Pleasant Meadows Senior Living

In the surveyor’s words

From the most serious findings on record at Pleasant Meadows Senior Living, in the surveyor’s own words.

• Immediate jeopardy, patternF600Sep 27, 2021

  Based on interview and record review the facility failed to supervise a resident (R1) with a known history of inappropriate sexual resident to resident contact, to prevent resident to resident sexual abuse. This resulted in R2 being sexually abused by R1. R1 and R2 are two of 22 residents reviewed for abuse in the sample list of 27. Staff allowed R1 unrestricted access, exposing residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24) on the unit who are unable to consent to sexual interactions, to potential sexual abuse. This failure resulted in an immediate jeopardy. While the immediacy was removed on 9/15/21, the facility remains out of compliance at a severity level 2. […]

• Immediate jeopardy, isolatedF700Jun 26, 2026

  Based on observation, interview and record review, the facility failed to assess residents for risk of entrapment from a bedrail and failed to calibrate an alternating air flow mattress setting for a resident's weight. These failures resulted in R12's mattress becoming overinflated which caused R12 to fall into the bedrail and to the floor. During the fall R12's arm became entrapped in the bedrail and R12 was unable to reposition R12's head and neck away from the bedrail which resulted in neck and sternum injuries. […]

• Immediate jeopardy, isolatedF689Oct 2, 2025

  Based on observation, interview, and record review the facility failed to prevent resident elopement by failing to ensure an exit door was alarmed/monitored to prevent residents from exiting unnoticed and failed to develop and implement a care plan for a resident at risk for elopement for one of three residents (R1) reviewed for elopement on a sample list of five. These failures resulted in R1, a cognitively impaired resident at risk for falls, leaving the facility unsupervised in a wheelchair in the dark. R1 was found three tenths of a mile from the facility in the middle of a country road near railroad tracks by a local citizen who alerted facility staff of R1's location. Findings include:The immediate jeopardy began on 9/05/25 at approximately 9:00 p.m. […]

• Immediate jeopardy, isolatedF684Sep 25, 2024

  Based on record review and interview the facility failed to ensure a resident (R1) received appropriate treatment for an infection of the heart muscle. The facility also failed to ensure the physician and Nurse Practitioner were aware of R1's infection treatment plan. Theses failures affect one (R1) of three residents reviewed for IV Medication/Infection in a sample list of three residents. These failures resulted in (R1) being hospitalized with sepsis and subsequently expiring due to R1's worsening infection. These failures resulted in Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689May 23, 2024

  Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review the facility failed to implement fall interventions and provide a safe transfer for a severely cognitively impaired resident at risk for falls. The facility failed to follow therapy recommendations for R1's transfer and delayed treatment of R1's injuries. Failing to follow therapy recommendations for R1's transfer resulted in R1 falling backwards and R1 hitting R1's head on the floor and R1 sustaining an Occipital Fracture, Left Hip Fracture, Subarachnoid Hemorrhage (traumatic), Traumatic Intraparenchymal Hemorrhage, and Traumatic Subdural Hematoma. R1 subsequently died on [DATE] while on Hospice care. […]