Pleasant View Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 12, 2021

  Based on interview and record review the facility failed to notify one resident's physician of a change in condition and promptly intervene when the resident was in distress. This affected on resident (Resident #1). The facility census was 27. 1. Review of the undated facility policy on change in condition showed: - The purpose of the policy was to ensure staff promptly notified the resident's physician when the resident experienced a change in condition. - Staff should notify the resident's physician when a resident experienced a deterioration in health. Review of the facility policy, dated [DATE], on physician notification, showed: - Staff should notify a resident's physician anytime a resident experienced a significant change in the resident's physical status. […]

• No harm, potential for more than minimal, patternF578May 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF700May 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF759May 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF550Apr 10, 2024

  Based 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. […]