Pleasant Acres Rehabilitation and Nursing Center

Inspectors wroteBased on review of facility meal tray test form, select facility grievances, review of resident council meeting minutes, review of the menu and select facility recipes, observations, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide foods that are palatable, attractive, and at appetizing temperatures.

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in five of five nourishment areas.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 35 residents reviewed (Residents 13 and 176). Findings Include: Review of Resident 13's clinical record revealed diagnoses that included bipolar disorder (a chronic mental health condition characterized by intense, fluctuating mood episodes, ranging from extreme highs to severe lows) and dementia (a general term for severe mental function loss). [...]

Inspectors wroteBased on policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure professional standards were followed when medications were left in the resident's room for one of 35 residents reviewed (Resident 41), and failed to accurately document the location of the treatment on the physician orders, the location of the skin tear on the care plan, and failed to apply a dressing as ordered by the physician for one of 35 residents reviewed (Resident 252).

Inspectors wroteBased on observation, facility policy review, product packaging, and staff interview, it was determined that the facility failed to store medication in accordance with manufacture guidelines for two of five medication carts reviewed (5th floor, South hall medication cart and 5th floor, North hall medication cart). Findings Include: Review of facility provided policy, titled Medication Storage, revised March 2021, revealed, Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Observation of the 5th floor, South hall medication cart on April 8, 2026, at 10:57 AM, revealed one insulin aspart (diabetic medication) pen that was removed from refrigeration on December 24, 2025; two insulin aspart pens with no date removed from refrigeration; [...]

Inspectors wroteBased on observations, review of facility policy, and staff interview, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen.

Inspectors wroteBased on observations, staff interviews, and review of pest control service reports, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the dish room.

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, and resident and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure each resident to be free from abuse, which resulted in mental anguish and actual harm as evidenced by multiple bruises and swelling to the right side of the resident's face, bilateral legs, and bilateral knuckle areas on his hands after an alleged staff to resident altercation for one of five residents reviewed (Resident 1). Findings Include:Review of facility policy, titled Abuse Policy- Prevention and Management, last revised September 8, 2022, read, in part, the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff, family, friends, visitors, etc. [...]

Inspectors wroteBased on review of facility policy, clinical record review, observations, and interviews with staff and residents, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for five of 41 residents reviewed (Residents 75, 150, 180, 195, and 310).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like interior on two of five nursing units (Main 1 and fifth floor nursing units).

Inspectors wroteBased on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for four of 41 records reviewed (Residents 144, 161, 221, and 265).

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to provide a rationale and duration for expending a PRN (as needed) psychotropic dedication beyond 14 days for one of 41 residents reviewed (Resident 92).

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards regarding the operation of the dish machine in the kitchen.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 41 residents reviewed (Residents 21, 259, and 351). Findings Include: Review of Resident 21's clinical record revealed diagnoses that include anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death and potential long-term impairments) and gastro-esophageal reflux disease (a chronic condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms). Review of Resident 21's Significant change MDS (Minimum Data Set is part of federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated December 19, 2024, revealed in Section O0110. [...]

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident's care plan to reflect the resident's current status for two of 41 residents reviewed (Residents 161 and 327).

Inspectors wroteBased on staff interviews, record review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when transcribing orders and administering medications to one of 41 residents reviewed (Resident 144).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 41 residents reviewed (Resident 120).

Inspectors wroteBased on facility policy, review of the clinical records, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with physician orders for three of 41 residents reviewed (Residents 121, 221, and 338).

Inspectors wroteBased on review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of two residents reviewed who received dialysis services (Resident 96). Findings Include: Review of facility policy, Dialysis Management, last revised March 28, 2024, read, in part, interchange of information necessary for the care of the resident, communication form is placed in the binder after completion of the pre dialysis assessment and sent to dialysis with the resident; dialysis center personnel to complete Dialysis communication form and return to facility; upon return the facility is to review information provided on the communication form and address as priorate; facility is to complete post-dialysis information/data and place in resident's medical record; [...]

Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure Medication Regimen Reviews were completed by a consultant pharmacist and responded to in a timely manner by the attending physician or prescriber for two of 41 residents reviewed (Residents 90 and 144).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike interior on one of five units observed (5th floor).

Inspectors wroteBased on policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered plan of care for three of 35 residents reviewed (Residents 220, 291, and 317). Findings Include: Review of the facility's policy, titled Care Planning Process and Care Conference, revised July 2023, read, in part, the facility will develop a comprehensive, resident centered care plan for each resident/patient. Care plan development, renewal and revision will be based upon the results of the resident assessment. The care plan is a working tool that provides a profile of the needs of the individual resident/patient; the resident/patient care plan will be available for use by staff caring for the resident. [...]

Inspectors wroteBased on facility policy review, clinical record review, facility document review, and staff interviews, it was determined that the facility failed to ensure resident medication regimens were free from unnecessary psychotropic medication for one of five residents reviewed for unnecessary medications (Resident 224).

Inspectors wroteBased on select facility document review, clinical record review, observations, and staff interviews, it was determined the facility failed to ensure the menu was followed at one of one meal observed, and failed to ensure residents on therapeutic diets needs were met for two of 52 residents observed (Residents 121 and 338).

Inspectors wroteBased on menu extension sheet review, observations, and staff interviews, it was determined the facility failed to ensure residents were served food prepared in a form designed to meet their individual needs for 13 of 52 residents observed at one of one meals observed (Residents 17, 43, 81, 90, 97, 111, 165, 170, 188, 193, 220, 311, and 338).

Inspectors wroteBased on policy review, observation, and staff interviews, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced or maintained resident dignity for one of 35 residents observed (Resident 146).

Inspectors wroteBased on clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that resident needs were accommodated regarding call bell accessibility for two of 35 residents reviewed (Residents 39 and 271).

Inspectors wroteBased on observation, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide the resident personal privacy during medical treatment for one of 38 residents reviewed (Resident 93). Findings Include: Review of facility policy, titled Dignity and Respect, last reviewed May 2023, revealed, Staff shall maintain an environment in which confidential clinical information is protected. Review of Resident 93's clinical record revealed diagnoses that included peripheral artery disease (a vascular disorder that causes arteries to narrow abnormally, reducing blood flow to the limbs) and cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). [...]

Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment for two of 35 residents observed (Residents 220 and 258).

Inspectors wroteBased on clinical record review, facility document review, and staff interview, it was determined that facility failed to provide an appropriate rationale to a pharmacy recommendation, resulting in the continuance of an antipsychotic medication for indications that were not present, for one of five residents reviewed for unnecessary medications (Resident 224).

Inspectors wroteBased on observations, policy review, and staff interview, it was determined that the facility failed to follow infection control standards for two of five residents observed for medication administration (Residents 93 and 281).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to timely notify a resident's physician of a change in condition for two of four residents reviewed (Residents 1 and 4); and failed to notify a resident's responsible party of a change in condition and/or treatment changes for four of four residents reviewed (Residents 1, 2, 3, and 4).

Inspectors wroteBased on facility policy review, clinical record review, facility incident report review, and staff interviews, it was determined that the facility failed to ensure that residents received adequate assistance to prevent accidents for one of three residents reviewed (Resident 3); and failed to ensure that a thorough investigation was conducted following falls for two of three residents reviewed (Residents 3 and 4).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of four residents reviewed (Resident 4). Findings Include: Review of facility policy, titled Change in Condition, with a last revised date of June 28, 2023, revealed the following, in part: The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Facility will notify the resident, attending physician and resident representative of changes in the resident's condition and/or status; 1. If the CNA [Certified Nurse Assistant] identifies a change in resident's condition he/she will immediately notify the nurse of the situation; 2. [...]

Inspectors wroteBased on observation and resident and staff interview, it was determined that the facility failed to maintain a safe, clean, home-like interior on three of five nursing units observed (100, 200, and 300 units).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 13 residents reviewed (Resident 9). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included dementia with agitation (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). [...]

Inspectors wroteBased on clinical record review, policy review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of six residents reviewed for respiratory care (Resident 5).

Inspectors wroteBased on review of facility investigation, facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility displayed past noncompliance, in that it failed to ensure the resident environment remains free of accident hazards while heating beverages for residents, which resulted in harm to one of three residents reviewed (Resident 1). Findings Include: Review of the facility's policy, titled Food-Reheating recently revised September 2023, read, in part, Staff members only are able to re-heat resident food and or liquids in the microwave to temperatures that are safe and palatable for residents. The policy continued, The staff member is to use the thermometer provided to ensure a maximum temperature of the item is not greater than 140 degrees F [Fahrenheit] at the time of service. [...]