Pleasant View Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview, and facility policy review, the facility failed to ensure oral care was provided daily as required for four residents (#81, #82, #100, and #101) of five residents reviewed for oral care. The facility census was 116.Findings include:1. Review of the medical record for Resident #81 revealed an admission date of 04/27/18. Diagnoses included but were not limited to Alzheimer's dementia, vascular dementia with psychotic disturbance, and unspecified protein-calorie malnutrition.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #81 revealed a Brief Interview of Mental Status (BIMS) score of 08 which indicated moderate cognitive impairment. Review of activities of daily living (ADLs) revealed the resident required maximum assistance for oral hygiene.Review of the care plan for Resident #81, which was last reviewed on 01/26/26, revealed she was dependent on staff assistance for oral hygiene.Review of the task called Denture care AM for the past…

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 record review, resident interview, staff interview, review of facility witness statements, review of facility self-reported incidents, and review of the facility policy, the facility failed to report an allegation of sexual abuse to the State agency. This finding affected one (Resident #47) of three residents reviewed for abuse. Review of the incident witness statement between Residents #47 and #119 authored by the DON dated 08/10/25 revealed the facility received a call reporting Resident #119 was sitting on the roommate's bed having a conversation with him when Resident #47 reported that Resident #119 tried to kiss and grab his genitalia. Resident #47 was assisted out of bed and removed from the room and taken to a common area where he was placed in a recliner. The DON instructed staff to move Resident #47's to a new room with Resident #47's permission. Review of Resident #47's witness statement dated 08/10/25 authored by the DON revealed Resident #119 sat on the resident's bed and tried to kiss and…

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 record review and interview, the facility did not ensure Resident #10 was transferred safely to prevent falls per the physician order. This finding affected one (Resident #10) of three residents reviewed for accident hazards. Findings include: Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including a non-displaced subtrachanteric fracture of the right femur (closed fracture with routine healing) dated 02/10/25 and a age-related current pathological fracture of the vertebrae with routine healing dated 11/02/23. Review of Resident #10's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition, was dependent for toileting and bathing. Review of Resident #10's fall investigation form dated 11/24/24 at 3:55 P.M. revealed the resident was assisted to the toilet and the resident fell to the bathroom floor. The Nurse Practitioner (NP) and brother were notified of the incident. Review of Resident #10's…

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, interview, and record review, the facility failed to ensure medications were secured at all times. This had the potential to affect 26 (Resident #5, Resident #6, Resident #8, Resident #11, Resident #12, Resident #17, Resident #26, Resident #27, Resident #29, Resident #33, Resident #35, Resident #37, Resident #46, Resident #47, Resident #54, Resident #59, Resident #63, Resident #67, Resident #68, Resident #70, Resident #76, Resident #78, Resident #84, Resident #89, Resident #95, Resident #99) of 26 residents who were cognitively impaired and independently mobile. Findings include: 1. Observation on 02/25/20 at 7:30 A.M. revealed a medication cart was unlocked on Side 1 in the facility. There were no staff in sight of the medication cart. Interview on 02/25/20 at 7:31 A.M. with Licensed Practical Nurse (LPN) #200 confirmed the medication cart was unlocked. 2. Observation on 02/26/20 at 11:43 A.M. revealed there was an unidentified loose pill in a medication cup on top of the medication cart near the Side 1 nurses station. There were no staff in sight of 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.

Based on observation, interview and record review, the facility failed to ensure Resident #11, Resident #14, Resident #28, Resident #43, Resident #56, Resident #77, Resident #114 were were served the proper portion of their pureed lunch according to the menu. This affected seven (Resident #11 Resident #14, Resident #28, Resident #43, Resident #69, Resident #77, and Resident #114 ) of seven residents that were served pureed meals in the small dining room, with the potential to affect all ten residents (Resident #11 Resident #14, Resident#16, Resident #28, Resident #43, Resident #56, Resident #69, Resident #77, Resident #114, and Resident #115) on a pureed diet. Findings include: Review of the facility lunch menu for 02/26/20 revealed residents on a pureed diet should be served pureed meatloaf with gravy using a number six scoop (5 and 1/3 ounces), and the pureed scalloped potatoes and pureed green beans did not have a scoop size listed. Residents on a regular diet were to receive a half cup (4 ounces) of scalloped potatoes and a half cup of green beans. Review of the Portion Control…

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 medical record review, staff interview and facility policy, the facility failed to notify the physician when Resident #37 refused numerous doses of medication. This affected one resident (Resident #37) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including cerebral atherosclerosis, cerebral infarction, vascular dementia, diabetes, delusional disorder, hypertension, encephalopathy, major depressive disorder and mixed receptive expressive language disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] Resident #37 had severely impaired cognition and required extensive assistance with activities of daily living. Review of the February 2020 medication administration record (MAR) revealed Resident #37 refused: five milligrams (mg) of Abilify (antipsychotic) and 75 mg Effexor XR (antidepressant) at lunch on 02/09/20 and 02/19/20, 40 mg of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were correct for three residents (Residents #29, #45, and #111) of 25 residents reviewed for MDS accuracy. Findings include: 1. Resident #29 was admitted to the facility with diagnoses including Alzheimer's disease, generalized anxiety disorder, and major depressive disorder. Review of Resident #29's medical record revealed a quarterly MDS 3.0 assessment dated [DATE]. The MDS revealed Resident #29 received the following medications in the previous seven days, one injection, six days of antipsychotics, seven days of antidepressants, seven days of anticoagulants, seven days of diuretics, and seven days of opioids. Review of Resident #29's December 2019 Medication Administration Record (MAR) revealed Resident #29 received one injection, six days of antipsychotics, seven days of antidepressants, seven days of anticoagulants, three days of diuretics, and seven days of opioids during the reference period of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #40's pressure ulcer interventions were in place at all times. This affected one (Resident #40) of three residents reviewed for pressure ulcers. Findings include: Resident #40 was admitted on [DATE] with diagnoses including orthopedic aftercare, part of neck of left femur fracture, vascular dementia and muscle weakness. Resident #40's physician orders, dated 12/29/19, revealed he should have bilateral heel boots. Resident #40's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed his cognition was moderately impaired, required two person extensive assistance for bed mobility, and was totally dependent on two people for transfers. Observation on 02/24/20 at 10:37 A.M. revealed Resident #40 was sitting in his wheelchair in his room, with his feet resting on food pedals. Resident #40 had a visible dressing to his left foot, with socks on both feet. Review of Resident #40's Wound Evaluation note dated 02/18/20…

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, record review and interview the facility failed to ensure Resident #247 was treated with dignity and respect. The affected one resident (Resident #247) of two residents reviewed for dignified treatment in the facility. Findings include: Record review revealed Resident #247 was admitted to the facility on [DATE] with diagnoses including heart and lung disease, multiple fractures of the ribs which resulted from a fall prior to admission to the facility, spinal stenosis (narrowing of the spinal canal causing numbness, weakness or pain in the arms and/or legs) spondylosis (spinal arthritis) and macular degeneration (blurred or no vision). The resident was admitted for rehabilitation following a fall at home. Review of Resident #247's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated he needed extensive assistance of one staff member with bed mobility (how one moves to and from a lying position, turns side to side, and positions body while in bed). Interview with Resident #247 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure accurate documentation of Resident #72's and Resident #247's toileting programs was maintained in the resident's medical records. This affected two residents (Resident #72 and #247) of 24 residents whose records were reviewed for accuracy of documentation. Findings include: 1. Resident #72 was admitted to the facility on [DATE] with diagnoses including dementia, heart, cerebral vascular and lung disease, urinary incontinence and altered mental status. A review of Resident #72's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated frequent urinary incontinence with a toileting program initiated. A review of the restorative toileting program initiated on 08/30/18 indicated to check Resident #72 for incontinence and offer to assist to the bathroom at 9:00 A.M., 11:00 A.M., 2:00 P.M., 5:00 P.M. and 8:00 P.M. An review of the documentation dated 01/01/19 to 01/14/19 of the scheduled toileting program indicated inaccurate documentation of 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.