Federal inspectors found multiple safety failures at Pleasant View Nursing Center during an August complaint investigation that revealed a pattern of neglected basic care and hazardous conditions affecting the facility's 101 residents.
The water temperature crisis began when maintenance staff struggled to control heating systems throughout the building. On August 18, the Maintenance Director measured temperatures ranging from 110 to 123 degrees in 12 resident bathrooms and two shower rooms. The facility's own policy required temperatures around 107-108 degrees to prevent burns.
"The surveyor was able to keep a hand under the water for only about five seconds," inspectors noted after testing the scalding water in rooms A1 and A3.
The Maintenance Director told inspectors someone had instructed him to keep shower temperatures at 114 degrees, though he acknowledged this was too hot. When he attempted to adjust the system, temperatures actually increased to 116 degrees. Even after multiple attempts to correct the problem, some bathrooms still registered 116 degrees the following day.
The Administrator promised to check temperatures every shift until the problem was resolved and monitor residents in the affected areas.
Meanwhile, outside the building, a different crisis was unfolding. Trash had been accumulating since August 8 when the waste removal company stopped service due to nonpayment. By the time inspectors arrived, three dumpsters were overflowing with bags scattered across the ground.
"Opened bags of trash, exposing dirty briefs with fecal matter, wipes covered in feces were observed scattered on the ground surrounding the dumpsters," the inspection report documented. "Swarms of flies and at least 50 large clear white trash bags on the ground around the dumpsters" contained food waste and soiled personal care items.
The Dietary Manager and Maintenance Director confirmed the unsanitary conditions had existed since the previous Monday. The Maintenance Director said he had notified the Administrator about the missed trash pickup on August 13 but received no specific instructions on handling the accumulating waste.
The Administrator acknowledged he had failed to provide staff with guidance on the trash crisis, despite being aware corporate offices had been notified about the payment issue on August 14.
Inside the facility, other safety violations put residents at additional risk. Two residents receiving oxygen therapy were getting 2.5 liters per minute instead of the prescribed 2.0 liters. The Unit Manager discovered one resident had been independently adjusting his oxygen flow meter, with staff failing to monitor the settings during medication rounds.
"R49 was at risk of COPD exacerbation by receiving more than the ordered amount of O2," the Director of Nursing acknowledged.
A resident with a left hand contracture never received the physical therapy, occupational therapy, and speech therapy evaluations ordered by his physician on May 2. During the inspection, the resident lay in bed with his third and fourth fingers folded into his palm, with no splint device.
The resident told inspectors he was concerned about not receiving therapy services for his contracture. The Director of Rehabilitation confirmed she was aware of his condition and believed he would benefit from range of motion therapy and a splint device, but no evaluation had been conducted.
Staff also failed to follow physician orders for a resident with a feeding tube who required water flushes with medications and feedings. No documentation existed showing the prescribed flushes were being performed.
Infection control failures created additional hazards throughout the facility. A nurse performing blood sugar testing placed supplies directly on an unsanitized cart surface without using protective barriers. In resident bathrooms, washbasins and urinals sat unbagged and unlabeled, violating basic sanitation protocols.
Two shower rooms in the behavioral health unit contained multiple safety hazards, including a bottle of 70 percent isopropyl alcohol on an unsecured cart, an electrical hair dryer plugged in with cords running under sinks, and soiled clothing and towels scattered on floors. An overfilled sharps container had a razor blade exposed.
"Someone could get seriously hurt," the Administrator said when shown the shower room conditions, acknowledging they were "unacceptable and posed numerous accident hazards."
Medication security also failed when nurses repeatedly left medication carts unlocked and unattended in hallways. One nurse admitted she had forgotten to lock the cart after a resident was transported to the emergency room.
The facility's linen storage violated infection control standards, with clean linens stored uncovered and pillows touching concrete floors in a storage room leading to the outdoor laundry facility.
The Regional Director of Nursing confirmed that no one was designated to change out full sharps containers, leaving dangerous items exposed throughout the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pleasant View Nursing Center from 2024-08-21 including all violations, facility responses, and corrective action plans.