Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 189
Deficiencies: 1
Date: Mar 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to infection prevention and control practices, specifically regarding the use of personal protective equipment (PPE) for a resident on droplet precautions.
Complaint Details
This was an incidental finding discovered during the course of the complaint investigation regarding PPE use and COVID-19 precautions.
Findings
The facility failed to ensure that staff donned PPE correctly for Resident #193, who was on droplet precautions to prevent COVID-19 spread. This failure potentially affected 29 residents on the Sandalwood unit.
Deficiencies (1)
F 0880: The facility failed to ensure personal protective equipment (PPE) was donned correctly for Resident #193 on droplet precautions, risking potential COVID-19 spread to 29 residents on the Sandalwood unit.
Report Facts
Residents potentially affected: 29
Facility census: 189
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #201 | Did not wear required PPE while providing care to Resident #193 and stated inability to breathe in N-95 mask | |
| Registered Nurse (RN) #205 | Donned PPE to assist CNA #201 in providing care to Resident #193 |
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 1
Date: Sep 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's provision of care and assistance with activities of daily living for residents.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00157469.
Findings
The facility failed to ensure Resident #135's nails were clean and her chin was free of hair. This issue affected one resident out of three reviewed for activities of daily living.
Deficiencies (1)
F 0677: Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to ensure Resident #135's nails were clean and her chin was free of hair.
Report Facts
Residents affected: 1
Facility census: 158
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #371 | Verified Resident #135's dirty nails and hairs on her chin |
Inspection Report
Routine
Census: 181
Deficiencies: 2
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess compliance with respiratory care and medication storage regulations at Pleasant Lake Villa nursing home.
Findings
The facility failed to ensure proper respiratory equipment maintenance and medication labeling practices. Specifically, oxygen tubing and aerosol equipment were not changed or dated weekly as required, and multiple dose insulin pens were not dated when opened.
Deficiencies (2)
F 0695: The facility failed to ensure recommended guidelines were followed for changing disposable respiratory equipment for Residents #12, #15, and #83. Oxygen tubing and aerosol masks were not dated or changed weekly as required by facility policy.
F 0761: The facility failed to ensure multiple dose insulin medications were dated when opened. Insulin pens for Residents #39, #54, #81, #88, and #285 were in use and not dated per facility policy.
Report Facts
Residents affected: 3
Residents affected: 5
Facility census: 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #916 | Verified oxygen tubing and aerosol equipment replacement policies and observations for Residents #12 and #15 | |
| Licensed Practical Nurse (LPN) #909 | Verified oxygen tubing replacement policy and observations for Resident #83 | |
| Registered Nurse (RN) #995 | Verified insulin dating policy and observations for Resident #285 | |
| Director of Nursing (DON) | Verified oxygen tubing and insulin dating policies and observations for multiple residents |
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 3
Date: Apr 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number OH00152308 regarding concerns about wound treatment, medication administration, and medication errors for Resident #152.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00152308.
Findings
The facility failed to ensure wound treatments were completed as ordered, administered expired medication, and did not provide anticoagulant medication as prescribed to Resident #152. These deficiencies affected one of three residents reviewed and represent non-compliance.
Deficiencies (3)
F 0684: The facility failed to ensure wound treatments were completed as ordered for Resident #152, with missing documentation of dressing changes from 02/29/24 through 03/04/24 and on 04/01/23.
F 0755: The facility failed to ensure Resident #152 was not administered expired budesonide medication, which was given for six days past its expiration date of 02/21/24.
F 0760: The facility failed to ensure Resident #152 received apixaban anticoagulant medication as ordered, missing 11 morning doses on dialysis days in February and March 2024.
Report Facts
Facility census: 171
Expired medication administration duration: 6
Missed apixaban doses: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #450 | Registered Nurse | Interviewed regarding wound dressing changes |
| Director of Nursing | Director of Nursing | Verified wound care and medication administration issues for Resident #152 |
| Licensed Practical Nurse #350 | Licensed Practical Nurse | Interviewed about dressing change procedures |
| Licensed Practical Nurse #449 | Licensed Practical Nurse | Interviewed about wound care for Resident #152 |
| Licensed Practical Nurse #369 | Licensed Practical Nurse | Reported expired medication to Director of Nursing |
Inspection Report
Complaint Investigation
Census: 170
Deficiencies: 3
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to provide proper transfer and discharge notices and bed hold notices for Resident #172, and failure to maintain adequate infection control measures to prevent the spread of Carbapenem-resistant Acinetobacter baumannii (CRAB).
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to provide required transfer and discharge notices and failed to maintain infection control measures to prevent spread of CRAB. The complaint numbers investigated were OH00148150 for transfer/discharge issues and OH00147595 for infection control issues.
Findings
The facility failed to provide Resident #172 and his Responsible Party with required transfer and bed hold notices when Resident #172 was transported to the hospital. Additionally, the facility failed to maintain an adequate infection control program, including failure of staff to don appropriate PPE and failure of Resident #155 to wash hands before leaving his room, risking spread of CRAB infection.
Deficiencies (3)
F 0622: The facility failed to provide Resident #172 and his Responsible Party with a transfer notice when Resident #172 was transported to the hospital via Emergency Medical Services. No documentation of transfer notice or bed hold notice was found.
F 0623: The facility failed to provide timely notification to Resident #172, his Responsible Party, and ombudsman before transfer or discharge, including appeal rights, violating facility policy and regulatory requirements.
F 0880: The facility failed to maintain an adequate infection prevention and control program. Staff did not don appropriate PPE when providing wound care to Resident #156 who was CRAB positive, and Resident #155 did not wash hands before leaving his room, risking spread of infection.
Report Facts
Facility census: 170
Residents affected by transfer/discharge deficiency: 1
Residents affected by infection control deficiency: 2
Residents potentially affected by CRAB spread: 64
Residents tested positive for CRAB: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #423 | Registered Nurse | Named in relation to Resident #172's transfer and communication with family |
| BOM #421 | Business Office Manager | Named in relation to bed hold and transfer notice issues for Resident #172 |
| DON | Director of Nursing | Named in relation to Resident #172's care and transfer documentation |
| FM #590 | Family Member / Responsible Party | Named in relation to Resident #172's transfer and lack of notification |
| LPN/SD/IP #526 | Licensed Practical Nurse/Staff Development/Infection Preventionist | Named in relation to infection control program and CRAB testing |
| WP #588 | Wound Physician | Named in relation to failure to don PPE during wound care for Resident #156 |
| RN/WN #447 | Registered Nurse/Wound Nurse | Named in relation to failure to don PPE during wound care for Resident #156 |
| MT #487 | Medication Technician | Named in relation to failure to don PPE during wound care for Resident #156 |
| Medical Director #589 | Medical Director | Named in relation to awareness and discussion of CRAB cases |
| Administrator | Facility Administrator | Named in relation to Resident #172 transfer and infection control issues |
Inspection Report
Routine
Census: 167
Deficiencies: 6
Date: Apr 27, 2023
Visit Reason
Routine inspection of Pleasant Lake Villa nursing home to assess compliance with health and safety regulations, including environment cleanliness, abuse prevention, treatment care, feeding tube management, and physician order documentation.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean environment affecting 41 residents, failure to implement abuse policies timely regarding misappropriation of resident property, failure to provide ordered skin treatments, failure to change enteral feeding bags per manufacturer guidelines, and failure to ensure physician orders were signed and dated.
Deficiencies (6)
F 0584: The facility failed to maintain a clean and well-maintained environment, including stained privacy curtains, improperly covered air conditioning units, worn fall mats, damaged closets, dirty floors, and dusty fans affecting 41 residents.
F 0607: The facility failed to implement abuse policies properly by not reporting allegations of misappropriation of resident property to the Ohio Department of Health within required timeframes, affecting one resident.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities, affecting one resident.
F 0684: The facility failed to provide treatments for skin impairments as ordered for one resident, including improperly applied or missing dressings on lower extremities.
F 0693: The facility failed to change an enteral tube feeding bag per manufacturer guidelines, resulting in a feeding bag being used beyond the recommended hang time for one resident.
F 0711: The facility failed to ensure physicians' orders were signed and dated, affecting five residents whose monthly recapitulations and telephone orders lacked physician signatures and dates.
Report Facts
Residents affected: 41
Facility census: 167
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Inspection Report
Annual Inspection
Census: 194
Deficiencies: 4
Date: Nov 21, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Pleasant Lake Villa nursing home.
Findings
The facility failed to provide required Medicaid/Medicare notices to residents prior to discontinuation of skilled services, did not implement adequate pain management for a resident with gout, improperly stored medications in residents' rooms, and failed to follow reverse isolation protocols for a resident.
Deficiencies (4)
F 0582: The facility failed to ensure residents received all required Medicaid/Medicare notices prior to discontinuation of skilled services for two residents. Notices such as the Skilled Nursing Facility Advanced Beneficiary Notice were not provided as required.
F 0697: The facility failed to provide safe and appropriate pain management for Resident #243 with gout, resulting in actual harm due to untreated severe pain and missed medication doses.
F 0761: The facility failed to ensure medications for Residents #247 and #167 were properly stored and not left unattended in residents' rooms, violating accepted professional principles.
F 0880: The facility failed to follow reverse isolation protocol for Resident #247, as staff entered the resident's room without proper personal protective equipment.
Report Facts
Facility census: 194
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #300 | Licensed Practical Nurse | Named in findings related to pain management and failure to follow reverse isolation protocol |
| LPN #304 | Licensed Practical Nurse | Named in findings related to pain management and medication administration |
| LPN #302 | Licensed Practical Nurse | Named in findings related to medication storage and administration |
| STNA #305 | State Tested Nursing Assistant | Named in findings related to pain complaints of Resident #243 |
| Licensed Social Worker #301 | Licensed Social Worker | Named in findings related to failure to provide Medicaid/Medicare notices |
| Director of Nursing | Director of Nursing | Interviewed regarding pain management issues for Resident #243 |
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