Pleasant Manor Healthcare and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 14, 2024

  Based on interview and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation; the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to: 1. ensure Resident #1 was evaluated and treated for urinary retention which led to Resident #1 requiring emptying of her bladder in the emergency department on 01/27/24 2. […]

• Immediate jeopardy, isolatedF697Feb 14, 2024

  Based on observation, interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for pain. The facility failed to: 1. ensure Resident #1's prescribed oxycodone was in the facility and provided to Resident #1 for her pain from bilateral broken ankles and surgery An Immediate Jeopardy (IJ) situation was identified on 01/31/24. […]

• No harm, potential for more than minimal, widespreadF812Nov 15, 2023

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for sanitation. The facility failed to ensure all food items were sealed and properly covered. CK H failed to wash and sanitize the food processor in between uses. DA I failed to wash her hands after handling trash and prior to beginning a food preparation activity. The Dietary Supervisor failed to ensure the dish machine was operating at the proper temperature for ware washing. These failures could place residents at risk of foodborne illness. Findings included: Observations of the kitchen's walk-in refrigerator on 11/13/2023 from 9:02 a.m. through 9:04 a.m. […]

• No harm, potential for more than minimal, patternF803Apr 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure menus were followed to meet nutritional needs of residents in accordance with established national guidelines for two sampled residents (R50 and R8) reviewed for menus, in that: The facility failed to utilize therapeutic menu extensions for carbohydrate-controlled diets for R50 and R8. The facility failed to follow portion sizes for all diets for two days. These failures had the potential to affect resident's dependent on the facility kitchen for their nutrients as well as 22 residents who had ordered carbohydrate-controlled (CC) diet, placing them at risk of spikes or drops in blood glucose levels and/or weight loss or weight gain Findings included: 1. […]

• No harm, potential for more than minimal, patternF684Mar 5, 2026

  Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #13) of 6 residents reviewed for quality of care and change in conditions.The facility failed to obtain daily weights for Resident #13 for the dates of 2/2/26, 2/3/26, 2/4/26, 2/5/26, 2/7/26, 2/8/26, 2/9/26, 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26, 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/21/26, 2/22/26, 2/23/26, 2/24/26, 2/28/26, 3/1/26, and 3/3/26.These failures placed residents at risk of weight gain, disease exacerbation, shortness of breath, decreased quality of life, heart problems, such as arrhythmia (irregular heartbeat).Findings… […]