Pleasant Springs Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF686Jan 2, 2024

  Based on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (Resident #1) of 1 resident reviewed for an in-house acquired pressure ulcer. The facility failed to ensure Resident #1 did not develop two avoidable facility acquired pressure injuries. The facility failed to initiate new orders for Resident #1. The facility failed to remove the immoblizer boot (a medical device worn during treatment and recovery of a variety of foot injuries - it is a form of immoblizing and weight bearing for injuries to foot areas) and accurately assess Resident #1's right lower leg during weekly skin assessments from 10/02/2023 - 10/18/2023. […]

• Immediate jeopardy, isolatedF607Jun 4, 2026

  Based on observation, interviews, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 2 of 3 (Residents #13 and #19) reviewed for physical abuse. 1. The facility Administrator failed to implement their abuse policy by removing the alleged perpetrator when the ADON and RN A reported to her on 5/26/2026 that Resident #13 stated CNA B pinched her and was rough with her. 2. The facility Administrator failed to implement their abuse policy by removing the alleged perpetrator during the week of 5/25/2026- 5/28/2026 when Resident #19 told RN A and LVN C that CNA B was rough with her when providing care and told her she did not care if she was fired from this job because she could go work somewhere else. […]

• Immediate jeopardy, isolatedF689Feb 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 3 residents (Resident #1) and 1 of 1 shower rooms (Hall C communal shower) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised after she had been wandering and exit seeking, which resulted in Resident #1 exiting the facility and being found outside the facility in the facility's driveway headed toward a busy public street on 05/17/2025. An IJ was identified on 02/19/2026. The IJ began on 05/17/2025 and removed on 06/13/2025. […]

• Immediate jeopardy, isolatedF689Dec 3, 2024

  Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's freestanding closet was secured to the wall resulting in him pulling it down on top of his self when he fell on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. Findings include: 1. […]

• Actual harm, isolatedF600Jun 4, 2026

  Based on interviews, observations, and record reviews, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents #13 and #19) reviewed for resident abuse. 1. The facility failed to protect Resident #13 from abuse during the week of 5/25/2026- 5/28/2026, when CNA B grabbed her by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her forearm. 2. The facility failed to protect Resident #19 from abuse during the week of 5/25/2026- 5/28/2026, when CNA B was rough with her when providing care and told her she did not care if she was fired from this job because she could go work somewhere else during the week of 5/25/2026- 5/28/2026. […]