Health inspection·June 13, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on interview and medical record review, the facility failed to ensure a preadmission screening and resident review (PASRR) Identification Screen was completed for a new diagnosis of a serious mental illness. This affected one Resident (#32) of five residents reviewed for PASRR. The facility census was 154. Findings include: Review of the medical record for Resident #32 revealed admission date of 03/10/23 and diagnoses including bipolar disorder, recurrent major depressive disorder, anxiety disorder, post traumatic stress disorder, and depressive type schizoaffective disorder. Review of the PASRR screen dated 03/30/23 revealed no evidence of schizoaffective disorder diagnosis was included on the screen. Review of Psychiatric Note dated 04/23/24 Resident #32 endorsed auditory hallucinations and delusions which supported diagnosis of schizophrenia. Additionally Resident #32's history revealed a consistent pattern of erratic behavior and challenges maintaining employment. It was recommended to add a new diagnosis of schizoaffective disorder. Review of the medical record revealed the diagnosis of depressive type schizoaffective disorder was added to Resident #32's diagnosis list on 04/23/24. Review of the medical record revealed there was no evidence of additional PASRR screening for Resident #32's newly added schizoaffective disorder diagnosis identified. There was no evidence of additional PASRR screens since 03/30/23. Interview on 06/11/24 at 10:30 A.M. with Director of Nursing (DON) and Social Service Designee (SSD) #581 confirmed a new diagnosis of schizoaffective disorder had been added for Resident #32 on 04/23/24. Interview on 06/11/24 at 11:00 A.M. with SSD #581 confirmed there had not been a PASRR screen completed for the 04/23/24 diagnosis. SSD #581 indicated she completed a PASRR screen on 06/11/24 to reflect the schizoaffective diagnosis. Review of the PASRR Result Notice dated 06/11/24 revealed Resident #32 did not require a level two evaluation and had no indications of serious mental illness and/or developmental disability. Page 1 of 4 365084 365084 06/13/2024 Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and medication storage policy, the facility failed to ensure accurate labeling and storage of resident medication for medication cart #1 located on the Ridgeview unit and proper storage of medication in a locked box for Resident #408. This had the potential to affect 26 residents (6, 7, 8, 19, 23, 24, 26, 33, 36, 40, 48, 51, 55, 60, 63, 64, 81, 82, 90, 91, 98,107, 110, 118, 128, 144) who resided on Ridgeview unit. The census was 154. Findings include: 1. Observation on 06/12/24 at 9:20 A.M. of the medication cart #1 on Ridgeview unit with Licensed Practical Nurse (LPN) #534, revealed four loose white pills at the bottom of the medication cart drawer located between the medication cards. The four loose pills were observed to be without a medication label or resident identifier. Interview on 06/12/24 at 9:34 A.M., LPN #534 verified the four white pills were unable to be identified and confirmed the loose pills were without a medication label or resident identifier. 2. Record review of Resident #408 revealed an admission date 05/30/24. Diagnoses included atrial fibrillation, nonrheumatic aortic valve stenosis, bradycardia, and arteriovenous malformation. Review of the Brief Interview for Mental Status (BIMS) score revealed no cognitive impairment. An Assessment for Self-Administration of Medications was completed on 05/31/24 and it was determined that Resident #408 was capable of self-administering her medications and granted approval. Review of the Physician Orders revealed Resident #408 had an order allowing her to self-administer Tikosyn 125 micrograms (mcg) twice daily unsupervised. The record did not include an order for Resident $408 to self-administer Preservision. Observation on 06/10/24 at 3:54 P.M. revealed two pill bottles sitting on the bedside tray table of Resident #408 that were identified as Preservision and Tikosyn and were not secured in a locked compartment. Interview with Resident #408 at the time revealed her husband brought the medications from home for her to self-administer. Resident confirmed she self-administers the two medications as ordered. Interview with Registered Nurse (RN) #583 on 06/11/24 at 2:39 P.M. confirmed she was unaware Resident #408 had and was self-administering Preservision and the medications were not secured in a locked drawer in the resident's nightstand. RN #583 revealed that Resident #408 never disclosed that her husband gave her Preservision to self-administer. Review of the facility policy titled Medication Storage in the Facility revised 01/2018 revealed all medications dispensed by the pharmacy are stored in the container with the pharmacy label. 365084 Page 2 of 4 365084 06/13/2024 Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, policy review, and surveyor taste test, the facility failed to serve food at a hot and palatable temperature. This had the potential to affect 145 residents that received meals from the kitchen with the exception of nine other residents (Residents #8, #19, #48, #72, #124, #135, #150, #310, #411) who were ordered nothing by mouth (NPO). The facility census was 154. Residents Affected - Some Findings include: Interview with Resident #103 on 06/10/24 at 9:28 A.M. revealed the facility's food comes cold and so does the tea. Interview with Resident #408 on 06/10/24 at 3:49 P.M. revealed the resident was served eggs and cereal and does not eat them. Resident #408 also reported an incident on 06/09/24 in which she did not receive meat with her dinner. Interview with Resident #121 on 06/11/24 at 7:27 A.M. revealed the facility's food, specifically meat, is hard to cut and chew. Interview with Resident #21 on 06/11/24 at 9:55 A.M. revealed the resident was allergic to strawberries and was served strawberry jam desserts. Resident #21 also reported an incident in which he did not receive meat with his meal. Observation of lunch meal occurred on 06/12/24. Tray service began at 11:01 A.M. Observation revealed food temperatures were taken and logged prior to the start of the observation. Food temperatures were listed as followed: beef 161 degrees Fahrenheit (F); pork 158 degrees F; soup 176 degrees F; mixed vegetables 170 degrees F, baked potatoes 185 degrees F. Staff utilized plates out of the plate warmer with heated bottom and dome lid. Staff that plated food were attentive and communicated with tray line staff. Trays were plated and placed in a meal cart immediately. A test tray had been requested and was the last tray plated at 12:24 P.M. The meal cart arrived on the unit at 12:24 P.M. The staff passed out lunch food trays to residents in a disorganized manor which caused staff to transport the meal cart from one end of the unit to the other end a total of three times before all trays were passed. Once the trays were passed, the test tray was sampled at 12:41 P.M. by two surveyors with Dietary Manager #504 present. Temperatures of the foods sampled were as followed: beef 120 degrees F; mixed vegetables 120 degrees F; baked potato 130 degrees F. Dietary Manager #504 was made aware during the test tray observation that the beef, mixed vegetables, and baked potato were not palatable at the temperatures they were served. Review of the Food Temperatures at Point of Service Policy dated 06/08/22 revealed the holding temperatures for hot food should be at or above 135 degrees F. 365084 Page 3 of 4 365084 06/13/2024 Pleasantview Care Center 7377 Ridge Rd Parma, OH 44129

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and review of facility policy, the facility failed to ensure residents had access to a non-flammable ashtray and properly disposed of used cigarettes. This affected 19 residents (#3, #7, #10, #12, #15, #22, #27, #38, #55, #71, #72, #76, #96, #109, #112, #132, #137, #147, and #416), whom the facility identified as smokers, and had the potential to affect all 154 residents residing in the facility. Findings include: Observation on 06/11/24 at 2:31 P.M. with the Administrator revealed many cigarette butts in the plastic trash receptacle mixed with three empty combustible cigarette boxes, paper napkins, and plastic candy wrappers. No metal ashtray was available in the resident smoking area at the time of observation. Interview at the time of observation with the Administrator verified the above findings. Review of the facility policy titled Resident Smoking, dated 11/30/23, indicated smoking areas would have non-flammable ashtrays and non-flammable trash cans. 365084 Page 4 of 4