interview for Mental Status (BIMS) assessment with a score of nine out of 15, which indicated moderate cognitive impairment. Resident R58 was observed on 8/25/2025 at 12:36 PM resting in bed with the call light button out of reach and sight of the resident. Resident R58 was again observed on 8/26/2025 at 4:02 PM resting in bed with her call light on the floor behind the bed and out of reach.Resident R58 was again observed on 8/27/2025 at 10:20 AM resting in bed. The call light was on the floor under the resident's bed against the wall.Resident R58 was again observed on 8/28/2025 at 9:50 AM resting in bed with the call light still on the floor behind the bed out of reach.During an interview on 8/28/2025 at 9:51 AM, Resident R58 stated that she did not have a call light, looked around her bed, and again stated she did not have a call light for use.During an interview on 8/28/2025 at 9:54 AM, Unit Manager (UM) 4 said that staff should ensure call lights were accessible to the residents.During an interview on 8/28/2025 at 9:56 AM, Certified Nurse Aide (CNA) 6 said that call lights should be pinned to the residents or placed near them.During a concurrent interview on 8/28/2025 at 9:59 AM, UM4 and CNA6 went into Resident R58's room and both confirmed the resident's call light was on the floor against the wall, under the bed, and out of reach of the resident. They pinned the call light to the resident. During an interview on 8/28/2025 at 10:03 AM, the Administrator stated that call lights should always be placed in reach of the resident.During an

interview on 8/28/25 at 2:10 PM, the Administrator stated that the facility did not have a policy regarding accommodation of needs or call light accessibility for residents.

Residents Affected - Few

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

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

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

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pruitthealth - Toccoa

633 Falls Road Toccoa, GA 30577

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on staff interview, document review, and facility policy review, the facility failed to report the results of

the investigation of sexual abuse to the State Survey Agency (SSA) within five working days of the incident for one of one resident (Resident (R) 68) reviewed for abuse out of a total sample of 31 residents.

Specifically, Resident R71 removed her clothes and incontinence brief and climbed into Resident R68's bed.Findings include:Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 11/15/2024, indicated Procedure, 2.A written report of the investigation .should be submitted to the appropriate agency within five working days of the occurrence.Review of the facility investigation, provided by the Administrator, into the allegation of sexual abuse, revealed that on 7/31/2025 at 5:25 AM, Resident R71 was unclothed sitting at the end of Resident R68's bed in their room. The file indicated that the SSA was initially notified on 7/31/2025 at 6:20 AM. However, the final report of the investigation was not sent to the SSA until 8/11/2025.During an interview on 8/26/2025 at 12:44 PM, the Administrator confirmed the results of the investigation were not submitted timely within five days to the SSA. The Administrator stated that she was out of the country at the time of this incident and that the Administrative Assistant was informed of the incident, reported the initial report to the SSA, and then sent the results of the abuse investigation to the SSA.

Event ID:

Facility ID:

If continuation sheet

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

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

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pruitthealth - Toccoa

633 Falls Road Toccoa, GA 30577

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 - Minimal harm or potential for actual harm

Based on interviews, record review, document review and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of sexual abuse for two of 31 sampled residents (Resident (R) 68 and Resident R71). The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from abuse.Findings include:Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 11/15/2024, indicated Procedure, 1. Documentation of the investigation should include. Signed statements from pertinent parties. Interview should be conducted of all individuals who have relevant information.Written signed statements from any involved parties should be obtained. patients involved, reliable patients who may have witnessed the incident.Review of the facility investigation, provided by the Administrator, into the allegation of sexual abuse, revealed that on 7/31/2025 at 5:25 AM, Resident R71 was unclothed sitting at the end of Resident R68's bed in their room. The investigative file did not include a statement from Resident R68 or from Resident R49 who was

the third resident who shared the room with Resident R68 and Resident R71.Review of Resident R68's electronic medical record (EMR) under the Resident Assessment Instrument (RAI) tab, the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/2025 indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident R68 was cognitively intact. Review of Resident R71's EMR under the RAI tab, the admission MDS with an ARD of 7/28/2025 indicated a BIMS that the resident was rarely/never understood, short-and long-term memory, therefore, a BIMS score was not obtained.Review of Resident R49's EMR under the RAI tab, the quarterly MDS with an ARD of 8/25/2025 indicated a BIMS score of nine out of 15, which indicated Resident R49's cognition was moderately impaired.During an interview on 8/25/2025 at 3:48 PM, Resident R68 stated that she remembered when her roommate (Resident R71) came to her side of the bed and was not wearing any clothes. Resident R68 stated that Resident R71 did not get in her bed. I used my call light to have the nurse come and help her.During an interview on 8/26/2025 at 2:18 PM, the Administrator confirmed that the investigative file contained all the interviews that were conducted. The Administrator confirmed that the file did not contain

an interview with Resident R68 or Resident R49. The Administrator stated that Resident R49 should have been interviewed even though her BIMS score was nine, to determine if she witnessed the incident. The Administrator stated that she was out of the country at the time of this incident and that the Administrative Assistant was informed of the incident and conducted the investigation. The Administrator confirmed it was not a thorough investigation.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet