Pleasantview Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 17, 2025

  Based on closed record review, review of a facility self-reported incident (SRI), and interviews with staff and the coroner, the facility failed to ensure Resident #145 was provided adequate and necessary care and services during the provision of personal care to prevent an accident/injury. Actual harm occurred on [DATE] when Resident #145, who had right hemiplegia/hemiparesis and was dependent on staff for bed mobility and personal care sustained a significantly displaced acute proximal right humeral neck fracture with medial angulation during care provided by staff. The resident displayed increased pain as a result of the incident and required orthopedic surgical follow-up. This affected one resident (#145) of three residents reviewed for accident hazards. […]

• Actual harm, isolatedF686Jun 29, 2023

  Based on closed medical record review, hospital record review, policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and timely identify bilateral heel pressure ulcers for Resident #165. Actual harm occurred on 01/31/23 when Resident #165, who was cognitively impaired required extensive/dependence on staff for bed mobility and activities of daily living (ADL) care, was found to have an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer to the right heel and a suspected deep tissue injury (SDTI) (a purple or maroon localized area of… […]

• No harm, potential for more than minimal, widespreadF812Mar 18, 2022

  Based on observation, interview, and facility policy review the facility failed to ensure food was stored and prepared appropriately to prevent potential foodborne illness. This had the potential to affect 139 residents who received meals in the facility. The facility identified 10 residents (Residents #14, #30, #56, #69, #87, #95, #122, #241, #378 and #429) as receiving no food by mouth. The facility census was 149. Findings include: Observation on 03/14/22 at 8:03 A.M. while completing the initial kitchen tour with Dietary Cook #661 revealed two tray carts with debris in the bottom of the carts, a straw on the floor of one cart, a food lid and debris in the bottom of a second cart, and two kitchen mixers had encrusted food materials behind the mixing bowls of the industrial mixer. […]

• No harm, potential for more than minimal, widespreadF880Feb 19, 2021

  Based on, observations, interviews and record review, the facility failed to ensure all health care personnel (HCP) utilized personal protective equipment (PPE) properly to attempt to prevent and/or contain the spread of infection related to the global pandemic of [CONDITION(S)]-CoV-2 infection (COVID-19). This had the potential to affect all 133 residents residing at the facility. Findings include: Interview on 02/07/21 at 4:38 P.M. with State tested Nurse Aide (STNA) #350 who was wearing an N-95 mask. STNA #350 stated, I wear one mask for the week, I either take my mask home and leave it in my car or I just leave it in the locker room. They gave us five masks so I wear one a week then change it. Observation on 02/07/21 at 4:51 P.M. revealed STNA #350 exited Resident #107's room. […]

• No harm, potential for more than minimal, patternF761Jun 13, 2024

  Based on observation, staff interview, and medication storage policy, the facility failed to ensure accurate labeling and storage of resident medication for medication cart #1 located on the Ridgeview unit and proper storage of medication in a locked box for Resident #408. This had the potential to affect 26 residents (6, 7, 8, 19, 23, 24, 26, 33, 36, 40, 48, 51, 55, 60, 63, 64, 81, 82, 90, 91, 98,107, 110, 118, 128, 144) who resided on Ridgeview unit. The census was 154. Findings include: 1. Observation on 06/12/24 at 9:20 A.M. of the medication cart #1 on Ridgeview unit with Licensed Practical Nurse (LPN) #534, revealed four loose white pills at the bottom of the medication cart drawer located between the medication cards. […]