Peachtree Nursing And Rehabilitation LLC

Based on observations, record reviews, and interviews, the facility failed to keep track of when to discard refrigerated food items through labeling and dating the items. This failure had the potential to negatively impact (through foodborne illness) 139 residents residing at the facility by exposing them to food items that may have spoiled.Findings include:An observation on 11/18/25 at 8:50 AM, during the Flash Tour. completed with the Director of Food and Nutrition Service (DFNS), of the kitchen revealed numerous food items located in the reach in refrigerators were not labeled or dated. The food items were as followed: cooked chicken breasts in a steam table pan, sliced ham covered by plastic wrap, opened packets of hot dogs, roast beef, fresh and cooked yellow squash located in a partially filled steam table pan, fresh broccoli, sliced cheese wrapped in plastic wrap, pork chops located in a partially filled steam table pan, raw fish located in a steam table pan, raw chicken breast located in a steam table pan, raw hamburger wrapped in plastic wrap, a container of ranch dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure physician orders for code status matched the residents' Physician Orders for Life Sustaining Treatment (POLST) and wishes for two of four residents (Resident (R) 57 and R49) reviewed for advance directives out of 29 sampled residents. This failure increased the likelihood of causing severe harm or death if CPR (Cardiopulmonary Resuscitation) was performed or withheld against a resident's wishes.Findings include:1. Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R57 was admitted to the facility on [DATE] and returned from a hospital stay on [DATE]. R57 had diagnoses which included cerebral infarction (stroke) and sepsis (a life-threatening condition where the body's response to an infection damages its own tissues and organs).Review of the Care Plan, tab of the EMR revealed an intervention, revised on [DATE], under the focus area cognitive loss/decision making poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure residents were free from abuse and neglect for one of four residents (Resident (R) 49) reviewed for abuse and neglect out of 29 sampled residents. The facility neglected the resident when Certified Nurse Aide (CNA) 1 removed the call light out of the resident's reach. CNA 1 intimidated R49 when she stood over her and told the resident not to use the call light again. These failures had the potential to cause unmet care needs. Findings include:Review of R49's undated admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, Reiter's disease, and cervicalgia. Review of R49's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/25 and located in the EMR under the MDS tab, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and policy review, the facility failed to ensure abuse and neglect by staff was reported timely to the Director of Nursing (DON) and to the State Survey Agency (SSA) when a resident's call light was placed out of reach, and told not to use the call light anymore by Certified Nursing Assistant (CNA)1 for one of four residents (Resident (R) 49) reviewed for neglect out of 29 sampled residents. Findings include:Review of R49's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/25, located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Review of R49's Nursing Progress Note, dated 10/30/25, located in the EMR under the Prog Notes tab, revealed Spoke with resident's daughter concerning agency staff removing call light out of residents reach. Daughter was notified that agency staff will not be returning to building. Daughter said thank you and expressed no other concerns.Review of a Facility Incident Report Form, dated 10/30/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure another method to call for assistance was provided when a resident's call light malfunctioned and was removed from the resident's wall for one of four residents (Resident (R) 157) reviewed for call lights out of 29 sampled residents. This failure had the potential to result in residents' care needs not being met by nursing staff. Findings include:Review of R157's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed she was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA), hemiplegia following CVA, and mild protein calorie malnutrition. R157 expired in the facility on [DATE]. Review of R157's change in condition Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was cognitively intact.Review of a Facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to ensure food items in the kitchen cooler were properly stored and labeled with open or discard dates, failed to dispose of expired foods in a resident nourishment pantry, and failed to ensure an ice maker was maintained in a clean and sanitary manner. The deficient practices placed the 106 residents (R) who consumed an oral diet from the kitchen at risk for avoidable foodborne illness. Findings include: The Food Safety policy was requested and was not provided. Observations of the kitchen cooler on 7/23/2024 at 9:15 am revealed the following: One industrial-size cooking sheet containing seasoned chicken was covered with plastic wrap with a light orange substance on the wrap without a label indicating a stored or discard date. Trays of bacon without a label indicating a stored or discard date. Opened condiments, including a wing sauce/glaze, strawberry topping, and salad dressing, without a label indicating a stored or discard date. A pan of green beans without a label indicating a stored or discard date. A pan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and a review of the facility policy titled Quality of Care and Quality of Life-Accommodation of Needs, the facility failed to provide dining assistance to one of 13 residents (R) (R38) selected for dining observation. The deficient practice placed R38 at risk for unmet care needs and a diminished quality of life. Findings include: A review of the facility policy titled Quality of Care and Quality of Life-Accommodation of Needs, dated July 8, 2021, revealed the Policy was To define a process to accommodate individual needs and preferences to the extent possible for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with residents' assessment and plan of care. The Definitions section included ADLs [Activities of Daily Living]: . Dining, including eating meals and snacks. The Procedure section included Staff Attitudes and Behaviors: 3.1 Accommodate individual needs and preferences; staff attitudes and behaviors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to provide an environment free from chemical hazards for one of four residents (R) (R91) reviewed for accident hazards. This deficient practice placed R91 at risk for avoidable chemical incidents, injuries, and a diminished quality of life. Findings include: A policy was requested and was not provided. A review of R91's clinical record revealed diagnoses including, but not limited to, unspecified dementia and cognitive communication deficit. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 4 (indicating severe cognitive impairment) and section GG (Functional Abilities and Goals) documented R91 required supervision with ambulation. A review of the care plan revised on 7/17/2024 revealed a focus area of cognitive losses, resident with memory deficit related to diagnosis of dementia. An observation on 7/23/2024 at 11:37 am revealed R91 lying on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Advance Directive, the facility failed to update the care plan for one of five sampled Residents (R#17) related to code status. Findings include: Record review of the facility policy titled Advance Directive with a revision date of [DATE], revealed under the change in condition, 3.3, initiate a new life-sustaining treatment (RPLST) form and update the care plan to reflect changes, or if no changes have been made, to document the date of review and discussion; Care Plan Review 4.1; all residents will be reviewed at care plan for advance directive and/or RPLST; 4.2 existing RPLST will be reviewed. If there is no change, sign, and date the RPLST form. Record review for R#17 revealed that the resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to encephalopathy, systemic inflammatory response syndrome, the presence of a cardiac pacemaker, and vascular dementia. Record review of the care plan for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.