F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper
authorities.
Based on interview and record review, the facility failed to immediately report allegations of Employee to
Resident Physical Abuse to the Administrator/Abuse Coordinator for one (R1) resident reviewed for abuse
in a sample of three.
Findings include:
The facility's Abuse and Neglect of a Resident Policy, dated 6/16/23 documents: 6. Protection of Residents:
Team members of this facility who have been accused of mistreatment will be removed from resident
contact immediately until the administrator or designee has reviewed the results of the investigation. Team
members accused of possible mistreatment shall not complete the shift as a direct care provider to
residents. 7. Internal Reporting: If a resident is alleging abuse or neglect (physical, sexual, verbal,
emotional, mental), the team member receiving the complaint will immediately notify their direct supervisor
and the Coordinator of Abuse Prevention.
Facility's Initial Report to State Department on R1 dated 3/27/24 documents: (V1 Administrator) of (Facility)
was notified on 3/27/24 by (V5 Certified Nursing Assistant/CNA) of conversation between her and (V6
Certified Nursing Assistant/CNA). V5 CNA stated that V6 CNA told her that (V6 CNA) punched (R1) in the
stomach. V6 CNA was placed on administrative leave immediately and investigation was initiated.
Facility's Final Report to State Department on R1 dated 4/3/24 documents: V5 CNA recalled V6 CNA
stated, I'm not getting abused, I punched her (R1) in the stomach.
On 4/17/24 at 9:30am, V5 Certified Nursing Assistant/CNA stated that on 3/26/24 at approximately 4:45pm
during mealtime, staff were passing drinks to residents in dining room, stated that she indicated to V6 CNA
that V5 had been having a little difficulty with R1 due to R1's behaviors. V5 CNA indicated that V6 CNA
stated, 'It's okay, (R1) was aggressive and combative at one time, and (V6) punched (R1) in the stomach
and she shut up.' V5 CNA stated that V6 CNA was very blunt in tone. V5 CNA stated that both she and V6
CNA finished their shifts on 3/26/24.
On 4/17/24 at 9:30am, V5 CNA stated that she did not immediately notify anyone; that when she was
leaving work on 3/26/24 at 7:12pm, she texted (V9 Clinical Scheduler's) phone at work regarding this
incident. Stated that V9 Clinical Scheduler got the message the next morning on 3/27/24 and informed V5
CNA.
At this same time, V5 CNA stated, I know we are supposed to report abuse immediately; did not call the
Administrator, it being my second day of work--just a little scared of calling (V1
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145801
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145801
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant View Luther Home
505 College Avenue
Ottawa, IL 61350
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0609
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Administrator). Felt more comfortable texting V9 Clinical Scheduler--had texted her before. Did not think to
text someone else. During orientation, they told us to notify someone right away.
On 4/17/24 at 10:00am, V9 Clinical Scheduler stated that V5 CNA texted the scheduling phone which is left
at the office after V9 leaves work; stated that staff should not be using that phone if they need immediate
responses. V9 stated, Policy for reporting alleged abuse to, if you see something, report to nurse
immediately. I got the message the next morning on 3/27/24 between 7 and 7:30, then let (V2 Director of
Nursing/DON and V1 Administrator) know. We have to report alleged abuse right away, definitely to your
nurse immediately.
On 4/16/24 at 2:40pm, V2 Director of Nursing/DON stated that V1 Administrator was notified on 3/27/24.
Stated that staff were supposed to report abuse concerns to (V1 Administrator) immediately according to
their Abuse Policy.
At this same time, V2 DON stated, Anytime there is suspected abuse or neglect, V1 as the Administrator,
she is to be first notified immediately when there is alleged abuse.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145801
If continuation sheet
Page 2 of 2
