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. 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 06/13/2024 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)