Pleasant View Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the planned menu, observations, staff interviews and facility policy review the facility staff failed to follow the planned menu for residents during the pureed meal preparation (Residents #16, #18 and #30) and for additional residents during meal service. The facility identified a census of 56 residents. Findings include: 1. Review of the menu identified the following items as part of the planned menu for the pureed and regular diet served at lunch on 7/1/25: a. Lemon Chicken b. Garlic Parmesan Pasta c. Roasted Caesar Vegetables d. Garlic Toast Observation of meal service on 7/1/25 at 11:41 AM, showed: a. Staff C, [NAME] prepared pureed meals for Residents #16, #18 and #30. Staff C placed four servings of chicken into a blender with one piece of garlic bread. When asked why Staff C used one piece of garlic bread, she replied, because it needed to be thickened. b. Staff C noted the pureed chicken would require #8 size scoop and #12 size scoop for a complete serving. Staff C obtained a pan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures, food palatable and appetizing for 4 of 15 residents reviewed (Residents #24, #42, #45 and #209). The facility reported a census of 56 residents. Finding Include: 1. Observation of meal service on 7/1/25 at 11:41 PM showed the lunch meal consisted of lemon chicken, garlic parmesan pasta, roasted caesar vegetables and garlic toast. a. The chicken appeared dry and burnt. The test tray temped immediately after plating showed: a. Lemon Chicken- 128.2 degrees Fahrenheit (F) b. Garlic parmesan pasta- 110.8 degrees F The test tray after the delivery of meal trays showed: a. Lemon chicken- 117.7 degrees F b. Garlic parmesan pasta- 98.8 degrees F c. Roasted caesar vegetables- 127.9 F In an interview on 6/30/25 at 1:49 PM, Resident #209 reported the food to always be cold and dry. Consumption of the test tray on 7/1/25 at 1:44 PM revealed the chicken difficult to cut, dry and burnt to taste.…

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

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food, and failed to prepare food in a sanitary manner. The facility identified a census of 56 residents. Findings included: The initial kitchen walkthrough on 6/30/25 at 11:35 AM revealed the following: a. East dining room kitchenette- refrigerator and freezer with dried liquid and various scattered food debris. b. [NAME] dining room kitchenette/dining area- white crust lime buildup found on ice machine, coffee machine and dishwasher. c. Drawers with utensils found with various food debris and dried liquid. Cupboards with small appliances found with various food debris. d. The main kitchen found a refrigerator with various food debris. Observation of meal service on 7/1/25 at 11:41 AM, showed: a. After pureeing pasta Staff C, [NAME] entered the dirty side of the kitchen in search of a measuring cup. Staff C touched the dishwasher handle and dish carts then returned to the clean side of the kitchen without completing…

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

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 47. Findings include: On 8/13/24 at 8:42 AM, Staff F, Dietary Aide (DA) grabbed a milk gallon jug off the kitchenette counter and poured a cup. She stated it was for a resident. A temperature check of the milk revealed the temperature was 44.4 degrees Fahrenheit (F). On 8/14/24 at 12:40 PM, a temperature check of each lunch menu item after lunch service revealed the following results. a) Salisbury steak was 128° F. b) Pureed Salisbury steak was 115° F. c) Pureed green beans were 134.5° F. A policy titled Taking Accurate Temperatures dated 2021 indicated temperatures should be taken periodically to assure hot foods stay above 135° F and cold foods stay below 41° F during the serving process. On 8/15/24 at 12:50 PM, the Administrator stated staff should follow the temperature guidelines.

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by failing to keep the kitchen food preparation area clean and by improperly handling food during meal service. The facility reported a census of 47 residents. Findings include: 1. On 8/12/24 at 5:28 PM, Staff C, Dietary Aide (DA) brought the steam table into the dementia unit and set it up for service. She used the tongs to poke through and remove the steam pan aluminum foil cover, picked up a sandwich with the same tongs, then laid the tongs on the cookie tray. She poured the stew into a bowl, moved the tongs, and placed the prepped plate where the tongs were. Another staff member took the plate to a resident. She used the tongs to plate another sandwich, laid the tongs on the cookie tray where the previous prepped plate was, and poured stew into a bowl on the plate and placed the plate on top of the tongs. She repeated this process for five (5) more plates. On 8/12/24 at 5:43 PM, Staff D, Activities Assistant, dropped a cup on the floor while serving dinner, picked it up…

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

Based on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 47 residents. Findings include: On 8/13/24 at 8:59 AM, Staff H, Certified Medication Aide (CMA) escorted a resident to her room to apply a patch on her. She left her laptop open with 10 residents' Electronic Health Record (EHR) information visible and a sheet of paper with an identified resident's documented narcotic medication administration time. At 9:10 AM, she indicated she was normally assigned a different duty. A policy titled HIPAA / Privacy Complaints effective 11/28/16 indicated It is the policy of this facility to ensure the privacy of Protected Health Information (PHI) as well as to ensure that such information is used and disclosed in accordance with all applicable laws and regulations. On 8/15/24 at 1:12 PM, the Director of Nursing (DON) stated staff should secure the EHR medical record when they leave the cart.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident observations, record review, staff interview, and policy review, the facility failed to refer to a resident by name and failed to dress a resident appropriately for meal service 2 of 16 residents (#3 & #46) reviewed for dignity. The facility reported a census of 47. Findings include: 1. On 8/13/24 at 7:57 AM, Staff K, Licensed Practical Nurse (LPN) was standing in the dining room and stated the long table in the dining room was the feeder table for residents who required help feeding. Resident #46 was seated at the long table. The Minimum Data Set (MDS) dated [DATE] revealed Resident #46's Brief Interview for Mental Status (BIMS) score could not be determined due to the resident was rarely or never understood. It included diagnoses of Cerebral Palsy (CP), epilepsy, autistic disorder, and wheelchair dependence. It indicated the resident was dependent in all Activities of Daily Living (ADLs) and mobility. It also indicated the resident's ability to hear was adequate. 2. On 8/13/24 at 8:23 AM,…

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

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portions for one (1) residents (#16) who received pureed scalloped potatoes and failed to serve the therapeutic diet for two (2) residents (#6 & #51) who were ordered renal diets. The facility reported a census of 47 residents. Findings include: On 8/14/24 at 11:25 AM, Staff E, Cook, pureed scalloped potatoes for lunch service. She added three (3) 4-ounce disher servings of scalloped potatoes and milk to the blender and pureed them. She poured the contents into a pitcher and stated it was 3 ½ cups total volume. She referenced the pureed disher conversion chart and stated it directed staff to use a #6 (5 1/3 oz) disher and a #8 (4 oz) disher. She wrote the disher numbers on the top of the steam pan aluminum foil cover. On 8/14/24 at 12:15 PM, continuous lunch service observation revealed Staff G, Dietary Aide (DA) used only the #6 (5 1/3 oz) disher to plate pureed scalloped potatoes for resident #16. On 8/14/24 at 12:40 PM, Staff G stated she…

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

2. On 8/13/24 at 8:32 AM, Staff I, Certified Nurse Aide (CNA) carried uncontained, soiled linen from a resident's room to the soiled utility room with gloves. The linen touched his uniform top and the gait belt hanging across his chest. On 8/14/24 at 4:45 PM, Staff J, CNA stated linen should be placed in a bag before it's carried to the soiled utility room. An undated document titled Linen Handling indicated linens need to be placed in plastic bag and taken to laundry bin. It also directed staff to never carry soiled linen against the body. On 8/15/24 at 1:12 PM, the Director of Nursing (DON) stated staff should discard linen per policy of linen removal. Based on observation, record review, staff interviews and policy review the facility failed to complete hand hygiene during medication administration for 2 out of 3 residents reviewed (Resident #25 and #33). The facility also failed to transport linen in a manner that prevented cross contamination. The facility reported a census of 51 residents. Findings include: 1. Observation on 8/14/24 at 8:48 AM showed Staff B, Registered Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to develop Care Plans to address opioid medication and antidepressant medication side effects to watch for 1 out of 5 sampled residents reviewed for comprehensive Care Plans (Resident #13). The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #13 documented diagnoses of heart failure, hypertension, and Non-Alzheimer's Dementia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. Review of the March Medications Administration History Report revealed the following orders: a. Escitalopram (antidepressant medication) daily for depression with a start date of 1/23/24 b. Hydrocodone- acetaminophen (opioid medication) as needed for pain with a start date of 11/21/23. Review of the MDS dated [DATE] revealed the resident was taking antidepressant medication in the review period. Review of the signed Physician Order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, chart review, and staff education review, the facility failed to ensure that residents were safe from accidents and hazards for 1 of 3 residents (Resident #33). A Certified Nurse Aide (CNA) failed to apply a gait belt before attempting to transfer Resident #33 from the shower chair to the wheel chair and the resident fell to the floor. The facility reported a census of 48 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #33 had a Brief Interview for Mental Status score (BIMS) of 8. She was at risk for falls and required extensive assistance with bathing. The Care Plan updated on 2/25/24, showed that Resident #33 was at risk for falling and had a history of falls. She was incontinent of bowel and bladder and was on 2 or more high fall risk drugs. She had impaired mobility and impaired cognition. A Nursing Note dated 1/09/2024 at 3:37 PM showed that Resident #33 fell in the shower room after getting a shower. The resident had stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that staff used adequate infection control practices to decrease the transmission of pathogens for 2 of 14 residents reviewed (Resident #1 and #34). Resident #34 required daily dressing changes for several wounds and staff failed to use proper hand hygiene during cares. Resident #1 required staff assistance with incontinence cares, they failed to use adequate hand hygiene when changing the resident. The facility reported a census of 48 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive deficits). She was independent with rolling in bed and required supervision with transfers. Resident #34 had diagnoses that included urinary tract infections, renal insufficiency, and was at risk for developing pressure ulcers. The Care Plan updated on 2/24/24, showed that Resident #34 had the potential for pain/discomfort…

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