Pleasant View Luther Home

Inspectors wroteBased on interview and record review, the facility to ensure licensed staff dispensed physician-ordered medications for one of three residents (R1) reviewed for medication administration in a sample of three.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure refrigerator and freezer temperatures were monitored and expired food products were discarded and not available for resident use. This failure has the potential to affect all residents who reside in the facility with a current census of 68 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 4 of 6 residents (R3, R19, R40, R55) reviewed for transmission based precautions in a sample of 33. The facility's Enhanced Barrier Precautions (EBP) Policy, dated 4/15/2025, documents EBP refers to an infection control intervention that employs targeted gown and glove use during high-contact resident care activities to reduce transmission of multidrug resistant organisms (MDROs). EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are to be posted on the door or wall outside the resident room indicating the type of precautions and (Personal Protective Equipment) PPE required as well as ensure PPE is available outside of the resident rooms. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic medication was necessary based on an appropriate diagnosis, associated behaviors, non-pharmacological intervention were care planned nor was the resident or resident representative informed in advance of the risks and benefits the medication, the treatment alternatives or other options for 1 of 6 residents (R61) who receive psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to have a PASRR Level I (Pre-admission Screening and Resident Review) re-evaluated with a new psychotic diagnosis for one of one resident (R9) reviewed for PASRRs in the sample of 33. R9's admission record documents R9 was admitted to facility on 2/18/23. R9's PASRR Level I screening, dated 2/6/23, documents, PASRR Level I determination: No Level II required - No SMI/ID/RC (Serious Mental Illness/Intellectual Disease/Related Condition). Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. R9's Diagnosis Report dated 1/28/26 documents R9 was newly diagnosed with psychotic disorder on 2/28/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care to address resident specific concerns for three of twenty residents (R5, R9 and R28), reviewed for care plans, in a sample of 33. The facility policy, Person- Centered Care Plan, dated (revised) 11/28/2017 directs staff, Person- centered care means to support the resident in making their own choices and having over their daily lives. The Person- centered care plan is in accordance with professional standards of practice and includes the resident's choice. The plan of care addresses the following: Identification of resident areas of needs, problems, strengths, goals, life history and preferences. 1. R5's Physician Order Sheet, dated January 2026 includes the following medications and diagnosis: 1/22/26 Cipro Oral Tablet 500 MG (milligrams) (antibiotic). [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer medications as ordered by the physician to two (R26 and R60) of nine residents reviewed for medication pass. This failure resulted in two errors out of twenty-eight opportunities for a 6.9 percent medication error rate.

Inspectors wroteBased on interview and record review, the facility failed to implement safety interventions for a resident at moderate risk for falls while on the toilet for one (R2) of three residents reviewed for falls in a sample of three. The facility's Mechanical Lift policy, reviewed 5/23/25, documents for the Power Stand-Up Lift Procedure: Assemble all supplies within reach, including lift and lift harness. b. Position the top of the harness around the upper body of the resident (approximately 4-5 inches below the underarm). c. Securely fasten the harness safety strap around the resident's chest. This form documents that when lifting a resident from a wheelchair or other chair, secure the harness loops onto the lift. b. Secure the shin straps around the resident's legs. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement psychosocial service interventions for one of three residents (R1) reviewed for social services in sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the recommended guidelines to properly treat and disinfect a resident room with suspected bed bugs to prevent the spread of bed bugs for 2 of 3 residents (R1, R2) reviewed for infection control in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to identify environmental hazards and implement fall prevention interventions for a resident who has a history of falls. This failure resulted in R1 tripping over a resident's wheelchair, falling and hitting his head on the floor sustaining a C1 (neck) fracture. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's representative of a change on resident's anti depressant medication to 1 of 5 residents (R2) reviewed for notification of change in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to notify a resolution of a grievance to 1 of 5 residents (R2) reviewed for grievances in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to provide incontinence care to a resident that need extensive assist with Activities of daily living (ADL) to 1 of 5 residents (R2) reviewed for incontinence care in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff completely covered hair in a sanitary manner while in the kitchen; failed to ensure food items were stored and labeled with dates and identification, and failed to ensure chemical product was not stored in the facility's Dry Food Storage Room. These failures have the potential to affect 76 of the 77 residents who consume food in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff were educated and competent in providing Hospice and End of Life Care for Hospice Residents for nine of nine residents (R14, R23, R40, R43, R51, R52, R61, R62, R65) reviewed for Hospice services in a sample of 38 residents

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene, glove changes and perform pressure ulcer dressing change in a manner to prevent cross contamination for one (R48) of four residents reviewed for pressure ulcers in the sample of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing and humidifier bottles were dated and changed per policy for two (R25 and R127) of four residents reviewed for respiratory care in the sample of 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure Hospice providers provided the facility with written physician orders for one of three residents (R42) reviewed for Hospice services in a sample of 38 residents.

Inspectors wroteBased on interview and record review, the facility failed to document clinical rationale for extending PRN (as needed) psychotropic medication for one (R6) of two residents reviewed for psychotropic medications in a sample of 38.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects three of four residents (R23, R42, R43) reviewed for Hospice care management in a sample of 38 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility Ombudsman posting was visible to residents residing on the second, third, and fourth floors of the facility. This has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's Survey Binder included all prior survey results conducted by the State Agency and was easily accessible to residents. This has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident/resident representative of the reason for transfer in writing for six (R1, R5, R6, R11, R31, R127) of six residents reviewed for emergency hospital transfer in a sample of 38. This has the potential to affect all 77 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the Bed Hold Policy for six (R1, R5, R6, R11, R31, R127) of six residents reviewed for emergency hospital transfer in the sample of 38. This has the potential to affect all residents that currently reside in the faclity.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a demented resident (R1) from sexual abuse by R2 with dementia and a known history of pacing, wandering, disrobing, and violence/aggression towards staff/others. This failure resulted in R2 placing his hand down R1's pants and performing repeated aggressive up and down sexual type motions. This failure resulted in R1 feeling frightened and requiring hospital examination where a minor tear near R1's vagina was noted. This failure has the potential to affect R1 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/18/24 the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their abuse prevention program to screen, protect, and report allegations of sexual abuse for two (R1 and R2) of three residents reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and report a potential allegation of resident to resident (R1 and R2) sexual abuse to the Abuse Coordinator for three residents reviewed for Abuse in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety during assisted ambulation for one (R1) resident of four reviewed for falls in a sample of four. This failure resulted in R1 receiving a fractured femur followed by a decline in condition and subsequent death.

Inspectors wroteBased on interview and record review, the facility failed to immediately report allegations of Employee to Resident Physical Abuse to the Administrator/Abuse Coordinator for one (R1) resident reviewed for abuse in a sample of three.

Inspectors wroteBased on interview, observation and record review, the facility failed to perform skin risk assessments, implement additional pressure relieving interventions after a change in condition, and identify a pressure ulcer prior to its status worsening to a Stage III for one of three residents (R9) reviewed for pressure ulcers in the sample of 38. This failure resulted in R9's pressure ulcer worseing without new interventions implemented. Findings Include: The facility's Pressure Injury Prevention policy (revised 01/10/24) documents the following: The community must ensure that : A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to answer a resident's call light in a timely manner for one of one resident (R34) reviewed for accommodation of needs in the sample of 38.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for chronic urinary tract infections, antibiotic and oxygen use for two residents (R21 and R53) of 18 reviewed for comprehensive care plans in a sample of 38.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to ensure a range of motion program was in place for a resident with functional limitations in range of motion for two of three residents (R36 and R53) reviewed for range of motion in the sample of 38.

Inspectors wroteBased on (observation), interview, and record review, the facility failed to provide justification for the use of an antipsychotic medication and create a care plan for the use of an antipsychotic medication for R34, failed to attempt a gradual dose reduction for an antipsychotic medication for R51 and failed to identify specific target behaviors to warrant the use of an antipsychotic medication for (R34, R47 and R51) three of five residents reviewed for antipsychotics in the sample of 38. Findings Include: The facility policy, Psychotropic Medication Management System, dated (revised) 10/26/2022 directs staff, (The facility) has developed a system to ensure a resident is not given psychotropic medications unless a comprehensive assessment identifies clear indications and parameters for their use, based upon regulatory compliance and best practices. Behavior Management: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety during van transport for one (R1) of four residents reviewed for falls in a sample of three. This failure resulted in a 5th metacarpal fracture of R1's hand.