Pleasantview Care Center: Medication Failures - OH
Resident 210 was supposed to receive Phos-NaK oral packets four times daily starting in late summer. The electrolyte supplement was ordered for someone already struggling with fluid and electrolyte imbalances alongside bladder cancer and swallowing difficulties.
Instead, she got almost nothing.
Her medication administration record showed nearly every dose marked as "other" — nursing home code for a medication that wasn't given. Only one evening dose was actually administered during her final days.
Progress notes from nursing staff told the story of institutional confusion. Day after day, nurses wrote that the medication was "on order" or they were "waiting for pharmacy to fill it." The facility's nurse practitioners knew about the problem. Nobody solved it.
The pharmacy finally told nursing staff the medication was available over-the-counter and should be provided by the facility itself. By then, Resident 210 had missed several days of ordered doses.
She died at Pleasantview Care Center.
When federal inspectors interviewed two certified nurse practitioners who had cared for Resident 210, both denied knowing she had been missing her ordered medications. The practitioners had provided her care throughout her stay at the 160-bed facility.
The Director of Nursing told a different story. She confirmed that their internal investigation had found "the concern with Resident 210's Phos-NaK" and acknowledged the resident "missed several days of ordered Phos-NaK doses."
The facility's own medication policy, dated December 2019, required nurses to notify physicians if three consecutive doses of any medication were unavailable. Nurses were supposed to document both the notification and the physician's response.
None of that happened.
The policy also stated medications were to be given according to orders — a basic standard that failed for a resident whose body was already struggling to maintain proper electrolyte balance.
Phos-NaK contains phosphorus and potassium, electrolytes essential for cellular function, muscle contractions, and maintaining the body's acid-base balance. For someone with existing electrolyte disorders, missing multiple doses can worsen already compromised physiological systems.
The breakdown revealed systemic problems with medication coordination at Pleasantview. Staff didn't understand which medications the facility was responsible for providing versus which came through the pharmacy. When confusion arose, it persisted for days without resolution.
The resident's medical complexity made the medication failures more concerning. Someone with bladder cancer, swallowing problems, and electrolyte imbalances needed consistent medical management. Missing ordered supplements added unnecessary stress to an already compromised system.
Federal inspectors found the violation during a complaint investigation in August. The deficiency was classified as causing minimal harm or potential for actual harm, affecting few residents.
After Resident 210's death, the facility scrambled to implement corrective measures. The Director of Nursing conducted a facility-wide audit of medication availability and communication with the pharmacy. She provided in-service training to nursing staff about medication availability and procedures when medications aren't accessible.
The facility also initiated intensive medication record audits — five days a week for two weeks, then twice weekly for ten more weeks — to ensure proper follow-through when medications are unavailable.
But those changes came too late for Resident 210, whose final days were marked by a basic failure of medication management. She needed four doses daily of an over-the-counter supplement to support her failing body's electrolyte balance.
Instead, nursing staff spent days writing notes about waiting for pharmacy while she received almost nothing.
The case illustrated how communication breakdowns between nursing staff and pharmacy can have serious consequences for vulnerable residents. When multiple medical conditions require careful medication management, every missed dose matters.
Federal regulators noted the deficient practice was corrected, but only after the resident had died and investigators arrived to examine what went wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pleasantview Care Center from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PLEASANTVIEW CARE CENTER in PARMA, OH was cited for violations during a health inspection on August 21, 2025.
Resident 210 was supposed to receive Phos-NaK oral packets four times daily starting in late summer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.