Pleasant View Center

In the surveyor’s words

From the most serious findings on record at Pleasant View Center, in the surveyor’s own words.

• Actual harm, isolatedF760Feb 26, 2025

  Based on interview and record review, it was determined that the facility failed to ensure residents remained free from significant medication errors which resulted in a resident requiring interventions and hospitalization for multiple nights for 1 of 1 residents reviewed for medication errors. (Resident identifiers is #5.) Findings include: Review on 2/26/25 of Resident #5's medical record revealed the following nursing note written by Staff E (Registered Nurse), dated 2/23/25 at 4:17 p.m.: During morning medication round I inadvertently administered the incorrect medication to the patient. While verifying the medication administration record (MAR) I recognized that the following medications were given. […]

• No harm, potential for more than minimal, widespreadF880Jul 25, 2024

  Based on interview, observation, and record review, it was determined that the facility failed to follow established infection control guidelines for facility water management that has the potential to effect the facility census of 148 residents who resided at the facility; and the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) to prevent spread of infections for 1 of 2 residents reviewed for EBP (Resident Identifier #101). Findings include: Review on 7/25/24 of the facility policy titled, Water Management Program with a revision date of 1/2024 revealed: .Policy Explanation and Compliance Guidelines: .1. […]

• No harm, potential for more than minimal, widespreadF865Dec 22, 2022

  Based on interview and record review, it was determined that the facility failed to implement corrective actions for an identified system failure for advance directives. Findings include: Review on 12/22/22 resident's Advance Directives revealed that 7 of 10 residents had discrepancies. Cross reference F:578 Request/Refuse/Discontinue Treatment; Formulate Advanced Directives. Review on 12/22/22 at 12:30 p.m. of the Quality Assurance and Performance Improvement (QAPI) agenda for the months of July to December revealed no reference to Advance Directives. The quarterly agendas listed old business (ongoing projects), departments reports, and new business. […]

• No harm, potential for more than minimal, patternF553Jan 12, 2026

  Based on interview and record review, it was determined that the facility failed to facilitate the inclusion of the resident and/or representative in quarterly care plan meetings for 5 of 5 residents reviewed for care plan meetings in a final sample of 30 residents. (Resident identifiers are #6, #13, #16, #37, and #68). Findings include: Resident #13 Interview on 1/9/26 at 12:44 p.m. with Resident #13 revealed that he/she had not attended a care plan meeting in over a year. Review on 1/9/26 of Resident #13's medical record revealed that there was a care plan meeting note, dated 10/29/24. Further review revealed that there was no documentation of a care plan meeting for Resident #13 after 10/29/24. Resident #16 Interview on 1/9/26 at 12:47 p.m. […]

• No harm, potential for more than minimal, patternF881Jul 3, 2025

  Based on interview, record review, and policy review, it was determined that the facility failed to implement the facility's antibiotic stewardship program and antibiotic use protocols for 1 of 1 month of antibiotic line list reviewed. (Resident identifier is #41.)Findings include:Review on 7/1/25 of the facility policy title, Antibiotic Stewardship Program, review date of 6/2025, revealed the following: .Antibiotic Stewardship Program leaders utilize existing resources to support antibiotic stewards' effort by working with the following partners: a. […]