Twin View Health And Rehab

F-F584, dated effective 9/2023, revealed:

Policy Statement: F 584 Residents have the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports [sic] for daily living safely.

Policy Interpretation and Implementation:

1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

5. The facility staff and management shall maximize, to the

extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:

a. Cleanliness and order;

b. Comfortable (minimum glare yet adequate (suitable to the task) lighting;

c. Inviting colors and decor;

d. Personalized furniture and room arrangements;

e. Pleasant, neutral scents;

f. Plants and flowers, were appropriate;

g. Sufficient individual closet space;

h. Comfortable temperatures; and

i. Comfortable noise levels.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 0584 During an observation of room [ROOM NUMBER] on 6/19/2024 at 9:47 am, a 6.5-inch-long by approximately 3-inch-wide hole was observed on the wall next to the left side of Bed 2. The wall near the head of the bed Level of Harm - Minimal harm or and behind the headboard had plaster missing and scrapes that were approximately 12 inches long and 3.5 potential for actual harm inches wide and included multiple scrapes.

Residents Affected - Some During an observation of room [ROOM NUMBER] on 6/20/2024, at 11:52 am, observation revealed a white plaster patch was visibly covering most of the hole in the wall, and there were about two inches of wall not covered by plaster. Plaster was pulled up on the top left corner.

During an interview on 6/21/2024 at 10:57 am, Certified Nurse Assistant (CNA) EE stated they also saw holes in the wall but were unsure of how long they were present. CNA EE stated they informed the nurse and maintenance verbally but were unsure when they told them. CNA EE then stated they did not use a computerized maintenance reporting system.

During an interview on 6/21/2024 at 11:11 am, the Plant Operations Director stated they had fixed the wall in Resident R70's room. When asked about the plaster not covering up the hole after the repair was made on 6/20/2024,

the Plant Operations Director stated they would have to repair the wall again and use a board that would cover the entire hole. The Plant Operations Director further stated they were working on repairing walls, painting, patching up spots and tears on walls, repairing window seals and light fixtures, and replacing blinds.

The Plant Operations Director stated they also had an assistant to help get some of the tasks completed in a timely manner.

27669

On 6/18/2024 at 10:00 am, during the initial tour of the facility, observation of room [ROOM NUMBER] revealed the walls were marred throughout the room. There was exposed sheetrock, peeled/cracked paint around the air vent in the ceiling, missing molding, and areas of unfinished wall repairs/painting.

Observation on 6/18/2024 at 10:10 am revealed multiple areas in room [ROOM NUMBER] had unfinished wall repairs. There was exposed sheetrock, missing crown molding, chipped/peeled paint around the air vent

in the ceiling surrounding the vent between beds B/C, and the wall was marred.

In an interview on 6/19/2024 at 2:00 pm, the Assistant Director of Nursing (ADON) stated that the Maintenance staff was currently at another facility assisting with their facility repairs for an extended period.

16683

An observation on 6/18/2024 at 11:16 am of room [ROOM NUMBER] revealed the following:

- Behind the headboard of Bed 2 were multiple, vertical scrapes of various depths across the width of the headboard (approximately 36 inches). In places, the scrapes abraded through only the paint. In other places,

the scrapes went through the outer paper layer of the drywall, leaving behind shreds/curls of the outer paper. At their greatest depth, the scrapes dug into the gypsum. The largest area of abraded/exposed gypsum was estimated to be approximately 12 inches by 18 inches.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 0584 - The headboard of Bed 2 had a length of gray, open-cell foam wrapped around the outer edge of the board.

The appearance of the length of open-cell foam was consistent with that of pipe insulation. The foam was Level of Harm - Minimal harm or torn in places. potential for actual harm - The wall behind Bed 1 (the bed by the door) was similarly damaged, with vertical scrapes of various depths Residents Affected - Some across the width of the headboard, through the paint, the outer paper layer of the drywall, and/or the gypsum.

- The wall behind the headboard of Bed 3 (the bed by the window) was also marred, not patched/repaired, and had been painted over where the scrapes had abraded the outer layer of the drywall paper and had dug into the gypsum.

- Between Bed 2 and Bed 3 was a wall-mounted television (TV). The power cord to the TV was plugged into

an electrical outlet. A coaxial cable was dangling loosely from the TV and was not long enough to reach a cable outlet.

- An observation of the side wall next to Bed 1 found two (2) holes in a vertical line that completely penetrated through the drywall. Each hole was approximately 1 inch in diameter.

In an interview on 6/19/2024 at 4:00 pm, the surveyor reported to the Administrator that the TV in room [ROOM NUMBER] room was not working, with the coaxial cable dangling from the TV and unable to be connected to a cable outlet. The Administrator stated that, if it were her, she would like to be able to watch TV in her room.

Observations of Rooms 33 through 40 were made between 12:13 pm, and 12:35 pm on 6/20/2024. The

observations were made in the company of Licensed Practical Nurse (LPN) CC, who confirmed the findings.

The findings included:

- Wall marring, including penetrations and scrapes of various depths through the paint, the outer paper layer of the drywall, and/or into the gypsum layer (all rooms observed)

- Walls missing the outer paper layer of drywall, especially around wall-mounted soap dispensers and paper towel dispensers in bathrooms (multiple rooms)

- Unsealed/unpainted oriented strand board sheathing covering tiled openings similar in size to that of single shower stalls (bathrooms of rooms [ROOM NUMBERS])

- Damage to bathroom doors through the outer layer of veneer, exposing the hardwood layer (multiple rooms, with the most extensively damaged surfaces on both sides of the bathroom door in room [ROOM NUMBER])

- Broken window blinds (multiple rooms)

- Broken wooden windowsills (rooms [ROOM NUMBERS])

- Missing wooden baseboard (room [ROOM NUMBER])

- Missing paper towel dispenser (shared bathroom between rooms [ROOM NUMBERS])

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 0584 - Rusted metal door frames to bathrooms (multiple rooms)

Level of Harm - Minimal harm or - Rusted grab bar (shared bathroom between rooms [ROOM NUMBERS]) potential for actual harm - Rusted and/or broken wall-mounted toilet paper holders (bathroom of room [ROOM NUMBER] and shared Residents Affected - Some bathroom between rooms [ROOM NUMBERS])

- Rusted ceiling-mounted tracks for privacy curtains (room [ROOM NUMBER])

- The wall behind the toilet where the exposed, manual flush valve of the toilet was mounted was damaged, with the outer paper layer of the drywall hanging loosely from the wall (shared bathroom between rooms [ROOM NUMBERS])

- Broken nightstand (behind the door to room [ROOM NUMBER]) and a chest of drawers with missing drawer pulls (behind the door in room [ROOM NUMBER])

- Splatters of a beige-colored substance on the ceiling above Bed 2 (the middle bed of a three-bedroom in room [ROOM NUMBER])

- Broken electrical outlet (behind Bed 1 in room [ROOM NUMBER])

- Blue paper painter's tape on walls (room [ROOM NUMBER])

During an interview on 6/21/2024 at 1:35 pm, the Administrator stated she and the Plant Operations Director completed a walk-through on 6/10/2024 and identified rooms that needed to be repaired. The Administrator stated the facility's goal was to complete all repairs by October 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 16683 Residents Affected - Some Based on observations, staff interviews, review of facility-posted signage and temperature logs, and a review of the facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, the facility failed to store vaccines under proper temperature controls with twice daily monitoring and failed to remove from use medications, needles, and laboratory supplies that were kept past their expiration dates in one of one medication storage room and one of two medication carts reviewed. This deficient practice created the potential for residents to receive vaccinations with altered effectiveness and the potential for the use of expired medical and laboratory supplies.

Findings include:

The facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, revised [DATE REDACTED], stated:

APPLICABILITY: This Policy 5.3 sets forth the procedures related to the storage and expiration dates of medications, biologicals, syringes and needles.

PROCEDURE: .

4. Facility should ensure that medications and biologicals that (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.

5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on

the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened [sic].

5.1 Facility staff may record the calculated expiration date based on the date opened on the primary medication container [sic].

5.2 Medications with a manufacturer's expiration date expressed in month and year (e.g. May, 2022) will expire on the last day of the month .

5.4 When an ophthalmic solution or suspension has a manufacturers [sic] shortened beyond use dated once opened, facility staff should record the date opened and the date to expire on the container .

10. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility Staff should monitor

the temperature of vaccines twice daily .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 10.3.2 Facility should monitor cold storage containing vaccines two times a day per CDC guidelines.

Level of Harm - Minimal harm or An observation of the medication room for Unit 1 was conducted in the presence of the Director of Nursing potential for actual harm (DON), beginning at 9:37 am on [DATE REDACTED]. Observation found the following stock medications kept past their expiration dates and available for use: Residents Affected - Some - Two 16-ounce bottles of Enulose 10 grams (GM) / 15 milliliters (ML) with expiration dates of ,d+[DATE REDACTED].

- Two 16-ounce bottles of Biotene Dry Mouth Oral Rinse with expiration dates of [DATE REDACTED].

The above were confirmed by the DON at the time of the observations.

An observation of the medication refrigerator in the Unit 1 medication room, in the presence of the DON, at 10:01 am on [DATE REDACTED], found four vials of pneumococcal vaccine polyvalent Pneumovax 23 vaccine, all with

an expiration date of [DATE REDACTED]. Posted on the cabinet door above the refrigerator was a sign that stated: FRIDGE TEMPS ARE TO BE RECORDED TWICE A DAY EVERY DAY.

Review of the refrigerator's temperature logs for [DATE REDACTED] found the following instructions: Completing the temperature long: Check the temperatures in both the freezer and the refrigerator compartments of your vaccine storage units and least twice each working day.

Review of the information recorded on the [DATE REDACTED] temperature logs found that twice daily recordings were not recorded for the following 10 dates: [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED].

The above observations were confirmed by the DON at the time of the observations.

An observation of the medication cart for Unit 3 was conducted in the presence of Licensed Practical Nurse (LPN) CC, beginning at 10:25 am on [DATE REDACTED]. Observation found the following prescription medications in the medication cart kept past their expiry or use by dates and which were available for use:

- One (1) bottle of Systane Lubricant Eye Drops for Resident (R)38 with an expiration date of ,d+[DATE REDACTED].

- One (1) bottle of Travatan Travoprost Ophthalmic Solution for Resident R30 with an expiration date of 2024-APR.

- One (1) bottle of latanoprost ophthalmic solution for Resident R31 marked [DATE REDACTED] and with a label stating: Discard

after 42 days Exp. Date [DATE REDACTED].

Additionally, the following supplies were found on Unit 3's medication cart and available for use:

- One (1) Vacutainer tube with an expiration date of [DATE REDACTED].

- One (1) filter needle with an expiration date of ,d+[DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 - One (1) safety needle with an expiration date of [DATE REDACTED].

Level of Harm - Minimal harm or - One (1) Bluewing Safety Blood Collection Set w/ Luer Adapter with an expiration date of 240505 [[DATE REDACTED]]. potential for actual harm - One (1) Eclipse blood collection needle with an expiration date of [DATE REDACTED]. Residents Affected - Some All the above observations were confirmed by LPN CC at the time of the observations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 115540 Department of Health & Human Services Printed: 09/23/2025 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 115540 B. Wing 06/21/2024

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

Twin View Health and Rehab 211 Mathis Avenue Twin City, GA 30471

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 43637

Residents Affected - Many Based on observations, staff interviews, and review of the facility policies titled Food Preparation and Service

F-F812, effective 10/23, revealed: 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.

Observation of the main kitchen on 6/18/2024 at 10:00 am, 6/19/2024 at 11:00 am, and 6/19/2024 at 12:15 pm revealed a substantial number of live flies in the kitchen area. This observation was confirmed in the presence of the Dietary Manager (DM), who was interviewed. On 6/18/2024 at 10:00 am, observation found

the back door in the main kitchen was slightly open, with an opening at the top of the door. The DM revealed

the door had been broken and had needed a repair for a while.

Observation of the main dining hall between Unit 1 and Unit 2 on 6/18/2024 at 12:23 pm revealed multiple live flies around the area while residents were eating lunch. Several unidentified residents were observed swatting the flies away while eating lunch.

On 6/19/2024 at 12:15 pm, observations found multiple eight-ounce (oz) glasses of juice, tea, and water were uncovered. Several insects were observed flying over the uncovered glasses. The DM acknowledged

the insects during an interview conducted at the time of the observation. The DM further stated in an

interview during the observation that the glasses should have been covered after they were prepared.

On 6/20/2024 at 2:30 pm, the Maintenance Director (MD) revealed pest control treated the kitchen and dining area at least once a month. The MD stated the cause of the flies was a result of the back kitchen door not being replaced and further stated he was unaware the door needed to be replaced. The MD stated he could put a weather strip to cover the opening of the kitchen door until an order was placed for a new door.

The MD revealed the back kitchen door had an air curtain (to prevent insects from coming into contact with

the kitchen area and dining area), and he stated that, sometimes, the air curtain was turned off by staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 115540