Pleasant View Luther Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 20, 2024

  Based 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. […]

• Actual harm, isolatedF689May 8, 2025

  Based 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. Findings include: R1's Final Incident Report dated 4/14/25 shows (R1) is alert to self only. He requires the assistance of one caregiver to complete activities of daily living. He ambulates with his walker. […]

• Actual harm, isolatedF689Jun 20, 2024

  Based 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. Findings include: The facility's Falls Prevention and Post-Falls Management policy, dated [DATE], documents Policy: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. […]

• Actual harm, isolatedF686Jan 31, 2024

  Based 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. […]

• Actual harm, isolatedF689Jan 11, 2024

  Based 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. Findings include: R1's current clinical record documents R1 is cognitively intact, and has diagnoses including generalized muscle weakness, low back pain, history of falls, and a left artificial hip joint (since 05/2023). R1's Incident note, dated 11/21/23, by V9, Licensed Practical Nurse/LPN, documents Resident slid from w/c (wheelchair) while exiting transport van. Small abrasion to forehead. Bleeding stopped and no c/o (complaint of) pain elsewhere. Neuros (neurological signs) WNL (within normal limits). On blood thinner. […]