Pleasantview Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, and facility policy review, the facility failed to ensure medications were given as ordered for Resident #210. This affected one resident (#210) of three residents reviewed for administration of medications. The facility census was 160. Findings include:Review of the closed medical record for Resident #210 revealed she was admitted to the facility on [DATE] and had diagnoses including bladder cancer, dysphagia, and other disorders of electrolyte and fluid imbalance. She expired in the facility on [DATE]. Review of Resident #210's physician's orders revealed an order for Phos-NaK oral packet (an electrolyte supplement) to be given four times per day starting [DATE]. Review of Resident #210's [DATE] Medication Administration Record (MAR) revealed all doses of the Phos-Nak, with the exception of the evening dose on [DATE], were marked 'other' on 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 interviews, record review, review of the facilities self-reported incident (SRI), and policy review, the facility failed to ensure all injuries of unknown origin were timely reported to management and the State Survey Agency, Ohio Department of Health (ODH). This affected one (Resident #145) of one resident reviewed for abuse reporting. The facility census was 142. Findings include: Review of the closed medical record for Resident #145 revealed an admission date of 02/27/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, osteopenia, atrial fibrillation, chronic pain, and convulsions. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 had impaired cognition. Resident #145 was dependent on staff for transfers, bed mobility (rolling left and right) and toileting. Resident #145 had impairment on one side of both lower and upper extremities. Review of the facilities SRI tracking number 258571 revealed 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, staff interview, and medication storage policy, the facility failed to ensure accurate labeling and storage of resident medication for medication cart #1 located on the Ridgeview unit and proper storage of medication in a locked box for Resident #408. This had the potential to affect 26 residents (6, 7, 8, 19, 23, 24, 26, 33, 36, 40, 48, 51, 55, 60, 63, 64, 81, 82, 90, 91, 98,107, 110, 118, 128, 144) who resided on Ridgeview unit. The census was 154. Findings include: 1. Observation on 06/12/24 at 9:20 A.M. of the medication cart #1 on Ridgeview unit with Licensed Practical Nurse (LPN) #534, revealed four loose white pills at the bottom of the medication cart drawer located between the medication cards. The four loose pills were observed to be without a medication label or resident identifier. Interview on 06/12/24 at 9:34 A.M., LPN #534 verified the four white pills were unable to be identified and confirmed the loose pills were without a medication label or resident identifier. 2. Record review of Resident #408 revealed an admission date 05/30/24. Diagnoses…

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, interviews, policy review, and surveyor taste test, the facility failed to serve food at a hot and palatable temperature. This had the potential to affect 145 residents that received meals from the kitchen with the exception of nine other residents (Residents #8, #19, #48, #72, #124, #135, #150, #310, #411) who were ordered nothing by mouth (NPO). The facility census was 154. Findings include: Interview with Resident #103 on 06/10/24 at 9:28 A.M. revealed the facility's food comes cold and so does the tea. Interview with Resident #408 on 06/10/24 at 3:49 P.M. revealed the resident was served eggs and cereal and does not eat them. Resident #408 also reported an incident on 06/09/24 in which she did not receive meat with her dinner. Interview with Resident #121 on 06/11/24 at 7:27 A.M. revealed the facility's food, specifically meat, is hard to cut and chew. Interview with Resident #21 on 06/11/24 at 9:55 A.M. revealed the resident was allergic to strawberries and was served strawberry jam desserts. Resident #21 also reported an incident in which he did not…

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 review of facility policy, the facility failed to ensure residents had access to a non-flammable ashtray and properly disposed of used cigarettes. This affected 19 residents (#3, #7, #10, #12, #15, #22, #27, #38, #55, #71, #72, #76, #96, #109, #112, #132, #137, #147, and #416), whom the facility identified as smokers, and had the potential to affect all 154 residents residing in the facility. Findings include: Observation on 06/11/24 at 2:31 P.M. with the Administrator revealed many cigarette butts in the plastic trash receptacle mixed with three empty combustible cigarette boxes, paper napkins, and plastic candy wrappers. No metal ashtray was available in the resident smoking area at the time of observation. Interview at the time of observation with the Administrator verified the above findings. Review of the facility policy titled Resident Smoking, dated 11/30/23, indicated smoking areas would have non-flammable ashtrays and non-flammable trash cans.

Based on interview and medical record review, the facility failed to ensure a preadmission screening and resident review (PASRR) Identification Screen was completed for a new diagnosis of a serious mental illness. This affected one Resident (#32) of five residents reviewed for PASRR. The facility census was 154. Findings include: Review of the medical record for Resident #32 revealed admission date of 03/10/23 and diagnoses including bipolar disorder, recurrent major depressive disorder, anxiety disorder, post traumatic stress disorder, and depressive type schizoaffective disorder. Review of the PASRR screen dated 03/30/23 revealed no evidence of schizoaffective disorder diagnosis was included on the screen. Review of Psychiatric Note dated 04/23/24 Resident #32 endorsed auditory hallucinations and delusions which supported diagnosis of schizophrenia. Additionally Resident #32's history revealed a consistent pattern of erratic behavior and challenges maintaining employment. It was recommended to add a new diagnosis of schizoaffective disorder. Review of the medical record revealed…

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 facility policy review the facility failed to ensure food was stored and prepared appropriately to prevent potential foodborne illness. This had the potential to affect 139 residents who received meals in the facility. The facility identified 10 residents (Residents #14, #30, #56, #69, #87, #95, #122, #241, #378 and #429) as receiving no food by mouth. The facility census was 149. Findings include: Observation on 03/14/22 at 8:03 A.M. while completing the initial kitchen tour with Dietary [NAME] #661 revealed two tray carts with debris in the bottom of the carts, a straw on the floor of one cart, a food lid and debris in the bottom of a second cart, and two kitchen mixers had encrusted food materials behind the mixing bowls of the industrial mixer. While in the walk-in freezer ice buildup was observed on food items underneath the condenser, and two moldy oranges were found in the bin of oranges in the walk-in refrigerator. At the time of the observation, Dietary [NAME] #661 confirmed the findings. Observation on 03/15/22 at 9:10 A.M. of pureed…

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, record review, and review of the facility policy the facility failed to ensure physician orders were followed and care planned interventions were implemented for Resident #230. This affected one (Resident #230) of three residents reviewed for pressure ulcers. The facility census was 149. Findings include: Review of Resident #230's medical record revealed an admission date of 02/22/22 with diagnoses including neoplasm of uncertain behavior of other specified digestive organs, diffuse large B-cell lymphoma, type two diabetes mellitus, and heart failure. The resident was discharged from the facility on 03/14/22. Review of Resident #230's Weekly Ulcer and Wound Documentation dated 02/22/22 revealed Resident #230 had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) to the sacrum measuring 15.9 centimeters (cm) in length by 11.6 cm width and a depth 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.

Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #232 implemented safe smoking practices while residing in the facility. This affected one resident (Resident #232) of three residents reviewed for safe smoking practices. The facility census was 149. Findings include: Review of Resident #232's medical record revealed an admission date of 03/08/22 with diagnoses including sepsis, cutaneous abscess of right upper limb, and chronic obstructive pulmonary disease. Review of Resident #232's medical record and progress notes from 03/08/22 through 03/14/22 did not reveal documentation Resident #232 used tobacco and was educated on the smoking policy and risks of smoking. Review of Resident #232's admission Assessment and Baseline Care Plan dated 03/08/22 did not reveal documentation Resident #232 used tobacco and was educated on the smoking policy and risks of smoking. Observation on 03/14/22 at 11:40 A.M. revealed Resident #232 walked out of his room with his surgical mask on. Resident #232 walked outside to the smoking…

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 interview, observation and record review, the facility failed to ensure the care plans were updated timely for residents with catheters. This affected two residents (Resident #44 and Resident #88) out of two residents reviewed for catheters. The facility census was 148. Findings Include 1. Resident #44 was admitted to the facility on [DATE]. Her admitting diagnoses included urinary tract infection, severe sepsis with septic shock, neuromuscular dysfunction of the bladder, chronic kidney failure and encephalopathy. According to Resident #44's Minimum Data Set 3.0 (MDS) assessment, dated 01/24/19, this resident had moderate cognitive impairment. She needed extensive assistance of staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of the bowel and bladder assessment of this MDS showed that the resident did have an indwelling urinary catheter. Review of Resident #44's physician orders revealed on 02/05/19 the physician wrote an order for the resident to have a foley…

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 record review, observation, and interview, the facility failed to ensure staff did not falsely record the removal of lidocaine patches for Resident #105. This affected one of seven residents reviewed for medication administration (Resident #105, #447, #62, #64, #98, #67, and #110). the facility census was 150. Findings include: Observation of a medication administration pass for Resident #105 on 04/02/19 at 8:25 A.M. by Licensed Practical Nurse #201 revealed the resident to have two Lidocaine 4% patches dated 04/01/19 already on their knees. The nurse removed the old patches then applied new patches on each knee. Record review of Resident #105 revealed orders for their lidocaine patches to be applied at 9:00 A.M. each morning and removed at 5:00 P.M. each evening. Review of their medication administration record revealed a staff member documented that the patches were removed on 04/01/19 at 5:00 P.M. No evidence could be found indicating a different set was applied in between that time and Licensed Practical Nurse #201's removal of the old patches on 04/02/19. This finding…

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.