Pleasant View Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for residents (Resident #26 and Resident #47) were correct when the Durable Power of Attorney (DPOA)'s name was printed on the DNR instead of the name of the resident and when the facility failed to ensure the DNR orders for residents (Resident #46 and Resident #47) were not signed by the DPOA prior to the residents being declared incapacitated. This affected three of 13 sampled residents (Resident #26, Resident #46 and Resident #47) The facility census was 51. Review of the facility's policy titled, Advance Directives, dated December 2016, showed: -Advanced directives will be respected in accordance with the state and state law; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for three of 13 sampled residents (Residents #11, #17 and #47). The facility census was 51. The facility did not provide the requested policy on entrapment assessments. 1. Review of Resident #11's Quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 02/26/25, showed: -Severe cognitive impairment; -Substantial assist for toileting and bathing; -Partial assistance for bed mobility; -Bed rails not used; -Diagnoses included, dementia, other fracture and high blood pressure. Review of the resident's care plan dated, 05/01/25, showed: -Assist of two staff for Activities of Daily Living (ADLs); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made two medication errors out of 26 opportunities for error which resulted in a medication error rate of 8%, this affected 3 residents of the 13 sampled residents, ( Residents #101, #46, #22). The facility census was 51. Review of the facility's undated Glucose Finger Stick policy, showed: Alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. 1. Review of Resident #101's Quarterly MDS, dated [DATE] showed: -Cognition intact; -Requires nursing assistance with self care and mobility; -Diagnoses: Diabetes, high blood pressure, renal insufficiency, parkinsons. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect when they stood to feed residents who required assistance (Resident #34 and #35) and when they failed to serve residents sitting at the same table at the same time during meal service (Resident #28, #17, #8, and #39. This affected six of twelve sampled residents. The facility census was 48. Review of facility policy, quality of life - dignity, dated August 2009, showed: -Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. -Residents shall be treated with dignity and respect at all times. -'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 1. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and comfortable homelike environment when staff failed to replace trim missing from the base of the nurses station, replace damaged drywall on the side of nurses station, repair the medication cart that had several pieces of black duct tape on top left side, failed to repair a pillar near the left entrance of the dining room which had a 3-4 inch and 1 to 11/2 inch gouges of paint removed and missing paint. The facility failed to keep oxygen concentrators and Continuous Positive Airway Pressure (CPAP) machine dust free when a layer of dust was on Resident #22's oxygen concentrator and CPAP machine. The facility failed to keep Resident #200's dry wall seam was peeling from the ceiling. [...]

Inspectors wroteBased on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected five of six sampled staff (RN A, [NAME] A, NA A, Maintenance Supervisor, and Care Partner A). The facility census was 48. Review of facility Policy, Abuse and Neglect, dated January 2017, showed: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer, the location to which the resident is transferred or discharged , a statement of the resident's appeal rights, including he name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff completed a Level I Preadmission Screen and Resident Review (indicated for any individual who may have an intellectual disability (ID), developmental disability (DD), or mental illness (MI). This affected two of 12 sampled residents, ( Resident #22 and #33). The facility census was 48. Review of the facility's undated policy for PASARR's (Preadmission Screening and Resident Review, a federal requirement to help ensure that individuals are inappropriately placed in nursing [NAME] for long term care) showed: - The Nursing Home Reform Act was passed as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA - 87), and amended by Public Law 100 -203 and 101 - 508, creating the Preadmission Screening and Resident Review ([NAME]) process; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care to include measurable objectives and appropriate timeframe's for five of 12 sampled residents (Resident #3, #6, #22, #34 and #39), when the facilty failed to address Hospice care for one resident (Resident #3), and when the facilty failed to address a pressure ulcer for one resident (Resident #6), and failed to address the use of oxygen and a Continuous Positive Airway Pressure (CPAP, a machine that helps the resident breathe easier) machine for one resident (Resident #22). Additionally, the facilty failed to address the use of cane rails (a device that enables the residnet's mobility) for two residents (Resident #34 and #39). The facility census was 48. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff followed professional standards of care for four of 12 sampled residents (Resident #18, #22. #35 and #46) when staff failed to ensure blood sugars were checked 30 minutes prior to meals which affected two residents (Resident #18 and #35), and failed to obtain a physician's order to check blood sugars for one resident who was receiving insulin (Resident #46) and when staff failed to obtain physician's orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (a machine that helps the resident breathe easier) and for changing the oxygen tubing one resident (Resident #22). The facilty census was 48. Review of the facilty's Medication Administration and Maintenance Policy, dated October 2017, showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility staff failed to ensure dependent residents who were unable to carry out activities of daily living (ADL's) received the necessary services to maintain good personal hygiene when staff did not ensure nail care was completed for one of 12 sampled residents, (Resident #33) and ensure shaving was completed for two sampled residents, (Resident #3 and #33). The facility census was 48. Review of the facility's undated policy on nail care showed it did not address when fingernail polish should be removed and reapplied. Review of the facility's shaving policy, revised October 2010, showed, in part: - The purpose of this procedure is to promote cleanliness and to provide skin care; - The policy did not address how often a female or male resident should be shaved. 1. Review of Resident #33's care plan, revised 7/1/23 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assess residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the residents size and weight, failed to complete quarterly assessments, and failed to obtain a physician's order prior to installation for two of twelve sampled residents (Resident #22 and #39). The facility census was 48. Facility did not provide a policy on entrapment assessments. Review of facility policy, proper use of side rails, revised December 2016, showed: -Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (5%). Facility staff made five medication errors out of 25 opportunities for error, resulting in a medication error rate of 20%. This affected four of 12 sampled residents, (Resident #21, #27, #33, and #43). The facility census was 48. Review of the facility's undated policy for medication administration and maintenance, showed, in part: - No medication or treatment shall be given without an order from a person lawfully authorized to prescribe such and the order shall be followed. Review of the facility's policy for eye drops/ointment administration, dated September, 2017 showed: - Eye drops and eye ointments will be administered according to physician orders and/or recommendations; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, and when the medications were left in pill cups on the dining table for residents in the dining room (Resident #18, #20, and #39) and when the facility failed to discard an opened vial of tuberculin purified protein derivative (skin test used to help diagnose tuberculosis infection), failed to date an opened vial of tuberculin purified protein derivative, and failed to date an opened insulin pen for Resident #46. The facility census was 48. Facility policy, Medication Administration and Maintenance, undated, showed: -No medications will be left unattended or unobserved by Certified Medication Technician or nurse administering to residents. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot and cold food was not served at an appetizing temperature and when pureed food was not made to proper consistency to three of twelve sampled residents (Resident #22, #39, and #34). The facility had a census of 48. Review of facility policy, general food preparation and handling, undated, showed: -Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. Review of facility policy, food temperatures, undated, showed: -All hot foods must be cooked to appropriate internal temperatures, held and served at temperature of at least 135 degrees Fahrenheit (F); [...]

Inspectors wroteBased on observation, record review, and interviews the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to clean and sanitize all areas of the kitchen, maintain a thermometer in the chest freezer, compete proper hand washing techniques, maintain a lid on trash cans, utilize and ensure proper parts per million (PPM) of sanitizer solution, discard expired food, ensure all employees wear hair and beard nets, invert clean pitchers for storage, label and date all foods. This had the potential to impact all residents in the facility. The facility census was 48 residents. 1. Review of facility policy, general food preparation and handling, undated, showed: -The kitchen will be kept neat and orderly; -Kitchen surfaces and equipment will be cleaned and sanitized as appropriate; [...]

Inspectors wroteBased on observation and interview the facility failed to assist one resident (Resident #6) to maintain hydration status when they failed to provide resident water in his/her room. The facility census was 48. Facility did not provide policy on hydration. 1. Review of Resident #6's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/5/24, showed: -He/She admitted on [DATE]; -Cognition severely Impaired. -He/She required partial/moderate assistance with eating, upper body dressing, rolling left and right, sit to lying, lying to sitting on side of bed -He/She required supervision or touching assistance for oral care; -Diagnoses included pneumonia, high blood pressure, wound infection, thyroid disorder, arthritis, anxiety, and depression. -He/she had mechanically altered diet Review of care plan, dated 2/6/24, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 48. Review of facility policy, Director of Food and Nutrition Services, undated, showed: -The director of food and nutrition services will be responsible for all aspects of the food and nutrition services department including but not limited to food safety, staff safety, cost management, and meeting nutritional needs of patients/residents served. -The Director of food and nutrition services will be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that did not have a full time dietician or must designate a person to serve as director of food and nutrition service. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to follow infection control standards and guidelines for catheter care when staff failed to ensure the urinary catheter drainage bag was not touching the floor for one of 12 sampled residents (Resident #3). The facility census was 48. Review of the facility's Urinary Catheter Care Policy, dated September 2014, showed: -The purpose of this procedure is to prevent catheter-associated urinary tract infections; -Use standard precautions when handling the drainage system; -Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facilty's Infection Prevention and Control Policy dated September 2023, showed: - The facilty will establish a safe, sanitary and comfortable environment to help prevent the development and transmission of infections for all residents; [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to prepare and serve food under sanitary conditions when staff failed to change gloves between dirty and clean tasks, failed to date opened food products and failed to store clean dishes in a manner to protect them from possible contamination from food and dust. This had the potential to affect all the residents who ate in the facility. The facility census was 42. Review of the undated general food preparation and handling policy showed: - Disposable gloves are a single use item and should be discarded after each use; - Employees should wash hands prior to putting gloves on and after removing gloves; - Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide at least two days notice of benefits end date for two of three residents sampled for beneficary notices (Resident #8 and #148) when changes were made to their Medicare coverage prior to the end of service date. The facility had a census of 42. The facility did not provide a policy. 1. Review of Resident #8's Skilled Nursing Beneficiary Protection Notification (SNBPN) Review (SNBPN) form showed: - Medicare Part A Skilled Services Episode Start Date: 12/8/22; - Last covered day of Part A Service: 12/22/22 - (Part A terminated/denied or resident was discharged ); - The facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted; - The resident's representative signed the form on signed on 12/22/22, the last day of services. 2. Review of Resident #148's SNBPN form showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they put a discharge planning process in place which addressed goals and needs, including caregiver support and referrals to local contact agencies, as appropriate and involved the resident and if applicable, the resident representative and interdisciplinary team in developing a discharge plan for one of two residents sampled for closed record review (Resident #44). The facility census was 42. Record review of the Discharge Planning Policy, dated September 2017, showed: - It is the policy to complete discharge planning on any resident where discharge is anticipated to home, another SNF/NF or other type post-acute setting; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete a comprehensive discharge summary for one of two residents sampled for discharge planning (Resident #44). The facility census was 42. Review of Discharge Policy dated September 2017 showed the discharge summary will include but is not limited to, the following: - Recapitulation of the resident's stay including, but not limited to diagnosis, course of illness/treatment or therapy, pertinent lab, radiology and consultation results. - Final summary of the resident's status at discharge. This summary will be available for release to authorized individuals and agencies with the consent of the resident or the resident's legal representative. The following items are required to be in the final summary of the resident's status: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring one of 12 sampled residents (Resident #12) during a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or reposition) transfer, during the use of a mechanical lift transfer for one sampled resident (Resident #33) and when staff used one sampled residents' (Resident #30) pants to reposition the resident in his/her wheelchair. The facility census was 42. 1. Review of the facility's policy for mechanical lift, dated January 2017, showed in part: - All transfers of residents requiring full-body mechanical lifts will be made by two nursing staff persons; [...]