A list of the most recent deficiencies for Pleasant Manor Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-22 | 2023-10-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-22 | 2023-10-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-10-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-10-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-02 | 2022-12-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-02 | 2022-12-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-02 | 2022-12-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-10 | 2022-07-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-10 | 2022-07-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-10 | 2022-07-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-10 | 2022-07-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-10 | 2022-07-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-10 | 2022-07-09 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-10 | 2022-07-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-06-10 | 2022-07-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-06-10 | 2022-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-10 | 2022-07-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-10 | 2022-06-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-10 | 2022-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-29 | 2021-10-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-25 | 2021-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-25 | 2021-09-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-25 | 2021-09-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-25 | 2021-09-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-26 | 2021-04-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-03-26 | 2021-04-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-03-26 | 2021-04-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2021-04-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-03-26 | 2021-04-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-26 | 2021-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-04-24 | N |
