Pleasant View Home

Inspectors wroteThe facility identified a census of 79 residents, with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to ensure staff responded appropriately with adequate supervision to prevent potential abuse and/or mistreatment of Resident (R) 1, a cognitively impaired resident. This placed R1 at risk for potential abuse and/or mistreatment.

Inspectors wroteThe facility identified a census of 79 residents with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to report an allegation of abuse for Resident (R) 1 immediately, but not more than two hours, to the required entities including Law Enforcement (LE) and the State Agency. This placed the resident at risk for unidentified and ongoing abuse or mistreatment.

Inspectors wroteThe facility identified a census of 79 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to immediately investigate an allegation of abuse for Resident (R) 1 and initiate protective measures to prevent further potential abuse until an investigation was completed. This deficient practice placed R1 at risk for ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 78 residents. The sample included 18 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to prevent a facility-acquired deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) for Resident (R) 15, who sustained a DTI to her left buttock (either of the two round fleshy parts that form the lower rear area of a human trunk) when staff placed a bed pan under R15 backward and left it under her for too long. [...]

Inspectors wroteThe facility had a census of 78 residents and one kitchen. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety. This placed the residents who received their meals from the facility's kitchen at risk for foodborne illness.

Inspectors wroteThe facility had a census of 78 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to identify and dispose of expired medications appropriately. This deficient practice placed residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 78 residents. The sample included 18 residents with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide Resident (R) 25 and R277 complete information on the Notice of Medicare Non-Coverage (NOMNC) Form-10123 which informed the beneficiary of the right to an expedited review by a Quality Improvement Organization (QIO). This placed the residents at risk of uninformed decisions about their skilled services and the inability to appeal.

Inspectors wroteThe facility had a census of 78 residents. The sample included 18 residents with seven reviewed for accidents. Based on observation, interview, and record review the facility failed to prevent accidents for Resident (R) 5 when staff transported her in a wheelchair without footrests and R5 fell forward onto the floor and hit her head. This placed R5 at risk for injuries and increased pain. The facility also failed to ensure an environment free from accident hazards when staff failed to secure hazardous chemicals placing all confused, independently mobile residents at risk for accidental ingestion.

Inspectors wroteThe facility had a census of 78 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure a communication process between the hospice provider and the facility for one of two residents reviewed for hospice services, Resident (R) 29. This placed the resident at risk of not receiving adequate end-of-life care.

Inspectors wroteThe facility had a census of 81 residents. Based on observation, record review and interview the facility failed to adhere to infection control for transmission based precautions (TBP-an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R)7, who had vancomycin resistant enterococci (antibiotic resistant bacterial infections), which placed the residents who received care from the exposed staff at risk for possible exposure of infection.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to notify Resident, (R) 26's physician and the resident representative of a bruise of unknown origin on R26's inner thigh. This placed the resident at risk for emotional and physical decline.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to administration a bruise of unknown origin on an inner thigh and failed to report to the state agency bilateral bruising of unknown origin to wrists for one sampled resident, Resident (R) 26. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate two separate areas of bruising for one sampled resident, Resident (R) 26, who had bilateral bruising of unknown origin to her wrists, and bruising of unknown origin to her inner thigh. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop a baseline initial care plan (a care plan that includes the instructions needed to provided effective and person- centered care of the resident that meet professional standards of quality care) for Resident (R)185 who received dialysis services (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). This placed the resident at risk for complications related to uncommunicated care needs.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically related social services to attain to maintain the highest practicable physical, mental, and psychosocial well-being of Resident (R) 56 who exhibited depression and had behaviors. This placed R56 at risk for further decline in depression.

Inspectors wroteThe facility had a census 81 resident. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a stop date for the use of an as needed antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) for Resident (R) 40 which placed R40 at risk for inappropriate use of antianxiety medication.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 40's as needed (prn) lorazepam (an antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic (altering mood or mind) medication use.

Inspectors wroteThe facility had a census of 81 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a medications error rate of less than five percent (%). The facility medications error rate was 8.33 % placing the residents at risk for complications related to medications errors.

Inspectors wrote- R22's Physician Order Sheet (POS) dated 07/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), weakness, unsteadiness on feet, and repeated falls. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident was independent with all activities of daily living. The assessment further revealed the resident had two or more falls without injury during the lookback period. The Significant Change MDS, dated 07/18/21, documented the resident had a BIMS score of five which indicated the resident had severely impaired cognition. [...]

Inspectors wrote- R22's Physician Order Sheet (POS) dated 07/23/21, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), weakness, unsteadiness on feet, and repeated falls. The Annual Minimum Data Set (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five which indicated the resident had severely impaired cognition. The assessment revealed the resident was independent with all activities of daily living. The assessment further revealed the resident had two or more falls without injury during the lookback period. The Significant Change MDS, dated 07/18/21, documented the resident had a BIMS score of five which indicated the resident had severely impaired cognition. [...]

Inspectors wroteThe facility had a census of 80 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to notify the physician of low blood sugars for one sampled resident, Resident (R) 4.

Inspectors wroteThe facility had a census of 80 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to assess and treat Resident (R) 4's low blood sugars, and failed to provide scheduled anticoagulant medication (medication used to prevent blood clots) for R62.