Mt Pleasant Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mt Pleasant Healthcare and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 20, 2023

  Based on policy review, record review, and interview, the facility failed to implement interventions to ensure a resident's environment remained free of accident hazards for 1 of 3 (Resident #2) sampled residents reviewed for accidents. This failure contributed to resident falls with injury. Findings included: 1. A review of the facility policy titled Accidents and Supervision, revised 03/23/2022, indicated, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: Identifying hazard(s) and risk(s). Evaluating and analyzing hazards(s) and risk(s). Implementing interventions to reduce hazards(s) and risk(s). […]

• No harm, potential for more than minimal, patternF803Jun 24, 2026

  Based on policy review, review of facility documents and interview, the facility failed to provide a Dietary Manual (an officially recognized, evidence-based reference used by healthcare facilities to guide the preparation, ordering, and administration of patient diets) that was approved by the Registered Dietician and the Medical Director. The census was 54, with all residents receiving meals from the kitchen. The findings include: Based on the facility policy titled, Diet Manual, dated 10/2019, revealed .It is the center policy to use an approved diet manual for manual planning for regular and therapeutic diet plans .The medical director reviews and approves the diet manual annually .The Dining Service Director ensures that a copy of the Diet Manual will be available in the Dining… […]

• No harm, potential for more than minimal, isolatedF880Jun 24, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 1 staff member (Certified Nurse Assistant (CNA) A) failed to properly handle soiled linens. The findings include: 1.Review of the facility policy titled, Infection Prevention and Control Program Policy, dated 4/2026, revealed .The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections.All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing… […]

• No harm, potential for more than minimal, isolatedF609Mar 20, 2025

  Based on facility policy review, medical record review and interview, the facility failed to report allegations of sexual abuse for 1 of 4 (Resident 165) residents reviewed. The findings include: 1. Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect Exploitation dated 2/19/2025, revealed It is the policy of this facility to report all allegations of abuse .are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations .Sexual Abuse is the non-consensual sexual contact of any type with a resident .the facility will report all alleged violations and all substantiated incidents to the state agency .Abuse: The willful infliction of injury .intimidation .It… […]

• No harm, potential for more than minimal, isolatedF677Mar 20, 2025

  Based on facility policy review, medical record review, observations and interviews the facility failed to provide adequate personal hygiene and bathing to 4 of 8 (Resident #8, #13, #19, and #32) sampled residents reviewed for Activities of Daily Living. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADLs), revised 1/2025, revealed .Care and services will be provided for the following .Bathing, dressing, grooming .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good .grooming, and personal and oral hygiene . […]