Health inspection·March 18, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure physician orders were followed and care planned interventions were implemented for Resident #230. This affected one (Resident #230) of three residents reviewed for pressure ulcers. The facility census was 149. Residents Affected - Few Findings include: Review of Resident #230's medical record revealed an admission date of 02/22/22 with diagnoses including neoplasm of uncertain behavior of other specified digestive organs, diffuse large B-cell lymphoma, type two diabetes mellitus, and heart failure. The resident was discharged from the facility on 03/14/22. Review of Resident #230's Weekly Ulcer and Wound Documentation dated 02/22/22 revealed Resident #230 had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) to the sacrum measuring 15.9 centimeters (cm) in length by 11.6 cm width and a depth of 0.1 cm. Review of Resident #230's admission assessment dated [DATE] included Resident #230 was at a high risk for skin breakdown. Review of Resident #230's physician orders on 02/24/22 revealed a low air loss mattress to the bed, check function every shift. Review of Resident #230's Treatment Administration Record (TAR) from 03/01/22 through 03/14/22 revealed there was documentation every shift Resident #230 had a low air loss mattress on the bed, and the function was checked every shift. Review of Resident #230's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #230 was cognitively intact and required the extensive assistance of two staff for bed mobility, transfers, and toilet use. Resident #230 was frequently incontinent of urine, always incontinent of bowel, and admitted with a pressure ulcer, but location and stage were not documented. Review of Resident #230's care plan revised 03/11/22 included Resident #230 had the potential for alteration in skin integrity related to bruises easily, history of skin tears due to fragile skin condition, abnormal labs, decreased circulation, oxygenation, vitamin deficiency, mood/behavior status, at risk for malnutrition, osteoarthritis, congestive heart failure, diabetes mellitus, obstructive sleep apnea, anemia. diffuse large B cell lymphoma with poor prognosis. Resident #230 would not develop skin breakdown through review date. Interventions included low air loss pressure redistribution (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 4 Event ID: 365084 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 365084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129 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)