Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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PLEASANT VIEW COMMUNITIES - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to an incident completed on June 16, 2022, it was determined that Pleasant View Communities was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

 Plan of Correction:

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Based on clinical record review and staff interview it was determined that the facility failed to ensure the development of a comprehensive person-centered plan of care based on results of the comprehensive assessment for one of three residents reviewed (Resident 1).

Findings Include:

Review of Resident 1's clinical record revealed diagnoses that included Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and weakness (reduced strength in one or more muscles).

Review of Resident 1's Minimum Data Set (MDS- periodic assessment of resident care and service needs) dated March 30, 2022, revealed in Section C -Cognitive Patterns -Subsection C1000 the resident is marked as severely impaired. The same MDS Section G -Functional Status Subsection 1A Bed Mobility the resident was marked as total dependence and physical assist of two.

Review of the care plan that was in place at the time of Resident 1's fall on May 14, 2022 revealed the resident was at risk for falls R/T poor safety awareness, increased muscle weakness and mobility requiring hoyer assistance with transfers. The care plan had several interventions related to this risk.

Review of Resident 1's interdisciplinary plan of care revealed no interventions developed to address Resident 1's bed mobility assistance concerns noted in the MDS of March 30, 2022.

An interview with the Director of Nursing on June 16, 2022, at 2:06 PM confirmed the facility had not developed the bed mobility care plan after the assessment but had recently added the care plan to the resident's record.

28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.11 (d) Resident care plan

 Plan of Correction - To be completed: 07/15/2022

1. Resident 1's care plan was reviewed and updated on May 17, 2022.
2. Education and training was provided on May 18, 2022 to all nursing staff on safe resident transfers, positioning and ambulation. The education included following the resident care plans and how to access care plan information for each resident.
3. Care plan audits to be completed on all healthcare residents to ensure care plans are up to date and comprehensive. Care plan audits to be completed no later than July 1, 2022.
4. Education and training will be provided to all RN's on Resident Care Plan Development. This will be completed by July 15, 2022.
5. In order to prevent this issue from occurring again, 6 resident care plan audits will be completed on each unit, monthly for a period of 1 year. Thereafter, 6 resident care plan audits will be completed on each unit, on a quarterly basis.

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