Pleasant Lake Villa

In the surveyor’s words

From the most serious findings on record at Pleasant Lake Villa, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF804Jun 2, 2026

  Based on review of the food committee minutes, observation, interviews, and review of the ServSafe guidelines, the facility failed to ensure that residents received food at palatable temperatures. This deficient practice had the potential to affect all residents except those who received nothing by mouth, residents (#69, #110, and #207). The facility census was 170.Findings include:Review of the Food Committee Minutes for April 2026, residents (not identified) stated the food was not served as hot as the residents would like. Resident interviews conducted on 05/26/26 from 10:54 A.M. to 11:06 A.M. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2026

  Based on observations and interviews, the facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner and food was properly labeled and dated. This had the potential to affect except three residents (#69, #110, and #207) who received nothing by mouth. The facility census was 170. Findings include:On 05/26/26 beginning at 8:50 A.M. and continuing through 9:13 A.M., a series of observations were conducted in seven kitchenettes with Diet Technician (DT) #603. The following was observed:-At 8:50 A.M. […]

• No harm, potential for more than minimal, widespreadF880Apr 28, 2022

  Based on observation, interview, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, and review of the CDC COVID-19 Tracker website, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This had the potential to affect all residents residing in the facility. The facility census was 185. Findings include: 1. Observation on 04/21/22 at 7:08 A.M. revealed two employees, Licensed Practical Nurses (LPN's) #301 and #302, were at the nurse's station with no mask or face shield on. Interview on 04/21/22 at 7:11 A.M. […]

• No harm, potential for more than minimal, widespreadF880Jan 21, 2021

  Based on observation, record review, interview, and review of Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, the facility failed to maintain proper infection control practices with regard to the use of eye protection, and isolation procedures to prevent the spread of infection, including COVID 19. This had the potential to affect all residents residing in the facility. The facility census was 146. Findings include: Observation of Registered Nurse (RN) #200 on 01/20/21 at 5:37 A.M. revealed she was wearing a surgical mask underneath an N95. […]

• No harm, potential for more than minimal, patternF584Jun 2, 2026

  Based on observations, interviews, and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary resident environment affecting 44 residents (#4, #8, #9, #11, #12, #13, #18, #19, #26, #29, #32, #33, #41, #45, #48, #50, #57, #58, #65, #76, #79, #102, #104, #109, #110, #114, #127, #133, #136, #141, #146, #147, #155, #158, #160, #171, #175, #178, #182, #188, #190, #192, #201, and #205) of 44 residents that resided on the Rosewood unit and had the potential to affect all 170 residents residing in the facility. Findings include: 1. During an interview on 05/26/26 at 10:32 A.M., Resident #32 reported that housekeeping did not routinely pick up trash or sweep and mop the floors. […]