Pleasant Ridge Healthcare Center

In the surveyor’s words

From the most serious findings on record at Pleasant Ridge Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 6, 2023

  Based on medical record review, review of a Self-Reported Incident (SRI), review of witness statements, review of employee corrective action forms, staff interviews, and review of the facility abuse policy, the facility failed to ensure Resident #58 was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and the potential for serious physical and/or psychosocial harm on 02/05/23 at approximately 3:30 P.M., when Resident #58, who was cognitively impaired and was exhibiting signs of agitation and aggression, was physically abused by facility staff. Licensed Practical Nurse (LPN) #200 and State tested Nursing Assistant (STNA) #400 were observed and video recorded to physically pull Resident #58 by his arms on the ground. […]

• Actual harm, isolatedF692Aug 16, 2023

  Based on record review, observation, resident interview, and staff interview, the facility failed to monitor and identify residents with weight loss and failed to ensure appropriate nutritional interventions were recommended and implemented to prevent severe weight loss. This resulted in Actual Harm when Resident #67, with a with a diagnosis of failure to thrive (FTT) and was at nutritional risk related to a body mass index (BMI) (A measure of body fat based on height and weight) of 19.5 was not weighed from 04/08/23 through 07/04/23. There was a lack of nutritional interventions and Resident #67's weight was not monitored while Resident #67 had decreased meal intakes from 04/08/23 to 07/04/23. […]

• No harm, potential for more than minimal, widespreadF812Aug 16, 2023

  Based on observation, staff interview, and policy review, the facility failed to ensure foods were stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all 86 residents in the facility. Findings include: Observation on 08/07/23 at 9:25 A.M. of the facility's walk-in cooler revealed two unlabeled metal pans covered in foil. Culinary Director (CD) #285 present at the time of the observation and identified one pan as pureed eggs and the other as pureed sausage. CD #285 verified neither pan was labeled or dated and stated all foods should be labeled and dated. Observation on 08/07/23 at 9:27 A.M. of the facility's walk-in freezer revealed the following: a. Two boxes of shakes stored directly on the floor. b. […]

• No harm, potential for more than minimal, widespreadF812Apr 5, 2023

  Based on observations, staff interview, review of the facility policy, and record review, the facility failed to ensure the kitchen, and kitchen equipment were maintained in a sanitary manner. This had the potential to affect all residents in the facility except Resident #29 that was listed as no food by mouth. The facility census was 83. Findings include: Observation of the facility's kitchen on [DATE] at 8:23 A.M. revealed there were two juice nozzles with a brown substance observed inside the juice machine cap and nozzle. There were also five dirty dinner trays from [DATE] in the dish room and a dirty mop head next to the stove. There was brown build up on the side of the dishwasher that Dietary Manager #801 was observed to be able to scrub off. […]

• No harm, potential for more than minimal, widespreadF925Apr 5, 2023

  Based on observations, staff interview, and record review, the facility failed to maintain an effective pest control program for flies in the kitchen. This had the potential to affect all residents in the facility except Resident #29 that was listed as no food by mouth. The facility census was 83. Findings include: Observation of the facility's kitchen on 04/04/23 at 8:23 A.M. revealed there were two juice nozzles that were still connected to the juice machine in a pitcher of water with two fruit flies floating on top. Observation of the kitchen revealed fruit flies to be flying in the dish room, in the room with the juice machine and in the kitchen next to the steam table. Interview with Dietary Manager #801 on 04/04/23 at 8:23 A.M. […]