Deficiency Records for Pleasant Acres Rehabilitation and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Pleasant Acres Rehabilitation and Nursing 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-09-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-08-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-25 | 2023-08-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-25 | 2023-08-12 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-17 | 2023-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-17 | 2023-07-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-17 | 2023-07-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-06-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-04 | 2023-06-20 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-04 | 2023-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-04 | 2023-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-06-20 | 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 | 2023-05-04 | 2023-06-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-04 | 2023-06-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-05-04 | 2023-06-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-04 | 2023-06-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-04 | 2023-06-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-04 | 2023-06-20 | 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 | 2022-05-26 | 2022-08-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-05-26 | 2022-08-01 | 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 | 2022-05-26 | 2022-08-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-26 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-08-01 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-26 | 2022-07-13 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-05-26 | 2022-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-07-13 | 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 | 2022-05-26 | 2022-07-13 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-26 | 2022-07-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-07-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-26 | 2022-07-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-26 | 2022-07-13 | 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 | 2022-05-26 | 2022-07-13 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-26 | 2022-07-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-05-26 | 2022-07-13 | 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 | 2022-05-26 | 2022-07-13 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-05-26 | 2022-07-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-26 | 2022-07-13 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-05-26 | 2022-07-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-07-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-26 | 2022-07-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-05-03 | 2022-06-21 | 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 | 2022-05-03 | 2022-06-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-03 | 2022-06-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-03 | 2022-06-21 | 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 | 2022-01-26 | 2022-03-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-26 | 2022-03-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-24 | 2021-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-15 | 2021-11-11 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-15 | 2021-11-09 | 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 | 2021-10-04 | 2021-11-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-03 | 2021-10-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-03 | 2021-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-03 | 2021-10-12 | 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 | 2021-07-15 | 2021-08-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-06 | 2021-06-08 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-06 | 2021-06-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-06 | 2021-06-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-06 | 2021-06-08 | 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 | 2021-05-06 | 2021-06-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-06 | 2021-06-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-06-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-06-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-05-24 | 2021-06-08 | 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 | 2021-05-24 | 2021-06-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-24 | 2021-06-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-05-24 | 2021-06-08 | 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 | 2021-04-22 | 2021-05-18 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-22 | 2021-05-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-22 | 2021-05-18 | 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 | 2021-03-30 | 2021-04-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-30 | 2021-04-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-30 | 2021-04-20 | Y |
