Inspection·June 29, 2023

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. Residents Affected - Few 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 discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear) pressure ulcer to the left heel. The ulcers deteriorated and on 05/23/23 the resident's daughter requested the resident be sent to the emergency room related to the condition of the heel ulcers, the ulcers had moderate amounts of copious drainage with a foul odor noted. The resident was subsequently admitted to the hospital and diagnosed and treated for heel ulcer wound infection. This affected one resident (#165) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #165's closed medical record revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted on [DATE] and discharged to the hospital on [DATE]. Resident #165 had diagnoses including essential hypertension, muscle weakness and adult failure to thrive. A plan of care dated 12/20/22 revealed the resident had the potential for altercation in skin integrity due to a diagnosis of failure to thrive (FTT), easily bruising, history of a skin tear due to fragile skin condition, abnormal labs, decreased circulation/oxygenation, vitamin deficiency, mood/behavior status and being at risk for malnutrition and incontinence. Interventions included to administer medications as ordered, administer treatments as ordered, Braden score quarterly and as needed, diet per recommendations, monitor for bruising, monitor labs, offload heels as tolerated, pressure redistribution cushion to chair. An intervention dated 01/04/23 indicated to implement a low air loss mattress to the bed. Review of Resident #165's admission assessment and baseline care plans form dated 12/30/22 revealed Resident #165 was at high risk for skin breakdown and no skin concerns or pressure areas were identified on the document. (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 06/29/2023 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)