Pleasant View Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Metter, Georgia.
- Location
- 475 Washington Street, Metter, Georgia 30439
- CMS Provider Number
- 115411
- Inspections on file
- 21
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pleasant View Nursing Center during CMS and state inspections, most recent first.
The facility did not conduct complete investigations into multiple abuse allegations, including failing to interview involved residents and witnesses as required by policy. In several cases, such as when a resident reported being hit, another alleged inappropriate physical contact, and a hospital social worker raised concerns about bruising, the facility did not document or perform thorough investigations. The Administrator confirmed these investigative steps were missed.
A resident was found to have bruising by a hospital Social Worker, who notified the facility's DON. The DON explained the bruising as resulting from a fall out of a wheelchair, but the facility did not notify the SSA of the physical abuse allegation as required by policy. The Administrator confirmed the incident was not reported.
The facility failed to maintain sanitary conditions for three garbage dumpsters, leading to trash spilling onto the ground and exposure of fecal matter. The issue arose due to nonpayment of the trash service bill, resulting in missed trash pickups. The Maintenance Director informed the Administrator, but no specific instructions were given to address the situation. The Administrator was unaware of the extent of the issue and believed the payment problem had been resolved.
The facility failed to maintain safe water temperatures in resident bathrooms and shower rooms, with temperatures exceeding recommended levels, posing risks of burns and scalds. Additionally, a shower room contained environmental hazards, including a plugged-in hair dryer and unsecured isopropyl alcohol, creating potential accident risks. The facility's policies on water safety and environmental hazards were not effectively implemented, leading to these deficiencies.
A medication cart was found unlocked and unattended on two occasions, contrary to the facility's policy requiring carts to be locked unless under a nurse's supervision. Staff interviews confirmed the oversight, with one nurse attributing the lapse to being distracted by an emergency situation.
The facility failed to follow infection control practices during a glucometer check, with an LPN not using a barrier for supplies. Additionally, washbasins and urinals were improperly stored, and linen handling policies were not followed, leading to potential cross-contamination. Sharps containers were overfilled, posing biohazard risks.
A resident's urinary catheter drainage bag was not covered with a privacy bag, compromising their dignity. Observations showed the bag was uncovered as the resident walked in the hallway. Interviews with the DON, CNA, and Administrator confirmed the need for coverage, but no policy was provided.
Two residents were found with unauthorized medications at their bedsides, including an albuterol inhaler and alcohol-containing mouthwash, despite not being assessed or approved for self-administration. The facility staff were unaware of these medications, indicating a lapse in monitoring.
The facility failed to conduct pre-employment screenings, including reference checks and fingerprinting, for four employees. The Director of Human Resources cited being busy as the reason for not completing these checks, while the Administrator was unaware of the oversight. This deficiency posed a potential risk to residents.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with dementia did not have a fall mat as required, while two residents with respiratory conditions received incorrect oxygen flow rates. Staff interviews revealed a lack of adherence to care plans.
The facility failed to follow physician's orders for two residents, resulting in deficiencies in care. One resident did not receive ordered therapy evaluations for a hand contracture, while another resident's gastrostomy tube water flushes were not documented as required. Staff interviews confirmed the lapses in following and documenting physician orders.
A resident with a contracture of the left hand did not receive necessary ROM services due to a lack of therapy evaluations and specific care instructions. Despite physician orders for therapy evaluations, the care plan did not include ROM exercises, and the contracture was not noted in the CNA Plan of Care. Observations and staff interviews confirmed the absence of ROM exercises, and the resident was not using a splint device.
Two residents receiving oxygen therapy were administered oxygen at 2.5 LPM instead of the prescribed 2.0 LPM, potentially increasing the risk of respiratory complications. Despite physician orders, staff failed to monitor and adjust the oxygen settings correctly. Interviews with staff, including an LPN, the Unit Manager, and the DON, confirmed the oversight, with the Unit Manager adjusting the oxygen to the correct level upon discovery.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct complete and thorough investigations into multiple allegations of abuse involving six residents out of a sample of twenty-two. According to the facility's own policy, all alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect are to be thoroughly investigated, including immediate investigation and interviews with the resident or other witnesses. However, in several cases, such as when a resident called the police alleging theft and inappropriate touching by other residents, and when another resident reported being hit in the chest by a male friend, the facility did not conduct additional resident interviews as required. The Administrator confirmed that these interviews were not performed during the investigations. Further review revealed additional failures to investigate allegations. In one instance, a resident alleged that another resident put a hand around her neck while removing a smoking apron, and although staff intervened and separated the residents, there was no evidence of a comprehensive investigation. In another case, a hospital social worker reported concerns about bruises on a resident's body after a fall, but there was no documentation that this allegation was investigated. The Administrator acknowledged awareness of the report but confirmed that no investigation was conducted. These actions and inactions demonstrate a pattern of incomplete abuse investigations, contrary to facility policy.
Failure to Report Allegation of Physical Abuse to State Survey Agency
Penalty
Summary
The facility failed to notify the State Survey Agency (SSA) of an allegation of physical abuse involving one resident. According to the facility's policy, all employees are required to immediately notify administrative staff and the SSA of any complaint or allegation of resident abuse as soon as the facility becomes aware. In this case, the Director of Nursing (DON) was informed by a hospital Social Worker about concerns regarding bruising observed on a resident's body. The Social Worker communicated that the bruises were noted during the resident's hospital stay, and the DON explained that the resident had previously fallen forward out of his wheelchair due to a tendency to lean forward. Despite being made aware of the bruising and the concern raised by the hospital Social Worker, there was no documentation that the SSA was notified of this allegation of physical abuse. The Administrator confirmed during an interview that the call from the hospital Social Worker was known and acknowledged that the incident was not reported to the SSA as required by facility policy.
Unsanitary Conditions of Garbage Dumpsters
Penalty
Summary
The facility failed to maintain three garbage dumpsters in sanitary conditions, as observed by surveyors. Trash was piled high and spilling over onto the ground, with opened bags exposing dirty briefs with fecal matter and wipes covered in feces scattered around the dumpsters. Swarms of flies were present, and at least 50 large clear white trash bags containing food, trash, and soiled personal care items were observed on the ground. The Dietary Manager and Maintenance Director confirmed the unsanitary conditions and reported that the issue had persisted since the previous Monday due to insufficient space in the dumpsters. The Maintenance Director revealed that the trash was not picked up because the facility had not paid the trash service bill. He informed the Administrator of the issue on 8/13/2024, but no specific instructions were given on how to handle the trash pile-up. The Administrator confirmed the unsanitary conditions and acknowledged the lack of guidance provided to staff. He stated that the corporate office was notified about the payment issue on 8/14/2024 and believed the bill had been paid. The Administrator was unaware of the trash spilling onto the ground and stated he would have addressed it if informed.
Unsafe Water Temperatures and Environmental Hazards in Facility
Penalty
Summary
The facility failed to maintain safe water temperatures in 12 of 28 resident bathrooms and two of three resident shower rooms, as observed by surveyors. The water temperatures in these areas were found to be higher than the recommended levels, with temperatures ranging from 110.3 to 123 degrees Fahrenheit. The Maintenance Director admitted to checking water temperatures daily but acknowledged that the temperatures were not consistently maintained at the recommended levels. The facility's policy on water temperatures was not effectively implemented, leading to potential risks of burns and scalds for residents. Additionally, the facility did not ensure an environment free from chemical and environmental hazards in one of the shower rooms. Observations revealed a cart containing a bottle of 70 percent isopropyl alcohol and a plugged-in hair dryer, along with various items scattered on the floor, creating potential accident hazards. The Administrator and Maintenance Director confirmed these findings and acknowledged the unacceptable condition of the shower room, which posed numerous risks to residents. The facility's failure to adhere to its policies on maintaining safe water temperatures and preventing environmental hazards in resident areas resulted in a deficient practice. The lack of a policy on environmental hazards further contributed to the unsafe conditions observed in the shower room, placing residents at risk of avoidable injuries and a diminished quality of life.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse, as required by their policy titled 'Medication Administration Guidelines.' This policy, dated August 2021, mandates that medication carts must be kept locked at all times unless under the direct supervision of a licensed nurse. During observations on August 18, 2024, the surveyor noted that Medication Cart 2 was left unattended and unlocked in the hallway on two separate occasions. In the first instance, the cart was left open from 12:15 pm to 12:21 pm until RN JJ approached and locked it. Later that day, at 6:41 pm, the same cart was again found unattended and unlocked until LPN II noticed the surveyor's presence and secured it. Interviews conducted with the nursing staff confirmed the oversight. RN JJ acknowledged that the cart was unlocked during her shift without a nurse present. LPN II admitted to leaving the cart open earlier in the shift, attributing the lapse to being preoccupied with a resident who was transported to the emergency room. Further interviews with the Unit Manager and the Director of Nursing reiterated the expectation that medication carts should always be locked unless a nurse is actively administering medications. The failure to adhere to this policy posed a potential risk of unauthorized access to medications by residents or visitors.
Infection Control Deficiencies in Glucometer Use and Linen Storage
Penalty
Summary
The facility failed to adhere to proper infection control practices during a glucometer check for a resident. An LPN was observed performing a fingerstick blood sugar test without using a barrier on the cart where supplies were placed, both before and after the procedure. This was confirmed by the LPN, the Unit Manager, and the Director of Nursing, who all acknowledged that a barrier should have been used to prevent cross-contamination. Additionally, the facility did not properly store personal care items such as washbasins and urinals in resident restrooms. Observations revealed that these items were unbagged and unlabeled, which was confirmed by the Director of Nursing as not meeting the facility's standards. This lack of proper labeling and storage could lead to cross-contamination among residents. The facility also failed to follow its own policies regarding the storage and handling of linen and biohazardous waste. Observations showed that clean linen was uncovered and exposed, and soiled linen was improperly stored in shower rooms. Furthermore, sharps containers were found to be overfilled, with exposed razors, indicating a failure to manage biohazardous waste correctly. These issues were acknowledged by the facility's staff, including the Administrator and the Infection Control Preventionist, as potential infection control concerns.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R251, by not covering the resident's indwelling urinary catheter drainage bag with a privacy bag. This deficiency was observed on two occasions, where the drainage bag was uncovered and visible as the resident walked down a hallway. The resident was admitted to the facility with a urinary catheter due to urinary retention, as indicated in the care plan, but there were no interventions noted for covering the drainage bag. Interviews with the Director of Nursing, a Certified Nursing Assistant, and the Administrator confirmed that the drainage bag should have been covered for dignity purposes. Additionally, the facility was unable to provide a policy regarding the use of privacy bags for catheter drainage bags.
Unauthorized Medications Found at Residents' Bedsides
Penalty
Summary
The facility failed to ensure that two residents did not have unsecured and unauthorized medications at their bedside, which placed them at risk for inappropriate and unsafe medication use. Resident 49, diagnosed with vascular dementia and other conditions, was found with a prescription albuterol inhaler in his room, despite not being assessed or approved to self-administer medications. The inhaler was obtained from a previous medical appointment, and the resident reported using it occasionally. The Unit Manager confirmed the presence of the inhaler and was unaware of its existence in the room, indicating a lapse in monitoring resident rooms for medications. Resident 1, with severe cognitive impairment and diagnosed with dementia, schizophrenia, and bipolar disorder, was found with a bottle of mouthwash containing alcohol at the bedside. There was no assessment for self-administration of medication for this resident. The Unit Manager confirmed the unauthorized mouthwash, which was not allowed due to its alcohol content, and removed it from the room. The Director of Nursing was unaware of these unauthorized medications and highlighted the potential risks associated with their use, such as increased heart rate and adverse effects on blood pressure.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility failed to ensure that pre-employment screenings, specifically reference checks and fingerprinting, were conducted prior to employment for four out of ten employees reviewed. This deficiency was identified during a review of employee files, which revealed that a reference check was not completed for a Dietary Supervisor hired in 1998, a Certified Nursing Assistant hired in 2024, and a Dietary staff member hired in 2024. Additionally, an Activities Assistant hired in 2024 did not have a fingerprint procedure completed, despite working multiple shifts without this requirement being fulfilled. The Director of Human Resources acknowledged the missing pre-employment requirements, attributing the oversight to being very busy and not having the opportunity to call references or complete the fingerprinting process within the required timeframe. The Administrator was unaware of the missing pre-employment requirements and did not provide an explanation for the absence of this information in the employee files. This oversight had the potential to place residents at risk of abuse, neglect, and exploitation from staff.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement person-centered comprehensive care plans for three residents, leading to deficiencies in their care. One resident, diagnosed with paranoid schizophrenia, Alzheimer's disease, and vascular dementia, had a care plan that included the use of a fall mat to prevent fall-related injuries. However, observations over several days revealed that the fall mat was not placed by the resident's bedside as required. Interviews with staff, including an LPN and the Regional Director of Nursing, confirmed the absence of the fall mat and highlighted a lack of adherence to the care plan. Two other residents, both with respiratory conditions, had care plans that required specific oxygen settings. One resident with chronic obstructive pulmonary disease was observed receiving oxygen at a higher flow rate than prescribed, and staff were unaware of the care plan's requirements to monitor and adjust the oxygen settings. Similarly, another resident with acute chronic respiratory failure was also receiving oxygen at an incorrect flow rate. Interviews with the Unit Manager and MDS Coordinator revealed a lack of awareness and adherence to the care plans, resulting in the incorrect administration of oxygen.
Failure to Follow Physician Orders for Therapy and G-tube Care
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in their care. For one resident, who was admitted with a diagnosis including contracture of the left hand, there was a physician's order for evaluations for physical therapy, occupational therapy, and speech therapy. However, these evaluations were not conducted, and the resident expressed concern about not receiving therapy services for a splint device and range of motion exercises. The Unit Manager and Director of Rehabilitation confirmed that the order was not followed, and the resident did not receive the necessary therapy evaluations. For another resident with diagnoses including dysphagia and severe protein-calorie malnutrition, the facility failed to document the required gastrostomy tube water flushes as per physician's orders. The orders specified water flushes after each medication and before and after feedings, but there was no documentation of these flushes in the medication administration record or progress notes. An LPN verified that the water flushes were not documented, and the Regional Director of Nursing stated that the nurse responsible for receiving the physician's order should have transcribed it onto the medication administration record.
Failure to Provide ROM Services for Resident with Contracture
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for a resident with a contracture of the left hand. The resident, identified as R43, was admitted with a diagnosis that included contracture of the left hand. Despite having a cognitive status indicating little to no impairment, the resident did not receive physical or occupational therapy as documented in the admission Minimum Data Set. Physician orders for therapy evaluations were issued, but the care plan did not include specific instructions for ROM exercises for the left hand, and the contracture was not noted in the Certified Nursing Assistants' (CNA) Plan of Care. Observations during the survey revealed that the resident was not using a splint device, and the fingers of the left hand were folded into the palm. Interviews with the resident and staff confirmed that ROM exercises were not being provided. The CNA acknowledged awareness of the contracture but did not perform ROM exercises. The Unit Manager and Director of Rehabilitation were aware of the contracture but confirmed that no therapy evaluation had been conducted. The Director of Nursing stated that therapy recommendations are typically added to the CNA Plan of Care after evaluations, which had not occurred in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders for two residents, R49 and R68, which had the potential to increase the risk of respiratory complications. R49, diagnosed with chronic obstructive pulmonary disease (COPD) with acute exacerbation and hypokalemia, had a physician order for oxygen at 2 liters per minute (LPM) at night and as needed. However, observations revealed that R49 was receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM. Similarly, R68, diagnosed with acute chronic respiratory failure with hypoxia and hypercapnia, had a physician order for oxygen at 2 LPM as needed for shortness of breath, but was also observed receiving oxygen at 2.5 LPM. Interviews with staff, including a Licensed Practical Nurse (LPN), the Unit Manager, the MDS Coordinator, and the Director of Nursing (DON), confirmed the discrepancy in oxygen administration. The LPN and Unit Manager were unaware of the incorrect oxygen settings, and the Unit Manager adjusted the oxygen to the correct level upon discovery. The MDS Coordinator noted that R49 had a history of adjusting his oxygen flow meter, and the DON emphasized the expectation for staff to ensure oxygen was administered according to physician orders. The failure to monitor and adjust the oxygen settings as prescribed placed the residents at risk for complications, particularly for R49, who was at risk of COPD exacerbation due to receiving more oxygen than ordered.
Latest citations in Georgia
Surveyors found that clean linens and personal clothing were stored and staged in close proximity to the dirty laundry area, with an open door between the clean and soiled sides and all washer and dryer doors open. Clean resident clothes, unlabeled garments, and bagged items were placed next to dryers and directly in front of the dirty linen room, and dirty barrels had to be pushed past racks of clean clothing to reach the washers, contrary to facility policies requiring separation of clean and soiled linens. Environmental staff believed keeping doors open and covering dirty barrels reduced infection spread, while the Environmental Services Director, IP nurse, and Administrator acknowledged that the dirty room door should be closed, linens should not be on dirty barrels, and clean resident clothing should not be stored in that location.
A resident with a suprapubic catheter, colostomy, sacral wound, and dependence on staff for bathing and hygiene was care planned for Enhanced Barrier Precautions (EBP), including use of PPE during high-contact care. During observed catheter care and a bed bath, a CNA wore only gloves and did not don a gown, despite EBP signage and a star posted on the door and PPE supplies available outside the room. In interviews, the CNA admitted forgetting to wear a gown and not recognizing additional required actions, while the IP nurse and DON confirmed that staff had been educated that gowns and gloves are required for high-contact care involving indwelling devices and wounds under the facility’s EBP policy.
A resident with multiple neurologic and psychiatric diagnoses, intact cognition, and unilateral functional limitations was found with an open box of lubricant eye drops stored at the bedside without any documented assessment for self-administration or prescriber’s order for self-administration or bedside storage, contrary to facility policy. Observations on multiple days confirmed the eye drops remained at the bedside, while staff interviews showed that CNAs and the IP recognized that residents were generally not to self-administer medications and that bedside medications required assessment and orders. The Administrator confirmed that the resident should not have had eye drops in the room and that residents with bedside medications are typically assessed for self-administration, and staff acknowledged that unsecured eye drops at the bedside could be accessed or ingested by other residents and cause harm.
The facility failed to maintain a safe, clean environment when multiple ceiling tiles throughout the building, including above a resident’s bed, near the nurses’ station, in a glass day room above a resident’s chair, and in a main hall, were observed with brown circular stains, bulging, and a white moldy substance. The Maintenance Director confirmed the stained and bulging tiles, acknowledged the risk that tiles above a resident’s bed could fall, and attributed the condition to rain-related roof leaks. The Administrator also confirmed that roof leaks and recent rainfall caused the brownish stains despite her reported daily rounds.
A resident with severe cognitive impairment, on hospice and fully dependent for ADLs, was sexually abused when another cognitively impaired male resident with a long-standing history of sexually inappropriate behavior toward female residents entered her room and placed his hand inside her pants. The abusing resident had multiple dementia and psychiatric diagnoses, was care planned for sexually inappropriate behaviors with prior documented incidents, and was on psychotropic medication for OCD-related sexual obsession. Despite these known risks and existing care plan interventions, he was able to access the female resident’s room and make inappropriate physical contact, and the facility’s investigation substantiated the abuse.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
A resident with a history of resistiveness to care and noncompliance with the non‑smoking policy had a comprehensive care plan that was not updated to reflect multiple interventions implemented in response to repeated smoking and vaping violations. Although the care plan noted the need for supervision while smoking and review of the smoking policy, it did not include measures such as daily room searches for smoking materials, added smoke detection in the room, relocation closer to the nurses’ station, q2h visual rounds for smoke, post‑outing nursing checks, initiation of a PAR process for vaping, or issuance of a discharge notice. Facility forms showed inconsistent documentation of daily room searches and incomplete IDT documentation on the PAR tracking, despite multiple documented episodes of policy violations and removal of vaping devices.
A cognitively intact but physically impaired resident with a history of noncompliance with the facility’s non‑smoking policy repeatedly smoked and vaped in his room while keeping multiple vape devices and other items at bedside. The facility’s Smoking Policy required that non‑compliant smokers have daily documented searches and be prohibited from keeping smoking materials in their rooms, yet monitoring forms showed many days without documented searches, Patient at Risk tracking was incomplete, and staff acknowledged that daily room checks and frequent rounds were not consistently performed. Multiple staff, including a CNA, social worker, Infection Preventionist, MDS coordinator, Activities Director, and the Administrator, reported ongoing violations and repeated discovery of vape devices in the resident’s room, including during surveyor observations, demonstrating that the environment was not maintained free from accident hazards and that required supervision and monitoring were not reliably implemented.
Surveyors found that a treatment cart containing topical medications was left unlocked and unattended in a hall across from a resident’s room after wound care was completed by an LPN. The facility’s policy requires that medication carts and supplies be locked or attended and accessible only to licensed or otherwise authorized staff. During interviews, the LPN confirmed the cart had been left unlocked and unattended, the IP LPN confirmed the LPN’s report that the cart was left unlocked, and the Administrator stated that all medications, including topical medications, were expected to be locked when not in sight of authorized staff.
The facility failed to implement its infection prevention and control program by not operationalizing a documented Legionella water management plan despite having a written policy, and by not fully implementing Enhanced Barrier Precautions (EBP) for residents with indwelling devices and other risks. A resident with an indwelling urinary catheter had no EBP care plan or orders, no EBP signage, and staff providing catheter care wore only gloves without gowns, while multiple staff members reported not knowing what EBP was or misidentified who should be on EBP. Another resident receiving tube feeding had care initiated by an LPN who wore gloves but no gown and repeatedly touched her hair with the same gloved hands before handling the feeding tube and equipment, later acknowledging she should have changed gloves and was unaware of EBP requirements, even though other clinical staff stated gowns and gloves should be used for feeding tube care. A resident on isolation for C. diff had a door sign indicating isolation but no instructions for visitors on required PPE or to seek staff guidance, and the IP confirmed there was no system to direct visitors about precautions, contributing to the overall infection control deficiency.
Failure to Maintain Separation of Clean and Soiled Laundry
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to separation of clean and soiled linens. Facility policies titled “Infection Prevention and Control Program” and “Handling Soiled Linens” required that clean linen always be separated from soiled linen. During an observation of the laundry area, all washer and dryer doors were open in the clean linen area. Clean linens, including sheets, towels, blankets, and washcloths, were folded on a table to the left of the washer and dryer room. On the right side of the room, next to the dryers and directly in front of the open door to the dirty laundry room, there were residents’ clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes. Dirty laundry barrels had to be pushed past the clean clothing on the racks to reach the washers, placing soiled items in close proximity to clean items despite policy requirements for separation. Environmental staff working in the laundry stated they believed they were reducing the spread of infection by keeping all doors open, covering dirty barrels, and circulating air, and they explained that the uncovered rack and bagged clothes near the dirty area were no-name clothes sometimes distributed to residents in need. They also stated that the rack of clean personal resident clothing parked in front of the open dirty linen room door was awaiting distribution by a staff member who worked only at night. The Environmental Services Director reported that the door to the dirty side of the laundry should always be closed and that no linen should be on top of dirty barrels. The Infection Preventionist nurse, when shown pictures and concerns about cross-contamination, confirmed there was a problem in the laundry but stated she had not been aware of it previously. The Administrator stated that residents’ clothes should not be stored where they were observed and should be handed out immediately once clean, and that she expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies for self-administration of medications and bedside medication storage for one resident. The facility’s policies require that residents who wish to self-administer medications must be assessed by the interdisciplinary team for cognitive, physical, and visual ability, and that a prescriber’s order for self-administration and bedside storage must be present in the medical record and reflected on the MAR and medication label. For the resident in question, who had diagnoses including cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, hemiplegia and hemiparesis, speech and language deficits, and cerebral atherosclerosis, the EHR showed no assessment for self-administration and no physician order for self-administration or bedside storage, despite active ophthalmic medication orders. The resident’s MDS documented intact cognition with a BIMS score of 15, use of corrective lenses, and functional limitations in range of motion on one side of both upper and lower extremities. Surveyor observations on two consecutive days found an open box of lubricant eye drops on the resident’s bedside table. Staff interviews revealed inconsistent understanding and enforcement of the facility’s policies. A CNA stated that residents did not self-administer medications and that only nurses administered them, but also reported that when she previously reported the eye drops, she was told the resident could have them because he was independent. The Infection Preventionist acknowledged the resident had an order for eye drops and believed he obtained them from the VA, and stated he should not have the lubricant eye drops because they were a hazard for other people. The Administrator confirmed that typically a resident with medications at the bedside should be assessed for self-administration and stated the resident should not have eye drops in his room. The report notes that unsecured medications at the bedside had the potential to cause adverse reactions if accessed or ingested by other residents.
Failure to Maintain Safe and Clean Ceiling Surfaces Throughout Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment as required by its Maintenance Service policy, which assigns the Maintenance Department responsibility for keeping the building in good repair and free from hazards. Surveyors observed multiple stained and damaged ceiling tiles in several areas of the facility, including near the nurses' station, in a resident bedroom (room [ROOM NUMBER]A), in the glass day room, and in the middle of the east hall. On several occasions, ceiling tiles near the nurses' station were noted to have tannish-brown circular stains of varying sizes, and at one point a white, moldy substance was observed on a ceiling tile in that same area. In room [ROOM NUMBER]A, surveyors observed brown rings roughly 16 inches in diameter on ceiling tiles located directly above a resident’s bed, with the Maintenance Director later confirming that these tiles were stained, bulging, and at risk of falling on the resident. Additional observations in the glass day room identified two stained ceiling tiles above a resident’s chair, each with brown circular stains approximately three inches in diameter. In the east hall, a ceiling tile with a brown circular stain approximately 10 inches in diameter was also documented. The Maintenance Director and the Administrator both acknowledged that the stains and damage were related to roof leaks associated with recent rainfall, and the Administrator confirmed awareness of roof leaks that had previously been repaired and that the brownish stains were due to recent rain.
Failure to Prevent Sexual Abuse of a Cognitively Impaired Resident by Another Resident
Penalty
Summary
The facility failed to protect a dependent, cognitively impaired resident (R113) from sexual abuse by another resident (R12). R113 had severe cognitive impairment with a BIMS score of 5, was on hospice care, and was fully dependent for toileting, bathing, dressing, footwear, and personal hygiene. On the day of the incident, a CNA observed R12 in R113’s room with his right hand inside R113’s pants while she was seated in a geriatric chair. Staff witness statements and nursing progress notes documented that R12 was found in R113’s room with his hand in her pants, and the facility’s investigation substantiated that R12 touched R113 inappropriately. R12 also had severe cognitive impairment with a BIMS score of 4 and multiple psychiatric and dementia-related diagnoses, including vascular dementia with mood disturbance, Alzheimer’s disease, major depressive disorder, obsessive-compulsive personality disorder, unspecified psychosis, and unspecified mood affective disorder. He required extensive physical assistance, used a manual wheelchair, and was fully dependent for toileting, bathing, lower body dressing, and footwear. R12’s care plan, in place since 2017, identified him as having sexually verbally and physically inappropriate behavior, including documented prior incidents in which he inappropriately touched or attempted to touch female residents. His care plan included interventions such as discussing his behavior when reasonable, explaining that it was inappropriate, intervening to protect others, diverting his attention, and removing him from situations as needed, as well as monitoring and recording occurrences of target behaviors such as sexual aggression toward others. Despite this known history of sexually inappropriate behavior toward female residents and the presence of care plan interventions, R12 was able to enter R113’s room and place his hand inside her pants. The Administrator confirmed that the CNA reported finding R12 in R113’s room with his hand in her pants while R113 was in her wheelchair, and that the facility’s investigation substantiated the abuse allegation. The facility’s abuse policy stated that it would not condone resident abuse by anyone, including other residents, and defined sexual abuse to include sexual harassment, sexual coercion, or sexual assault. The occurrence of this incident demonstrated that the facility did not effectively prevent sexual abuse of R113 by another resident, despite R12’s documented behavioral history and existing care plan.
Failure to Develop and Implement Complete Care Plans for Antipsychotic Use and Foley Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for identified resident needs, as required by its Comprehensive Care Plan policy. The policy states that care plans must address all needs identified in the comprehensive assessment, including medical, nursing, mental, and psychosocial needs, and must be developed within seven days after completion of the comprehensive MDS assessment. It also requires that all triggered Care Area Assessments (CAAs) and other factors identified by the IDT or resident preferences be incorporated into the plan of care. For one resident, R44, the clinical record showed physician orders for Haloperidol 10 mg by mouth twice daily for schizophrenia, along with orders for behavior monitoring and psychiatric medication side effect monitoring. Despite these orders, the resident’s care plan dated 03/11/2026 did not include any care plan addressing antipsychotic medication use or its indication. The MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place beginning with the date the medication was originally ordered, and upon review of the record confirmed that such a care plan was not present for this resident at the time of the survey. For another resident, R3, the care plan dated 03/13/2026 identified a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer, with goals including remaining free from catheter-related trauma. The listed interventions included positioning the catheter bag and tubing below bladder level, monitoring and documenting intake and output per policy, and monitoring for pain, discomfort, and signs and symptoms of UTI. However, the care plan did not address the amount of water in the catheter balloon, use of a leg strap or securement device, or other securement measures. Physician orders specified checking a leg strap every shift and documented that the resident was admitted with an 18F catheter attached to a bedside drainage bag, but observations showed the Foley catheter positioned under the resident’s leg without a leg strap or securement device on two occasions, and a CNA reported being unaware that a leg strap was required. The MDS Coordinator confirmed that these ordered interventions were missing from the care plan.
Failure to Revise Care Plan for Ongoing Smoking Policy Noncompliance
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan to reflect current interventions implemented in response to ongoing noncompliance with the facility’s non‑smoking policy. The facility’s policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and that it include measurable objectives, timeframes, and alternative interventions as needed, with qualified staff notified when changes are made. The resident’s care plan included a focus on resistiveness to care and noncompliance with smoking, noting that the resident continued to go outside beyond facility property to smoke, and an intervention to review the smoking policy with the resident. Another care plan focus identified the resident as a smoker requiring supervision while smoking, with interventions stating the resident required supervision while smoking and that the charge nurse should be notified if a smoking policy violation was suspected. Despite repeated and ongoing noncompliance with the non‑smoking policy, the care plan was not revised to include additional interventions that were actually implemented. These unreflected interventions included daily room searches for smoking paraphernalia, placement of a smoke detector in the resident’s room, relocation of the resident’s room closer to the nursing station, every‑two‑hour visual rounds to check for smoke, nursing checks upon return from outings, initiation of a Patient at Risk (PAR) process for vaping noncompliance, and issuance of a 30‑day discharge notice for repeated violations of the non‑smoking policy. Documentation on the Smoking Materials Monitoring Form showed initials on selected days only, indicating daily room searches were not consistently completed and documented for the entire month. The PAR Smoking Tracking form documented multiple observations of vaping in the room, repeated room checks, removal of vapor devices, and the resident’s refusal to comply with facility policies, with later weeks lacking IDT signatures and documentation, while the PAR Grid showed multiple prior entries for violating the non‑smoking policy.
Failure to Control Smoking and Vaping Hazards for a Noncompliant Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision for a resident with a known history of noncompliance with the facility’s non‑smoking policy. The facility’s Smoking Policy requires that residents not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their possession or rooms, and that non‑compliant smokers receive daily searches with documentation, while compliant smokers receive weekly searches. The policy also requires incident reports and review in a “Patients at Risk” process whenever smoking materials are found. Despite these written procedures, the resident’s Smoking Materials Monitoring Form for April showed multiple days without documented searches, indicating that required daily room searches were not consistently completed or recorded. The resident at issue was cognitively intact, with a BIMS score of 15, and had significant physical impairments including hemiplegia and hemiparesis on the left side, use of a manual wheelchair, and other neurologic and psychiatric diagnoses such as cerebral aneurysm, cerebral infarction, major depressive disorder with psychotic symptoms, PTSD, and speech and language deficits. The care plan identified the resident as resistive to care and noncompliant with smoking, noting that he continued to go outside beyond facility property to smoke, and also identified him as a smoker requiring supervision while smoking. Progress notes and Patient at Risk documentation showed a pattern of repeated violations of the non‑smoking policy, including multiple instances of vaping and smoking in his room, with staff repeatedly finding vape devices and other smoking paraphernalia in his possession and in his room. Throughout the period reviewed, staff observations and interviews confirmed ongoing noncompliance with the smoking policy and inconsistent implementation of the facility’s own interventions. Staff documented several occasions when the resident was observed vaping or smoking in his room, including in the presence of a state surveyor, and room searches revealed multiple vape devices hidden under the sheets. Staff interviews indicated that daily room checks were not always performed due to competing demands, that logs of every‑two‑hour rounds were not maintained, and that there was confusion or inconsistency regarding whether the resident could keep items such as air freshener at bedside. The social worker, Infection Preventionist, MDS coordinator, Activities Director, CNA, and Administrator all acknowledged that the resident’s room had to be searched for cigarettes and vaping paraphernalia and that prohibited items were repeatedly found, while documentation showed gaps in the required daily searches and incomplete follow‑through on the Patient at Risk tracking process. These actions and inactions resulted in the environment not being kept free from accident hazards as required by the facility’s policy and regulatory standards. The deficiency is further supported by the facility’s own records showing repeated entries on the Patient at Risk grid for violations of the non‑smoking policy over an extended period, as well as narrative notes describing the resident’s statements that he would continue to vape in his room and would simply obtain new devices if they were confiscated. Despite the known pattern of behavior and the facility’s policy requiring close supervision, daily searches, and thorough documentation for non‑compliant smokers, the monitoring forms and staff interviews demonstrate that these measures were not consistently carried out. The presence of multiple vape devices and cans of air freshener at the bedside during surveyor observations, along with staff acknowledgment that room checks were missed and that logs of frequent rounds were not kept, illustrate the facility’s failure to effectively implement its own safety procedures to prevent accident hazards related to smoking and vaping in the resident’s room.
Unlocked and Unattended Treatment Cart with Topical Medications
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a treatment cart containing topical medications was left unlocked and unattended in a hall. The facility’s policy titled “Medication Storage in the Facility,” effective 10/01/2025, states that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that medication rooms, carts, and supplies are to be locked or attended by authorized personnel. During an observation on 04/29/2026 at 9:35 AM, after wound care was provided to resident R3 by the wound care LPN, the treatment cart was observed left in the [NAME] hall across from R3’s room, unlocked and unattended for 30 minutes. In an interview, the wound care LPN confirmed that the treatment cart had been left unlocked and unattended. The Infection Preventionist LPN later confirmed that the wound care nurse told her the cart was left unlocked, and the Administrator stated that her expectation was that all medications, including topical medications, be locked when not in sight of a licensed nurse or authorized person. This deficient practice occurred in a facility with a census of 94 residents and involved the failure to follow the facility’s own policy requiring that medication carts be locked or attended by authorized personnel, resulting in unsecured access to topical medications on the treatment cart.
Failure to Implement Legionella Water Management and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to provide and implement an infection prevention and control program, including a documented water management plan for Legionella and other waterborne pathogens, and a fully implemented Enhanced Barrier Precautions (EBP) program. The Administrator stated there was no Legionella water program in place, and the Maintenance Supervisor reported he was unaware of the requirement for such a program. This was despite the existence of a written Legionella Water Management Program policy, revised in September 2022, which described the need for an interdisciplinary water management team, detailed water system diagrams, identification of risk areas and situations for Legionella growth, control measures, monitoring systems, and annual review. Interviews confirmed that the expectation was that the facility would be conducting this water program, but it was not being done. The facility also failed to implement EBP for residents with indwelling medical devices and other risk factors, as required by its own policy. One resident with Alzheimer’s disease, urinary obstruction, and emphysema had an indwelling urinary catheter documented in the care plan and physician orders, but the care plan did not address EBP related to the catheter, and there was no order for EBP in the record. During catheter-related care, a CNA wore gloves but did not wear a gown, and there was no EBP signage or PPE setup at the room. Multiple staff members, including CNAs and a housekeeper who regularly worked on the resident’s hallway, reported they did not know what EBP was or incorrectly associated EBP only with residents on Transmission-Based Precautions. The DON acknowledged that an attempt to roll out EBP months earlier had not been completed, and that expected signage and PPE caddies for EBP were not fully in place. Additional infection control lapses were observed during tube feeding care and contact isolation. A resident receiving continuous tube feeding had a care plan and physician’s order for enteral nutrition, and an LPN initiated the feeding while wearing gloves but no gown. During the procedure, the LPN repeatedly touched her hair with the same gloved hands and then handled the feeding tube, pump, and syringe used to inject air and check residuals, only removing gloves and using hand sanitizer at the end. The LPN later acknowledged she should have changed gloves after touching her hair and stated she did not know what EBP was or that a gown was required for feeding tube care, while another LPN and the IP stated that EBP with gown and gloves should be used for feeding tube care and that staff should not touch their hair during care without changing gloves and performing hand hygiene. For a resident with a positive urine culture and a subsequent positive C. difficile culture who was on isolation, the door sign indicated isolation but did not provide instructions for visitors on required precautions or direct them to staff for guidance. The IP confirmed there was no system to direct visitors about PPE use for residents on contact isolation and acknowledged that visitors would not know to wear PPE if it was simply present in or on the door of the room. Overall, the survey findings show that the facility did not operationalize its written Legionella water management policy and did not consistently apply its EBP policy for residents with indwelling devices or wounds. Staff interviews and observations demonstrated a lack of knowledge and implementation of EBP, incomplete use of PPE during high-contact care activities such as catheter care and tube feeding, and unclear isolation signage that did not instruct visitors on appropriate precautions. These combined inactions and omissions in policy implementation, staff education, and practice led to the cited infection prevention and control deficiency.
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