Inspection Reports for Pleasant View Center

The facility failed to obtain radiology services for 1 of 1 residents reviewed for radiological services in a sample of 29 residents. Resident #46 did not complete a scheduled CT scan, and no follow-up imaging results were found in the medical record. The resident refused the rescheduled CT scan, and no further appointment was made despite instructions from Infectious Disease to obtain the scan.

The facility was found deficient in multiple areas including failure to ensure residents' advance directives were accurately documented, improper use of physical restraints, lack of notification for hospital transfers and bed holds, failure to provide medications upon admission, untimely completion of significant change assessments, incomplete care plans, inadequate fall prevention reviews, failure to implement trauma-informed care, failure to obtain ordered radiology services, inadequate antibiotic stewardship, and failure to properly implement pneumococcal and COVID-19 vaccination policies.

The complaint investigation revealed that the facility failed to immediately report an alleged abuse violation involving Resident #5 to the State Survey Agency. Resident #5 was administered incorrect medications on 2/23/25, resulting in lethargy, administration of Narcan, 911 emergency response, and hospitalization. The facility reported the incident to the SSA on 2/26/25 after beginning an internal investigation on 2/24/25. The facility had been cited for similar reporting violations on the last four consecutive surveys.

The facility failed to timely report an alleged abuse violation involving medication errors for Resident #5, who received incorrect medications resulting in hospitalization. The facility also failed to provide timely medications for residents #1 and #4, failed to ensure licensed nurses had appropriate competencies (notably Staff E), and failed to maintain accurate controlled substance records for Resident #2. The facility lacked performance improvement projects related to reporting alleged violations of abuse and neglect.

The complaint investigation found that the facility did not report an alleged abuse incident involving Resident #1 within the required 24-hour timeframe and failed to report the results of the investigation. The alleged perpetrator was identified as Staff D, whose contract was terminated. The investigation also revealed medication administration delays for Residents #5 and #6.

The facility failed to report an alleged abuse violation within 24 hours and did not report the results of the investigation to the State Survey Agency for one resident. Additionally, the facility failed to ensure timely administration of medications for two residents, with multiple medications administered more than two hours late.

The complaint investigation found that the facility did not notify Resident #8's DPOA-H of changes in condition and medication, and did not report allegations of neglect related to Resident #3's elopement to the State Survey Agency.

The facility failed to notify the DPOA-H of a resident's change in condition and medication changes for Resident #8, and failed to report allegations of neglect involving Resident #3's elopement to the State Survey Agency. Both deficiencies were determined to pose minimal harm and affected a few residents.

The facility was found deficient in multiple areas including failure to assess clinical appropriateness for self-administration of medication, failure to notify residents of bed hold policies, failure to report alleged abuse timely, incomplete care plans, failure to follow physician orders for wound care, inadequate pain management, improper pharmaceutical record keeping, unsecured medication carts, expired medications, and failure to implement infection prevention and control programs including water management and enhanced barrier precautions.

The facility failed to develop comprehensive care plans for residents regarding supervised smoking and anticoagulant monitoring, did not follow physician orders for wound care, had discrepancies and missing documentation in controlled substance records, and failed to ensure medications were properly labeled, stored, and secured.

The complaint involved alleged misappropriation/diversion of medications. Interviews revealed a pattern of narcotics signed out of the narcotic book but not documented in residents' electronic Medication Administration Records (eMAR). The facility administration was unaware of these allegations prior to the investigation.

The facility failed to timely report suspected abuse related to medication diversion and failed to ensure accurate accounting for controlled medications for 4 of 8 residents reviewed. Discrepancies were found between narcotic sign-outs and medication administration records, with excess narcotics signed out without corresponding administration documentation.

The facility was found deficient in multiple areas including failure to assess residents' ability to self-administer medications, failure to timely report and investigate neglect allegations, failure to transmit MDS assessments timely, failure to revise care plans after falls, failure to provide appropriate pressure ulcer care, and failure to properly label, store, and secure medications including maintaining proper refrigerator temperatures.

The complaint investigation was substantiated for failure to provide oversight to prevent Resident #1 from eloping and falling. Resident #1 was found outside the facility after signing out and being missing for several hours. The facility lacked adequate interventions to prevent elopement and had no baseline assessments for walking outside alone.

The facility failed to provide necessary oversight to ensure Resident #1 avoided potential harm after eloping from the facility and sustaining a fall without injury. The resident was found outside after several hours, and the investigation revealed gaps in monitoring, care planning, and baseline assessments for walking outside alone.