Pleasant View Shiawassee County Medical Care Facil

In the surveyor’s words

From the most serious findings on record at Pleasant View Shiawassee County Medical Care Facil, in the surveyor’s own words.

• Actual harm, isolatedF656Mar 9, 2023

  This citation pertains to intake number MI00130737. Based on interview and record review the facility failed to ensure one out of eight residents (Resident #2) plan of care was followed, resulting in Resident #2 falling out of bed, and sustaining an ankle fracture while receiving care. Findings Included: Per the facility face sheet Resident #2 (R2) had been a resident at the facility since 7/23/2019. Diagnoses included muscle weakness, right and left shoulder, and right hand contractors. R2 no longer resided at the facility at the time of the onsite investigation. Record review of a facility incident report (FRI) dated 7/5/2022 revealed R2 fell out of bed while being repositioned and sustained a fracture to her right ankle. […]

• Actual harm, isolatedF689Mar 9, 2023

  This citation pertains to intake number MI00130737. Based on interview and record review the facility failed to ensure one out of two residents (Resident #2) was free from accidents, resulting in Resident #2 falling out of bed, and sustaining an ankle fracture while receiving care. Findings Included: Per the facility face sheet Resident #2 (R2) had been a resident at the facility since 7/23/2019. Diagnoses included muscle weakness, right and left shoulder, and right hand contractors. R2 no longer resided at the facility at the time of the onsite investigation. Record review of a facility incident report (FRI) dated 7/5/2022 revealed R2 fell out of bed while being repositioned and sustained a fracture to her right ankle. […]

• Actual harm, isolatedF684Sep 1, 2021

  This citation pertains to MI 505 and MI 016. Based on observation, interview and record review, the facility failed to ensure that residents received treatment/care in accordance with professional standards of practice for R1, resulting in unrecognized weight gains and delays in treatment and hospitalization , and putting an additional 23 facility residents (who were either full code and/or wanted aggressive treatment) with [CONDITION(S)] at risk for delayed treatment and increased risk for hospitalization s and further deteriorations in health. Resident #1 (R1) According to the Minimum Data Set (MDS), dated [DATE], R1 was moderately cognitively impaired, was totally dependent on 2 or more staff for transfers, did not walk and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF684Jul 2, 2026

  Based on observation, interview, and record review the facility failed to complete resident treatments per physician order for seven residents (R4, R5, R7, R8, R9, R10, R11) of eight residents reviewed. Findings include:A review of the facilities Facility Reported Incident (FRI) investigation summary revealed that on [DATE], Certified Nursing Assistant (CNA) D and RN E recognized that RN F was being inattentive to her assigned resident's needs. She was observed spending time on her personal cellphone with prolonged periods of sitting in the nurses station and had not completed a dressing for a resident but charted she had done so. These concerns were reported to the on-call manager, RN G on [DATE] at 6 PM. RN F was interviewed and reported that she believed she had completed the dressing. […]

• No harm, potential for more than minimal, isolatedF842Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure accurate medical records for seven residents (R4, R5, R7, R8, R9, R10, R11) of eight residents reviewed. Findings include:A review of the facilities Facility Reported Incident (FRI) investigation summary revealed that on 5/16/26, Certified Nursing Assistant (CNA) D and RN E recognized that RN F was being inattentive to her assigned resident's needs. She was observed spending time on her personal cellphone with prolonged periods of sitting in the nurses station and had not completed a dressing for a resident but charted she had done so. These concerns were reported to the on-call manager, RN G on 5/16/26 at 6 PM. RN F was interviewed and reported that she believed she had completed the dressing. […]