Pleasant Manor Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Pleasant Manor Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF609Aug 25, 2021

  Based on record review and interview, the facility failed to ensure an allegation of resident-to-resident sexual abuse was immediately reported to the Administrator, the Office of Long Term Care (OLTC), and other authorities in accordance with State Law, which resulted in a delay implementing protective measures to prevent further potential abuse and a delay in initiating an investigation for 1 (Resident #2) of 4 (Residents #2, #6, #7 and #8) sampled residents who were female. […]

• Immediate jeopardy, patternF610Aug 25, 2021

  Based on record review and interview, the facility failed to ensure an allegation of resident-to-resident sexual abuse was investigated and protective measures were immediately put in place to prevent further potential abuse for 1 (Resident #2) of 4 (Residents #2, #6, #7 and #8) sampled residents who were female. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #2, who was the alleged victim of sexual abuse, and had the potential to affect 41 residents who were female, as documented on the Matrix for Providers list provided by the Minimum Data Set (MDS) Coordinator on 8/23/21 at 4:14 p.m. The Administrator was informed of the immediate jeopardy on 8/25/21 at approximately 3:30 P.M. The findings are: 1. […]

• Immediate jeopardy, isolatedF689Oct 29, 2021

  Based on observation, record review and interview, the facility failed to ensure interventions to prevent elopement were developed and care planned promptly after an elopement risk assessment identified a resident as at risk for elopement and failed to ensure a resident who was at risk for elopement and was actively exhibiting exit-seeking behaviors was adequately supervised in order to prevent the resident from eloping by exiting the building through his bedroom window for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents who resided on the Secure Memory Unit. […]

• No harm, potential for more than minimal, widespreadF812Jul 18, 2024

  Based on observation, record review and interview, the facility failed to ensure the ice machine and ice scoop were maintained in a clean and sanitary condition to prevent potential growth of harmful bacteria that could be transferred to the residents food, failed to ensure opened food items in the refrigerator, freezer and storage room were covered, sealed and dated to maintain freshness and prevent potential cross contamination, failed to ensure dietary staff practiced good hand washing techniques to potential cross contamination of food and clean dishes, failed to ensure hot food item was maintained at the required temperature on the stove and serving line to prevent potential foodborne illness. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2023

  Based on observation and interview, the facility failed to ensure eggs were stored below other foods and cooked food items were maintained the proper temperatures to reduce the chances of food borne illness; dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; 1 of 1 ice machine was maintained in clean condition; foods stored in the storage area refrigerator and freezer were sealed, labeled, and dated. These failed practices had the potential to 73 affect residents who received meals from the kitchen (Total Census:76), as documented on a list provided by the Dietary Supervisor on 09/20/23 at 2:15 PM. The findings are: 1. […]