A list of the most recent deficiencies for Pleasant Acres Care Center. 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 that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-20 | 2023-11-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-10-20 | 2023-11-17 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-19 | 2023-11-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-19 | 2023-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-19 | 2023-11-15 | 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 | 2023-10-19 | 2023-11-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-19 | 2023-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-19 | 2023-11-15 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-10-19 | 2023-11-15 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-10-19 | 2023-11-15 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-19 | 2023-11-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-19 | 2023-11-15 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-20 | 2023-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-20 | 2023-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-20 | 2023-10-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-10-20 | 2023-10-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-10-20 | 2023-10-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-20 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-20 | 2023-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-20 | 2023-10-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-07 | 2022-08-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-07 | 2022-08-04 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-07 | 2022-08-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | 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 | 2022-07-07 | 2022-08-04 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-07 | 2022-08-04 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-07-07 | 2022-08-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-07 | 2022-08-04 | Y |
| Post nurse staffing information every day. | Health | 2022-07-07 | 2022-08-04 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-07-07 | 2022-08-04 | Y |
| 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 | 2022-07-07 | 2022-08-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-07 | 2022-08-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-07 | 2022-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-07 | 2022-08-04 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-07 | 2022-08-04 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-08 | 2022-07-25 | 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 | 2022-07-08 | 2022-07-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-08 | 2022-07-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-08 | 2022-07-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-08 | 2022-07-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-08 | 2022-07-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-08 | 2022-07-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-07 | 2022-07-21 | Y |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-08 | 2022-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-08 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-08 | 2022-07-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-08 | 2022-07-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-31 | 2019-12-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-31 | 2019-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-31 | 2019-12-11 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-31 | 2019-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-31 | 2019-11-30 | 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 | 2019-10-24 | 2019-11-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-24 | 2019-11-24 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-10-24 | 2019-11-24 | 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 | 2019-10-24 | 2019-11-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-24 | 2019-11-24 | 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 | 2019-10-24 | 2019-11-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-24 | 2019-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-24 | 2019-11-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-24 | 2019-11-24 | N |
| 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 | 2019-10-24 | 2019-11-24 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-10-24 | 2019-11-24 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2019-10-24 | 2019-11-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-24 | 2019-11-24 | 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 | 2019-10-24 | 2019-11-24 | 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 | 2019-10-24 | 2019-11-24 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-10-24 | 2019-11-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-24 | 2019-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-11-24 | N |
