A list of the most recent deficiencies for Pleasant Meadows Senior Living. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-19 | 2024-01-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-19 | 2024-01-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-19 | 2023-12-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-19 | 2023-12-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-19 | 2023-12-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-19 | 2023-12-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-19 | 2023-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-19 | 2023-12-27 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2023-12-15 | 2023-12-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-12-15 | 2023-12-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-15 | 2023-12-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-15 | 2023-12-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-15 | 2023-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-15 | 2023-12-23 | 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 | 2023-12-15 | 2023-12-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-15 | 2023-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-15 | 2023-12-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-15 | 2023-12-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-15 | 2023-12-23 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-12-15 | 2023-12-23 | 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 | 2023-12-15 | 2023-12-23 | 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 | 2023-12-15 | 2023-12-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-15 | 2023-12-23 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-15 | 2023-12-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-15 | 2023-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-15 | 2023-12-23 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-12-15 | 2023-12-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-22 | 2023-12-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-11-22 | 2023-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-11-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-30 | 2023-11-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-10-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-10-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-30 | 2023-09-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-30 | 2023-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-30 | 2023-09-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-30 | 2023-09-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-11 | 2023-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-07-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-07 | 2023-07-08 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-06-07 | 2023-07-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-06-07 | 2023-07-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-07 | 2023-07-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-07 | 2023-07-07 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-24 | 2023-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-14 | 2023-04-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-04-14 | 2023-04-22 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-04-14 | 2023-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-03-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-03 | 2023-03-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-03 | 2023-03-16 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-03 | 2023-03-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-03 | 2023-03-16 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-01-13 | 2023-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-03-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-13 | 2023-03-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-13 | 2023-03-16 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-01-13 | 2023-03-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-01 | 2023-02-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-07 | 2023-02-16 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-07 | 2023-02-16 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-01 | 2023-02-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2022-12-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-09 | 2022-12-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-09 | 2022-12-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-29 | 2022-12-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-29 | 2022-12-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-26 | 2022-10-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-26 | 2022-10-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-26 | 2022-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-10-27 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-26 | 2022-10-27 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-08-25 | 2022-09-15 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-08-25 | 2022-09-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-29 | 2022-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-29 | 2022-08-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-29 | 2022-08-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-14 | 2022-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-08 | 2022-02-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-28 | 2022-01-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-28 | 2022-01-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-28 | 2022-01-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-28 | 2022-01-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-28 | 2022-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-28 | 2022-01-14 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-26 | 2021-12-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-15 | 2021-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-15 | 2021-11-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-27 | 2021-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-27 | 2021-11-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-03 | 2021-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-03 | 2021-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-23 | 2021-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-23 | 2021-11-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-27 | 2021-10-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-27 | 2021-10-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-27 | 2021-10-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-03 | 2021-10-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-23 | 2021-10-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Develop a communication plan. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-26 | 2021-09-24 | 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 | 2021-08-26 | 2021-09-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-26 | 2021-09-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-08-23 | 2021-09-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-23 | 2021-09-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-23 | 2021-09-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-08-23 | 2021-09-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-08-23 | 2021-09-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-08-23 | 2021-09-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-08-23 | 2021-09-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-23 | 2021-09-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-23 | 2021-09-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-23 | 2021-09-07 | 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 | 2021-08-23 | 2021-09-07 | N |
| Provide or obtain dental services for each resident. | Health | 2021-08-23 | 2021-09-07 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-23 | 2021-09-07 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-08-23 | 2021-09-07 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-08-23 | 2021-09-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-23 | 2021-09-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-23 | 2021-09-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-21 | 2021-08-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-21 | 2021-08-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-03 | 2021-08-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-03 | 2021-03-16 | Y |
