Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant Lake Villa during CMS and state inspections, most recent first.
A facility failed to ensure proper PPE use for a resident on droplet precautions, risking COVID-19 spread. A CNA entered the resident's room without the required PPE, citing difficulty breathing in an N-95 mask. The resident had a history of kidney transplant and diabetes, with impaired cognition and dependency on staff. The facility's policy mandated specific PPE, which was not adhered to, affecting 29 residents on the unit.
A resident with cognitive impairment and a self-care deficit was found with long, dirty fingernails and chin hair, despite a care plan indicating the need for nail care. The resident expressed embarrassment and a desire for cleaner nails. An LPN confirmed the resident's condition, which was not in compliance with the facility's ADL policy.
The facility failed to date insulin pens upon opening, affecting five residents with type II diabetes. Observations of two medication carts revealed that insulin pens were in use without being dated, contrary to the facility's policy. Interviews with nursing staff confirmed the oversight, highlighting a lapse in medication management.
The facility failed to follow guidelines for changing disposable respiratory equipment weekly for three residents, leading to deficiencies in care. One resident with pneumonia and heart failure had undated oxygen tubing and unused new equipment. Another resident with dementia had tubing unchanged since March, and a third with acute respiratory failure had undated nasal cannula tubing. Staff confirmed the lapses, which violated the facility's policy.
The facility failed to ensure wound treatments were completed as ordered for a resident with multiple diagnoses, leading to a wound infection. Documentation revealed missed dressing changes, and staff interviews confirmed the lapses in care.
A resident with eosinophilic esophagitis, diabetes mellitus, and dependence on renal dialysis was administered expired budesonide liquid for six days and experienced delays in receiving a new supply of the medication. The expired medication was identified on 03/01/24, and it took a few days to obtain a new supply from a specialty pharmacy.
A resident with multiple diagnoses, including atrial fibrillation, did not receive the prescribed anticoagulant medication on several occasions. The DON confirmed that the medication was not administered on dialysis days, leading to significant medication errors.
Failure to Properly Don PPE for Resident on Droplet Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was donned correctly for a resident on droplet precautions, potentially preventing the spread of COVID-19 infections. During an observation, it was noted that a Certified Nursing Assistant (CNA) entered the room of a resident on droplet precautions without wearing the required PPE, which included a gown, N-95 mask, and face shield. The CNA admitted to not wearing the PPE because she found it difficult to breathe in an N-95 mask. A Registered Nurse (RN) did don PPE to assist the CNA in positioning the resident for lunch. The resident involved had a medical history that included a kidney transplant, type one diabetes mellitus with chronic diabetic kidney disease, pressure ulcers on both heels, and a history of urinary tract infections. The resident had moderately impaired cognition and was dependent on staff for bed mobility, toileting, and transferring. The facility's policy required staff to use specific PPE for residents on droplet precautions, but this was not followed, as evidenced by the CNA's actions. This deficiency was discovered during a complaint investigation and had the potential to affect 29 residents on the Sandalwood unit.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure proper personal hygiene for Resident #135, who was observed with long, dirty fingernails and hairs on her chin. Resident #135, who has diagnoses including diabetes mellitus, Alzheimer's disease, and anxiety disorder, was admitted on an unspecified date. Her care plan, dated 04/14/22, indicated a self-care deficit related to cognition and generalized weakness, with interventions including nail care as needed. The comprehensive Minimum Data Set (MDS) 3.0 assessment dated 08/06/24 revealed that Resident #135 had moderately impaired cognition and required substantial/maximal assistance with activities of daily living (ADLs). On 09/14/24, during an observation and interview, Resident #135 expressed a preference for the length of her nails but wished they were cleaner and was embarrassed by the hairs on her chin. She mentioned that she used to manage these aspects of personal care when she was at home. An LPN verified the condition of Resident #135's nails and chin hair. The facility's policy on ADLs, dated 11/30/23, included maintaining personal hygiene tasks such as nail care and shaving. This deficiency was investigated under Complaint Number OH00157469.
Failure to Date Insulin Pens Upon Opening
Penalty
Summary
The facility failed to ensure that multiple dose medications, specifically insulin pens, were dated when opened, as required by their policy. This deficiency was identified during an observation of two medication carts, Oakwood front and Rosewood back, affecting five residents with type II diabetes. The insulin pens for these residents were found to be in use without any indication of the date they were opened, which is a violation of the facility's medication storage policy. The policy mandates that nurses date medications upon opening and adhere to the manufacturer's expiration date. Interviews with the nursing staff, including a Registered Nurse and the Director of Nursing, confirmed the oversight. The RN verified that the insulin for one resident was not dated when opened, and the DON acknowledged that the insulins for all five residents were not dated as per the facility's policy. The facility's policy, dated November 2021, clearly states that medications should be dated when opened, and the manufacturer's expiration date should be followed. This oversight in medication management was observed in a facility with a census of 181 residents.
Failure to Change Respiratory Equipment Weekly
Penalty
Summary
The facility failed to adhere to recommended guidelines for changing disposable respiratory equipment for three residents, leading to deficiencies in respiratory care. Resident #12, who had diagnoses including pneumonia and heart failure, was observed using undated oxygen tubing and aerosol equipment that had not been changed as per the facility's policy. The new tubing, dated 05/29/24, was found unused in a bag, indicating a lapse in the weekly replacement schedule. Licensed Practical Nurse (LPN) #916 confirmed that the equipment was not dated and had not been changed as required. Resident #15, diagnosed with dementia and heart disease, was found using oxygen tubing dated 03/05/24, with no physician's order to change it weekly until after surveyor intervention. The Director of Nursing (DON) verified the lack of a weekly change order and the absence of documented evidence of tubing replacement since March. Similarly, Resident #83, with acute respiratory failure, was using undated nasal cannula tubing, with the last change documented on 04/30/24. LPN #909 confirmed the lack of dating and the requirement for weekly changes. The facility's policy mandates weekly changes and dating of disposable respiratory supplies, which was not followed in these cases.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to ensure wound treatments were completed as ordered for Resident #152, who had multiple diagnoses including diabetes mellitus, dependence on renal dialysis, and calciphylaxis. The resident had a treatment order to cleanse a skin tear on the right elbow daily and apply a dressing. However, documentation revealed that the dressing change was not completed from 02/29/24 through 03/04/24 and on 04/01/23. This lapse in care led to a wound infection, for which a new order for doxycycline was issued on 03/03/24. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurses, and the Director of Nursing, confirmed that the dressing changes were not completed as ordered. The Director of Nursing verified that the resident did not receive the required dressing changes, and the Licensed Practical Nurses acknowledged that all dressings should be initialed, dated, and documented at the time of the dressing change. The resident was unable to provide information regarding the treatments due to confusion about the events leading to the skin tear.
Expired Medication Administration and Availability Issue
Penalty
Summary
The facility failed to ensure that Resident #152 was not administered expired medication and that the medication was available for administration. Resident #152, who had diagnoses including eosinophilic esophagitis, diabetes mellitus, and dependence on renal dialysis, was prescribed budesonide liquid to be taken by mouth one hour before meals. The medication was started on 02/11/24, discontinued on 03/29/24, and had an expiration date of 02/21/24. However, the medication was administered until 03/01/24, resulting in the resident receiving expired medication for six days. Additionally, the medication was not available for administration on several days in March 2024, specifically on March 1, 2, 3, 4, 5, 14, and 19, due to delays in obtaining a new supply from a specialty pharmacy after the expired medication was identified on 03/01/24. The Director of Nursing (DON) confirmed that the expired medication was administered and that it took a few days to obtain a new supply of the medication. The unit manager (LPN #369) identified the expired medication on 03/01/24, notified the family, and contacted the doctor. The nurses were subsequently educated on checking medications to ensure that expired medications were not being given to residents. This deficiency was investigated under Complaint Number OH00152308.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received an anticoagulant medication as ordered, leading to significant medication errors. Resident #152, who had multiple diagnoses including diabetes mellitus, dependence on renal dialysis, pulmonary hypertension, and calciphylaxis, was prescribed apixaban 2.5 mg twice daily for atrial fibrillation. However, the medication administration record revealed that the morning doses of apixaban were not administered on multiple days in February and March 2024, totaling 11 missed doses. An interview with the Director of Nursing (DON) confirmed that the resident was not receiving the apixaban on dialysis days, as the nurses were not administering it. The DON verified that the medication was not given as ordered. The Medscape website indicates that missing doses of apixaban increases the risk of thrombotic events, and the medication is not expected to be dialyzable. This deficiency was investigated under Complaint Number OH00152308.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Parma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasantview Care Center | 0.2 mi | ★★★★★ | 1 | 0 |
| North Royalton Post Acute | 1.4 mi | ★★★★★ | 11 | 0 |
| Mt Alverna Home Inc | 1.4 mi | ★★★★★ | 7 | 0 |
| Greenbrier Health Center | 2.2 mi | ★★★★★ | 25 | 1 |
| Royal Oak Nursing & Rehab Ctr | 3.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.