Pleasant Acres Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Aug 2, 2023

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility failed to implement interventions, supervision, and effective safety measures to prevent elopement of a resident with a history of elopement (Resident 1). This failure placed 65 additional residents at the facility in an Immediate Jeopardy situation who were identified as having orders to be able to independently go outside of the facility to the main entrance area (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, and 67). […]

• Immediate jeopardy, isolatedF600Jul 25, 2023

  Based on staff interviews, clinical record review, facility policy, and documentation review, it was determined that the facility failed to promptly take measures necessary to protect residents from further sexual abuse after sexual abuse was identified with two of five residents reviewed (Residents 1 and 5). This failure resulted in sexual assault for one resident (Resident 1) and placed residents in an immediate jeopardy due to the potential for further sexual abuse to occur. […]

• Actual harm, isolatedF600Dec 22, 2025

  Based on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident to be free from abuse, which resulted in mental anguish and actual harm as evidenced by multiple bruises and swelling to the right side of the resident's face, bilateral legs, and bilateral knuckle areas on his hands after an alleged staff to resident altercation for one of five residents reviewed (Resident 1).Findings Include:Review of facility policy, titled Abuse Policy- Prevention and Management, last revised September 8, 2022, read, in part, the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff,… […]

• Actual harm, isolatedF689Oct 3, 2023

  Based on review of facility investigation, facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility displayed past noncompliance, in that it failed to ensure the resident environment remains free of accident hazards while heating beverages for residents, which resulted in harm to one of three residents reviewed (Resident 1). Findings Include: Review of the facility's policy, titled Food-Reheating recently revised September 2023, read, in part, Staff members only are able to re-heat resident food and or liquids in the microwave to temperatures that are safe and palatable for residents. […]

• Actual harm, isolatedF600Sep 3, 2021

  Based on document review, clinical record review and staff interview it was determined that the facility failed to ensure each resident the right to be free from neglect, resulting in physical harm for one of three residents reviewed (Resident 2). Findings Include: Review of the facility's policy titled Abuse, most recently revised March 2021, describes neglect as Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility's policy titled Certified Nursing Assistant Position Description effective October 2018, summarizes the position of the nursing assistant as The primary purpose of this position is to assume the responsibility of providing the highest level of quality of nursing care for specific residents as prescribed… […]