Pleasant Acres Care Center

In the surveyor’s words

From the most serious findings on record at Pleasant Acres Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 7, 2022

  Based on clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure residents at risk for elopement were unable to exit the facility unattended for 1 of 1 resident reviewed for elopement (Resident #121). The facility failure resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to provide adequate nursing supervision to prevent injuries for 1 of 1 resident reviewed (Resident # 8). The facility reported a total census of 16 residents. Findings include: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident # 121 documented diagnoses of [CONDITION(S)],COVID-19 and [CONDITION(S)]. The MDS did not include a Brief Interview for Mental Status (BIMS) score. […]

• No harm, potential for more than minimal, widespreadF801Jul 7, 2022

  Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietitian. The facility reported a census of 16 residents. Findings include: On [DATE] at 2:02 p.m., review of the facility contract with the Dietician was signed on [DATE] and continued for a 12 month period thereafter. Interview on [DATE] at 4:02 p.m., with the Regional Nurse Consultant revealed the contract did not contain the wording the contract auto renewed and the contract had expired. […]

• No harm, potential for more than minimal, widespreadF880Jul 7, 2022

  Based on observation and staff interview, the facility failed to follow infection control guidelines for use of personal protective equipment (PPE). The facility reported a census of 16 residents. Findins include: On 6/27/22 at 11:50 a.m. Staff D agency RN stated she had taken shifts at the facility for 6 months. She stated she was not vaccinated. She needed to wear a mask and goggles. She picked up the goggles from the med cart and put them on. She had already given medications to 4 residents. She wore a surgical mask. On 6/27/22 at 12:10 p.m. the Director of Nursing (DON) stated staff who had not been vaccinated should wear an N95 mask and goggles or a shield. On 6/28/22 at 6:58 a.m. Staff A CNA stated she wore a mask and a shield because she had not had the booster (for Covid). […]

• No harm, potential for more than minimal, patternF812Feb 19, 2026

  Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food. The facility identified a census of 37 residents.Findings included: During the initial kitchen walkthrough on 12/16/26 at 10:35 AM, the following observations were made:Refrigerator units contained various scattered food debrisFreezer units with ice build upThe following foods not labeled: ranch dressingfrozen meatfrozen pizza During the initial tour, the Dietary Manager (DM) reported the facility had recently lost two kitchen staff, which resulted in some duties not being consistently completed. […]

• No harm, potential for more than minimal, patternF803Dec 12, 2024

  Based on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the residents nutritional needs. The facility reported a census of 27 residents. Findings include: On 12/11/24 at 12:45 PM Staff D, [NAME] stated that she used one bag of diced chicken for the lunch meal. Staff D stated she followed the recipe for 36 servings of Chicken [NAME] Alfredo. Staff D acknowledged the menu required 9 lbs of chicken. Staff D acknowledged that she used 1 bag of diced chicken from the box that contained 2 bags of diced chicken. […]