Pleasant View Nursing Center

F-F695

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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** 36377 potential for actual harm Based on observations, staff interviews, and record review, the facility failed to follow the physician's orders Residents Affected - Few for two residents (R) (Resident R43 and Resident R78). Specifically for an evaluation for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) for Resident R43 and for gastrostomy tube (G-tube) water flushes for Resident R78.

This failure had the potential for Resident R43 and Resident R78 to not receive medical treatment according to their needs and placed them at risk for adverse consequences.

Findings include:

1. A review of Resident R43's Face Sheet revealed Resident R43 was admitted to the facility on [DATE REDACTED] with a diagnosis including, but not limited to, contracture of left hand.

A review of the admission Minimum Data Set (MDS), dated [DATE REDACTED], and the quarterly MDS, dated [DATE REDACTED], revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented the resident did not receive PT, OT, or ST.

A review of Resident R43's Physician Orders revealed an order dated 5/2/2024 for evaluations for PT, OT, and ST.

Observation during the survey from 8/18/2024 through 8/20/2024 revealed Resident R43 lying in bed with no splint device, and his left hand third and fourth fingers were folded into the palm of his hands.

During an interview on 8/18/2024 at 3:25 pm, Resident R43 reported a concern about not receiving therapy services for a splint device and range of motion (ROM) for his left-hand contracture.

In an interview on 8/21/2024 at 12:58 pm, the Unit Manager acknowledged that Resident R43 had a physician order for therapy evaluation. She reported being unaware that the order was not followed up on.

In an interview on 8/21/2024 at 1:10 pm, the Director of Rehabilitation confirmed the therapy department had not performed therapy evaluations for Resident R43. She confirmed that she met the resident at the time of admission and was aware of his contracture. She stated she felt the resident would benefit from ROM therapy services and a splint device.

In an interview on 8/21/2024 at 4:55 pm, the Director of Nursing (DON) reported that her expectation was for physician orders to be followed.

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2. A review of Resident R78's Face Sheet revealed diagnoses including, but not limited to, dysphagia and unspecified severe protein-calorie malnutrition.

A review of Resident R78's Significant Change MDS, dated [DATE REDACTED], revealed section K (Swallowing/Nutritional Status) documented Resident R78 had a feeding tube and received 51 percent or more of total calories and 501 cubic centimeters (cc) or more per day of fluid intake through the feeding tube.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 A review of Resident R78's care plan, revised on 8/12/2024, revealed Resident R78 will receive feeding and hydration via G-tube as ordered. Level of Harm - Minimal harm or potential for actual harm A review of the Physician's Orders revealed an order dated 8/10/2024 to flush the G-tube with 5 cc of water

after each medication and flush the G-tube with 30 cc of water before and after feedings. Further review Residents Affected - Few revealed an order dated 8/11/2204 for Jevity 1.5, give 237 milliliters (ml) every four hours.

A review of the medication administration record (MAR) dated 8/2024 revealed no documentation of G-tube water flushes with medications or feeding.

A review of the Progress Notes revealed no documentation of water flushes of the G-tube.

In an interview on 8/20/2024 at 4:15 pm, Licensed Practical Nurse (LPN) AA verified water flushes of the G-tube were not documented on the MAR or in the clinical record. She revealed her expectations were for staff to follow physician orders by flushing the G-tube and document if it was performed.

In an interview on 8/21/2024 at 4:14 pm, the Regional Director of Nursing revealed the nurse who receives

the physician's order was responsible for transcribing it onto the MAR. She stated her expectation was for physician orders to be listed on the MAR and followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36377

Residents Affected - Few Based on observations, staff interviews, and record review, the facility failed to provide services to increase or prevent a decrease in range of motion (ROM) for one of 52 sampled residents (R) (Resident R43). The deficient practice had the potential to place Resident R43 at risk for medical complications, unmet needs, and a diminished quality of life.

Findings include:

A review of Resident R43's Face Sheet revealed that Resident R43 was admitted to the facility on [DATE REDACTED] with a diagnosis including, but not limited to, contracture of the left hand.

A review of the admission Minimum Data Set (MDS), dated [DATE REDACTED] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented the resident did not receive Physical Therapy (PT) or Occupational Therapy (OT).

A review of Resident R43's Physician Orders revealed an order dated 5/2/2024 for evaluations for PT, OT, and Speech Therapy.

A review of 43's care plan, last revised on 7/26/2024, revealed a focus area of being at risk for complications related to contractures, being dependent on staff for ADLs (Activities of Daily Living), and having impaired mobility. Interventions included providing ROM as tolerated during ADL care.

A review of the Plan of Care (POC) used by the Certified Nursing Assistants (CNAs) revealed no instruction to provide ROM to the resident's left hand. Continued review revealed the contracture of the left hand was not identified on the form.

Observation during the survey from 8/18/2024 through 8/20/2024 revealed Resident R43 lying in bed with no splint device, and his left hand third and fourth fingers were folded into the palm of his hands.

In an interview on 8/18/2024 at 3:25 pm, Resident R43 reported that staff was not providing ROM of his left hand. Resident R43 reported that he did not have full flexion of the fingers on his left hand. He further stated he had not been evaluated by therapy since admission to the facility.

In an interview on 8/21/2024 at 12:54 pm, CNA DD confirmed not providing ROM to Resident R43's left hand. She reported being aware that the resident had a contracture of the left hand.

In an interview on 8/21/2024 at 12:58 pm, the Unit Manager reported she was aware that Resident R43 had a contracture of the left hand. She stated she thought the resident was referred for PT and OT to evaluate him to address the contracture.

In an interview on 8/21/2024 at 1:10 pm, the Director of Rehabilitation stated the therapy department had not performed a therapy evaluation for Resident R43. She confirmed that she was aware of the resident's contracture of his left hand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0688 In an interview on 8/21/2024 at 4:55 pm, the Director of Nursing (DON) stated once the therapy department evaluated a resident, therapy recommendations were added to the CNA POC. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 45811

Residents Affected - Some Based on observations, staff interviews, record review, and review of the facility policy titled, F-689 Accidents -Water Temperatures, the facility failed to maintain safe water temperatures at the hand washing sink in 12 of 28 resident bathrooms and two of three resident shower rooms. In addition, the facility failed to ensure an environment free from chemical and environmental hazards in one of three shower rooms. This deficient practice placed the residents residing in the affected rooms and using the affected shower rooms at risk of avoidable injuries and a diminished quality of life. The census was 101 residents.

Findings include:

1. A review of the facility's undated policy titled, F-689 Accidents - Water Temperatures, revealed the section titled F - 689 Description stated, The facility must ensure that the resident environment remains free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. The section titled Purpose included, The purpose of recording your water temperatures is to assure the Surveyor that your facility is remaining as free from accidental burns and scalds as possible and that any issues are addressed in a prompt and consistent manner.

During observation on 8/18/2024 at 2:00 pm, the hot water in the shared bathroom of Rooms A1 and A3 felt hot to touch. The surveyor was able to keep a hand under the water for only about five seconds.

During an interview on 8/18/2024 at 2:45 pm, the Maintenance Director revealed he checked water temperatures every day and randomly picked rooms and sinks to test.

On 8/18/2024, the following water temperatures in resident bathroom sinks were obtained by the Maintenance Director using the facility's calibrated thermometer:

4:23 pm Rooms A1 and A3 shared bathroom = 117 degrees Fahrenheit (F).

4:24 pm Rooms A9 and A11 shared bathroom = 116 degrees F.

4:50 pm Rooms B3 and B5 shared bathroom = 114 degrees F.

4:53 pm Rooms B7 and B9 shared bathroom = 114 degrees F.

4:56 pm Room B11 bathroom = 114 degrees F.

5:00 pm Room B1 bathroom = 112 degrees F.

5:05 pm Rooms A5 and A7 shared bathroom = 111 degrees F.

5:07 pm Rooms A10 and A12 shared bathroom = 110.3 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0689 5:10 pm Rooms D2 and D4 shared bathroom = 119 degrees F.

Level of Harm - Minimal harm or 5:12 pm Rooms D1 and D3 shared bathroom = 123 degrees F. potential for actual harm 5:15 pm Room D19 bathroom = 115 degrees F. Residents Affected - Some 5:17 pm Room D16 bathroom = 111 degrees F.

5:19 pm D Hall Shower = 112 degrees F.

5:27pm C Hall Shower = 116 degrees F.

A review of a temperature logbook dated 5/20/2024 through 8/16/2024 revealed documented temperatures for the shower rooms ranging from 112 to 118 degrees F.

During an interview on 8/18/24 at 5:00 pm, the Director of Maintenance stated the hot water temperature should be 107 or 108 degrees F. He verified the temperatures documented in the logbook and stated someone had told him to keep the temperatures at 114 degrees F for the shower rooms.

During an interview on 8/18/2024 at 6:00 pm, the Maintenance Director stated the mixing valve unit was set at 110 degrees F and further stated he turned the device down, but it went up to 116 degrees F. He stated

the hot water heater in the Behavioral Unit was at 115 F, and he had turned it down.

On 8/18/2024 at 6:15 pm, the Administrator was informed of the elevated water temperatures. He stated the temperatures of the entire building would be checked every shift until the temperatures were down, and the residents in the Behavior Unit would be monitored until the water temperatures were down.

During an interview on 8/18/2024 at 6:45 pm, the Director of Maintenance stated the mixing valve was set at 112 degrees F. He stated he may have turned it up instead of down, and he turned it down.

During an interview on 8/19/2024 at 10:00 am, the Director of Maintenance stated water temperatures in resident rooms were checked every four hours during the evening and night shifts, and the temperatures were below 110 degrees F. He stated he would continue to check the temperatures every four hours.

During an interview and observation of hot water temperatures on 8/19/2024 at 1:00 pm with the Director of Maintenance, the following temperatures were observed:

Rooms D1 and D3 shared bathroom = 116 degrees F.

Rooms D6 and D8 shared bathroom = 115 degrees F.

During an interview on 8/19/2024 at 1:45 pm, the Administrator stated he would notify the [NAME] President of the company to discuss the rising water temperatures in the Behavioral Unit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0689 During an interview on 8/19/2024 at 2:30 pm, the [NAME] President stated there was a faulty thermostat on

the re-circulation pump and the Director of Maintenance would re-adjust it, which should maintain the Level of Harm - Minimal harm or temperatures. potential for actual harm

During an interview on 8/19/2024 at 4:00 pm, the Director of Maintenance stated he checked the water Residents Affected - Some temperatures in the building, and none were elevated.

Observations of temperature checks with the Maintenance Director on 8/19/2024 at 6:25 pm revealed the water temperature in Rooms D1 and D3 shared bathroom = 100 degrees F and in

Rooms D6 and D8 shared bathroom = 94 degrees F.

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2. Observations on 8/18/2024 at 5:27 pm, 8/19/2024 at 2:46 pm, and 8/19/2024 at 5:50 pm in the D Hall Shower Room located in the secured Behavioral Health Unit revealed a cart containing a bottle of 70 percent isopropyl alcohol and a hand-held hair dryer. The hair dryer was plugged into a wall electrical outlet on one side of the sink, with the cord running under the sink. Further observation revealed four wet floor signs, shoes, clothing, toilet paper, and towels scattered on the floor.

During observation and interview on 8/19/2024 at 3:35 pm, the Administrator and the Maintenance Director confirmed the findings in the D Hall Shower Room. The Administrator unplugged the hair dryer from the wall and placed it on the cart next to the sink stating someone could get seriously hurt. He stated that the condition of the shower room was unacceptable and posed numerous accident hazards.

During observation and interview on 8/19/2024 at 4:50 pm, Licensed Practical Nurse (LPN) BB confirmed the bottle of 70 percent isopropyl alcohol was on a cart and stated it should be in a locked cabinet.

In an interview on 8/21/2024 at 4:53 pm, the Regional Director of Nursing revealed hazardous chemicals, such as isopropyl alcohol, should not be in resident shower rooms.

A policy pertaining to environmental hazards was requested and not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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** 36377 potential for actual harm Based on observations, staff interviews, record review, and review of the facility policy titled, Respiratory Residents Affected - Few System Management Standard, the facility failed to ensure two residents (R) (Resident R49 and Resident R68) receiving oxygen (O2) therapy were administered O2 in accordance with the physician order. The deficient practice had the potential to increase the risk of respiratory complications for Resident R49 and Resident R68. The sample size was 52 residents.

Findings include:

A review of the facility's undated policy titled, Respiratory System Management Standard, revealed the section titled Oxygen Therapy Protocol stated, Standard oxygen therapy is the administration of oxygen at concentrations greater than ambient air to: Treat or prevent hypoxemia, decrease work of breathing, decrease myocardial work. Procedure to follow in order (1). Check the physician's orders in the resident's clinical record.

1. A review of Resident R49's medical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with acute exacerbation and hypokalemia.

A review of the quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed section O (Special Treatments and Programs) documented that Resident R49 received O2 while a resident.

A review of the Physician Orders revealed an order dated 7/10/2024 for O2 per nasal cannula (NC) at 2 liters per minute (LPM) at night and as needed (PRN).

Observations on 8/18/2024 at 1:01 pm, 4:00 pm, and 5:55 pm, 8/19/2024 at 11:11 am, and 8/20/2024 at 10:48 am, revealed Resident R49 receiving O2 by a concentrator and via a NC at 2.5 LPM.

2. A review of Resident R68's medical record revealed diagnoses including, but not limited to, acute chronic respiratory failure with hypoxia and hypercapnia.

A review of the quarterly MDS dated [DATE REDACTED] revealed section O (Special Treatments and Programs) documented that Resident R49 received O2 while a resident.

A review of Resident R68's Physician Orders revealed an order dated 6/11/2024 for O2 per NC at 2 liters LPM PRN shortness of breath (SOB).

Observations on 8/18/2024 at 2:00 pm and 4:03 pm, 8/19/2024 at 9:00 am, and 8/20/2024 at 10:48 am revealed Resident R68 receiving O2 by a concentrator and via a NC at 2.5 LPM.

In an interview at the time of observations on 8/19/2024, Licensed Practical Nurse (LPN) CC confirmed that Resident R49 and Resident R68 were receiving O2 by a concentration and via a NC at 2.5 LPM instead of 2.0 LPM. LPN CC reported being unaware to monitor and ensure Resident R49's O2 was set on the correct liter. She further stated she was unaware if the resident adjusted the O2 flow meter on the concentrator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 During an interview and observation on 8/20/2024 at 10:48 am, the Unit Manager confirmed that Resident R49 and Resident R68's O2 were set to 2.5 liters instead of 2.0 liters. She adjusted the O2 to 2.0 LPM for both residents. She Level of Harm - Minimal harm or reported that her expectation was to ensure residents were receiving O2 as ordered. She said that Resident R49 was potential for actual harm capable of putting on his NC appropriately but not competent in adjusting the flow meter for the correct liter per his physician's order. She reported that her expectation was for the nurse to monitor the O2 during the Residents Affected - Few medication pass. She reported that the resident independently adjusting his O2 and staff not monitoring the O2 setting placed Resident R49 at risk for complications.

In an interview on 8/21/24 at 6:36 pm, the MDS Coordinator stated Resident R49 had a history of adjusting the flow meter on his O2 concentrator. She reported that her expectation was for staff to monitor Resident R49 and Resident R68 's O2 settings.

In an interview on 8/21/2024 at 12:17 pm, the Director of Nursing (DON) reported that her expectation was for staff to ensure O2 was administered according to the physician's order. She further stated that Resident R49 was at risk of COPD exacerbation by receiving more than the ordered amount of O2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 45811 Residents Affected - Some Based on observations, interviews, and a review of the facility's policy titled, Medication Administration Guidelines, the facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse. The deficient practice had the potential to allow unauthorized persons, including residents and visitors, to access medications. The census was 101 residents.

Findings include:

A review of the facility policy titled, Medication Administration Guidelines, dated August 2021, revealed the section titled Safe Medication Administration included, Medication carts are to be kept locked at all times and under the vision supervision of the licensed nurse.

During observation on 8/18/2024 from 12:15 pm to 12:21 pm, Medication Cart 2 was parked in the hallway, unattended, and unlocked. The medication drawer was pulled, and it opened without a problem. Registered Nurse (RN) JJ approached the cart and locked it.

During an observation on 8/18/2024 at 6:41 pm, Medication Cart 2 was parked in the hallway, unattended, out of sight of a nurse, and unlocked. Licensed Practical Nurse (LPN) II noticed the surveyor looking at the cart and locked it.

During an interview on 8/18/2024 at 7:00 pm, RN JJ revealed the medication cart should be locked unless a nurse was at the cart. She confirmed that the cart was unlocked this shift and there was not a nurse at the cart.

During an interview on 8/18/2024 at 7:05 pm, LPN II revealed the medication cart needs to be locked unless

the nurse was at the cart. LPN II confirmed she left the cart opened earlier this shift and stated she had a resident who was transported to the emergency room and she forgot and left the cart open.

During an interview on 8/21/2024 at 5:00 pm, the Unit Manager stated the medication cart should always be locked unless the nurse is present and giving medications.

During an interview on 8/21/2024 at 5:30 pm, the Director of Nursing (DON) revealed the medication cart should be locked when the nurse is not present at the cart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 36377 potential for actual harm Based on observations and staff interviews, the facility failed to ensure three of three garbage dumpsters Residents Affected - Many were maintained in sanitary conditions, free from trash and debris on the ground, and with secure fitting lids.

The deficient practice had the potential to promote the harboring of pests, rodents, insects, and other organisms. The facility census was 101 residents.

Findings include:

Observation of the dumpster on 8/18/2024 at 3:15 pm with the Dietary Manager (DM) and Maintenance Director revealed trash piled up high and spilling over to the ground in three of three dumpsters. Further

observation revealed opened bags of trash, exposing dirty briefs with fecal matter, wipes covered in feces were observed scattered on the ground surrounding the dumpsters. Continued observation revealed swarms of flies and at least 50 large clear white trash bags on the ground around the dumpsters. The large clear bags contained food, trash, and soiled personal care items.

An interview at the time of observation on 8/18/2024 at 3:16 pm was conducted with the DM and Maintenance Director. Both staff members confirmed that the dumpsters were not being maintained in sanitary conditions. They confirmed the exposure of feces from the briefs, food items, and trash. The DM reported the problem with the dumpsters had existed since the previous Monday. She stated that trash bags

on the ground increased due to not having enough room in the dumpsters to place the trash. The Maintenance Director reported the problem existed because the bill for the trash service had not been paid by the facility.

In an interview on 8/18/2024 at 3:41 pm, the Maintenance Director revealed that trash was not picked up due to nonpayment to the trash pick-up company. He reported the trash started to pile up the previous Sunday.

He stated the scheduled days for trash pick-up were Monday and Thursday, and the trash was last picked up

on 8/8/2024. The Maintenance Director further stated he informed the Administrator of the failure of the trash being picked up on 8/13/2024. He stated he was not given specific instructions on what to do about the trash.

In an interview on 8/21/2024 at 9:18 am, the Administrator confirmed the dumpsters were not maintained in sanitary conditions, and he had failed to provide staff with instructions on handling the trash pile up. He stated the corporate office was notified on 8/14/2024 about a problem with payment to the trash pick-up company, and he understood the bill was already paid. He stated having trash dumpsters in an unsanitary manner increased the risk of animals, pests, and insects. He stated he was unaware the bags were spilling trash on the ground and stated that if he had been notified of trash on the ground, he would have removed it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45811 potential for actual harm Based on observations, staff interviews, and review of the facility's policies titled, Laundry Linen: Handling of, Residents Affected - Some and Biohazardous/Infectious Waste, the facility failed to follow acceptable infection control practices to prevent cross-contamination during a glucometer check for one resident, during the storage of linen in one linen storage room, during the storage of soiled linen in two shower rooms, and during the storage of washbasins and urinals in three resident restrooms. These deficient practices had the potential to increase

the risk of cross-contamination and spread infections.

Findings include:

1. During observation of the glucometer procedure on 8/19/2024 at 10:30 am, Licensed Practical Nurse (LPN) GG performed a fingerstick blood sugar on one resident. Observation revealed LPN GG placed the supplies on the surface of the cart before entering the resident's room without sanitizing or placing a barrier

on the cart. She performed the procedure and placed the used supplies (including the glucometer, used alcohol pad, and used fingerstick device) on the surface of the cart without sanitizing or using a barrier on the surface of the cart. In an interview at the time of the observation, LPN GG confirmed she did not use a barrier to put her supplies on. She stated she should have used a barrier under the meter and supplies.

During an interview on 8/21/2024 at 4:30 pm, the Unit Manager stated the nurse should use a barrier to put

the glucometer and supplies on and not just lay them on the surface of the cart.

During an interview on 8/21/2024 at 4:45 pm, the Director of Nursing (DON) stated the nurse should use a barrier on the surface of the cart after using the glucometer.

49138

2. An observation on 8/18/2024 at 2:45 pm of room [ROOM NUMBER]A 400 Hall revealed one washbasin in

the bathroom unbagged and not labeled with a resident's name.

An observation on 8/18/2024 at 2:37 pm of room [ROOM NUMBER]B 400 Hall revealed one washbasin in

the bathroom unbagged and not labeled with a resident's name.

An observation on 8/18/2024 at 2:32 pm of room [ROOM NUMBER]B 200 Hall revealed three washbasins in

the tub and one urinal hanging on the toilet paper holder unbagged and not labeled with a resident's name.

In an interview on 8/20/24 at 3:25 pm, the DON confirmed all washbasins and urinals should be bagged and labeled with a resident's name.

49675

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0880 3. A review of the facility policy titled, Laundry Linen: Handling of, revised September 2023, revealed the section titled, Transportation of Clean Linen included . 3. Cover stored linen to protect from contamination Level of Harm - Minimal harm or until the linen is distributed for resident use. 5. Transport collected and bagged linen by cart or soiled linen potential for actual harm chute to the laundry area at regular intervals as needed. a. Do not allow hampers to overfill, lids must be closed. Residents Affected - Some

A review of facility policy titled, Biohazardous/Infectious Waste, revised September 2023, revealed the section titled Overview included The facility will dispose of Infectious Waste according to the Federal Government Environmental Protection Agency (EPA) requirements or according to state and local regulations, whichever is the strictest. The section titled Procedure included . 5. Dispose of sharps, used and unused, in an impervious, rigid, puncture-resistant, leak-proof on the sides and bottom, closable sharps container. Do not overfill.

Observation on 8/19/2024 at 1:23 pm revealed a small storage room with an exit door from the main building that led to the outdoor laundry facility. The storage room contained two wire racks. The bottom shelf of the racks contained pillows that were touching the concrete floor. The other shelves contained linen which was uncovered and exposed to the environment.

During an observation and interview on 8/19/2024 at 1:35 pm, the Account Manager stated he was over the laundry and housekeeping departments and confirmed the pillows in the storage room were touching the floor, and the linen was uncovered. He stated this was a mistake and would be corrected.

Observations on 8/18/2024 at 5:19 pm and 8/19/2024 at 11:58 am of the D Hall Shower Room revealed a basket of soiled clothes, a plastic hamper of soiled towels, soiled towels lying on the floor, soiled toilet paper lying next to the toilet, a box fan turned on and running covered in dirt and dust sitting on the back of the toilet, numerous clothing items such as shoes and clothes hanging on grab bars and lying on the floor, two rolls of toilet paper lying on the floor, and a sharps container overfilled with a razor exposed.

Observations on 8/18/2024 at 5:27 pm and 8/19/2024 at 11:55 am of the C Hall Shower Room revealed soiled wet towels in the shower stall, numerous soiled wet towels in a pile on the shower room floor, an overflowing trash can, and an uncovered plastic tub full of clothing on a shower bed.

During observation and interview on 8/19/2024 at 3:35 pm, the Administrator and Maintenance Director confirmed the findings in both shower rooms. The Administrator stated the findings in the shower rooms were unacceptable. He acknowledged the identified concerns were infection control issues and would be corrected.

During an observation and interview on 8/19/2024 at 4:50 pm, LPN BB confirmed a sharps container located

in the D Hall Shower Room was full and had an exposed disposable razor. LPN BB stated the sharps container was full and needed to be changed out.

In an interview on 8/21/2024 at 4:30 pm, the Infection Control Preventionist (ICP) stated her expectations were for staff to ensure linens were always covered during storage and for linen and clothing to be off of the floors to avoid exposure to contamination. She further stated sharps containers should be changed out when

they were full and acknowledged these concerns could spread infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 115411 Department of Health & Human Services Printed: 09/12/2025 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 115411 B. Wing 08/21/2024

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

Pleasant View Nursing Center 475 Washington Street Metter, GA 30439

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 0880 In an interview on 8/21/2024 at 4:53 pm, the Regional Director of Nursing confirmed that sharps containers should be emptied when they are full. She revealed there was no one designated to change out sharp Level of Harm - Minimal harm or containers. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 115411