Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aspire Of Pleasant Valley during CMS and state inspections, most recent first.
Delayed UTI Evaluation and Lab Communication Failure: A resident with a urinary catheter, neurogenic bladder, and paraplegia reported cloudy, foul-smelling urine, mucus, hematuria, and other UTI symptoms, but staff delayed collecting the UA specimen for several days after the order was written. The UA and C&S later showed an infected urine culture with Klebsiella pneumoniae and Enterococcus faecalis, yet the resident stated she did not receive the results before discharge. Staff interviews showed confusion about the timing of the specimen collection and whether the provider had been notified or had authorized the order.
A resident with multiple venous ulcers and an ESBL-positive infection did not receive wound care in accordance with infection control protocols. Nursing staff failed to perform hand hygiene, change gloves between tasks, disinfect reusable equipment, and consistently conduct wound care in the resident's room, as required by facility policy. Staff interviews confirmed lapses in following proper procedures during wound dressing changes.
The facility did not maintain an effective pest control program, resulting in reports and evidence of ants and mice in resident rooms. A resident with intact cognition reported seeing ants and an incident involving a mouse in her bed, while another resident confirmed the presence of a mouse and a mouse trap in his room. Staff interviews indicated past issues with mice, especially in rooms where food was kept, and the facility's pest control contract had lapsed without the administrator's knowledge.
A resident with severely impaired cognition and at moderate risk for pressure ulcers developed a Stage 3 pressure ulcer due to the facility's failure to notify the physician of wound deterioration and implement nutritional orders. The resident's condition worsened, leading to hospital admission for a complicated wound infection. The facility did not follow up on physician orders or provide consistent wound assessments, contributing to the resident's declining health.
A resident with diabetes and other health conditions did not consistently receive meals that met her vegetarian preferences, leading to skipped meals. Despite her ability to express dietary preferences, the facility failed to provide appropriate meal substitutions, and the alternate menu lacked Registered Dietician authorization.
The facility's QAPI program was found ineffective, with repeated deficiencies in nursing staff sufficiency, ADL care, quality of care, food service, and infection control. Despite quarterly QAPI meetings, the lack of an improvement plan for previous deficiencies contributed to their recurrence.
The facility failed to maintain adequate staffing levels, leading to multiple shifts with insufficient CNAs. This shortage contributed to an incident where a CNA, overwhelmed by stress, threw a box of gloves at a resident during a verbal altercation. The resident, who required assistance for daily activities, was indirectly hit by the gloves. The facility's administrator acknowledged the staffing issues and attempted to manage staff burnout, but high turnover and call-ins continued to affect care quality.
The facility failed to ensure the Dietary Manager had the required national certification for food service management and safety. Despite being hired over a year ago, the Dietary Manager faced interruptions in taking the certification test, including a test shutdown and work obligations. The facility also lacked a policy on necessary certifications for Dietary Managers, and the dietician worked remotely without an on-site schedule.
The facility failed to properly prepare pureed meals for residents, as the Dietary Manager did not measure food portions before or after blending, leading to incorrect serving sizes. The facility's policy lacked guidance on measuring pureed foods, contributing to the deficiency.
The facility failed to maintain proper food safety and hygiene practices, leading to potential cross-contamination. Staff did not perform adequate hand hygiene, and several food items were improperly stored. Uncovered garbage cans and inadequate chemical concentration in cleaning solutions were also noted. The facility's policy lacked specific instructions on these issues.
The facility failed to serve food at safe and palatable temperatures, as evidenced by resident complaints and test tray observations. A resident reported overcooked vegetables and cold food, while a test tray showed food temperatures below the expected 145 F. The Dietary Manager acknowledged the need for additional steps to maintain food warmth, and the facility's HACCP Procedures Manual set a minimum holding temperature of 135 F.
A facility failed to implement Enhanced Barrier Precautions during wound care for two residents and while emptying a urinary catheter collection bag for another. Despite the presence of signs and PPE, staff did not wear gowns as required by the facility's infection control policy. Interviews confirmed the expectation to use gowns and gloves, which was not adhered to, leading to deficiencies in infection control practices.
A resident with quadriplegia did not receive necessary range of motion (ROM) exercises due to the facility's failure to include these in the care plan and the absence of a restorative nursing program. The resident, dependent on staff for daily activities, expressed frustration over the lack of therapy. Interviews with staff confirmed the deficiency, with the DON acknowledging the need for ROM exercises and the PTA noting the absence of recommendations due to the lack of a restorative program.
A resident with multiple sclerosis and muscle weakness developed 2+ pitting edema in both lower legs and feet, but the facility failed to notify the physician or document any follow-up interventions. The care plan required monitoring and physician notification for edema, but this was not done, and the physician's notes did not address the condition. The DON confirmed the lack of documentation and follow-up.
The facility failed to provide pneumococcal and influenza immunizations as required for two residents. One resident's record showed no pneumococcal vaccine offered or declined since the last administration, and another had no record of influenza vaccine offered or declined. The MDS Coordinator confirmed missing permission forms and was unsure if vaccines were refused or not offered. Facility policy mandates annual influenza and pneumococcal immunizations unless contraindicated or refused, with documentation required.
A resident experienced physical abuse when a CNA, overwhelmed by understaffing and personal stress, threw a box of gloves at the resident. The incident occurred in a facility where the resident, who had intact cognition and required assistance with daily activities, was verbally aggressive. The CNA, who was described as generally providing good care, was stressed due to understaffing and personal issues, leading to the incident.
A facility failed to separate a CNA from residents after an alleged abuse incident involving a resident with intact cognition. The CNA, frustrated during an understaffed shift, threw soapy washcloths and a box of gloves at the resident, reportedly hitting them. Despite the facility's policy requiring immediate suspension of accused staff, the CNA continued to care for another resident before being asked to leave. The administrator acknowledged the failure to follow policy, emphasizing the facility's zero tolerance for abuse.
A facility failed to prime an insulin pen before administration and did not follow physician orders for a resident readmitted after hospitalization. An LPN administered insulin without priming the pen, unaware of the requirement, and the facility's policy lacked instructions on priming. Additionally, physician orders for insulin, glucose monitoring, and Vitamin D were not transcribed correctly for a cognitively intact resident, leading to a delay in implementation. The facility had several new admissions and only one floor nurse to double-check orders, contributing to the oversight.
Two residents with significant mobility impairments did not receive the required number of baths due to staffing shortages. Despite facility policies mandating regular bathing, both residents reported missed baths, and staff interviews confirmed that insufficient staffing often led to incomplete care. Documentation inconsistencies were also noted.
The facility failed to act on a high white blood cell count for a resident, delaying necessary medical intervention for two days, and did not document or notify a physician about another resident's edema. These oversights led to deficiencies in care, as revealed by staff interviews and record reviews.
A facility failed to perform dressing changes as ordered for a resident with a stage 4 pressure ulcer, particularly over weekends, leading to the wound enlarging. The resident, who was cognitively intact and dependent on staff, reported that dressings were not changed on weekends. An LPN confirmed finding unchanged dressings after weekends and reported this to the DON. The facility's skin management policy did not address the completion of dressing changes as ordered.
A resident, dependent on staff for transfers due to conditions like chronic pain and COPD, was improperly transferred without a mechanical lift, contrary to their Care Plan. This led to a fall involving the resident and two CNAs. Staff interviews confirmed the lift was not used as required, and the facility's Administrator was unaware of the incident.
A resident undergoing dialysis reported missing meals due to insufficient staff assistance after returning from treatment. The resident, who required help with eating, often did not receive food after dialysis and was sometimes given a peanut butter and jelly sandwich after using the call light. Staff interviews confirmed the resident was occasionally forgotten for meals, and a former cook frequently overlooked the resident's needs.
Delayed UTI Evaluation and Failure to Communicate Catheter-Related Lab Results
Penalty
Summary
The facility failed to notify the physician of changes in a resident’s condition, failed to intervene in a timely manner by collecting a urinalysis specimen for immediate processing, and failed to communicate laboratory results that indicated treatment was required to the resident’s physician after discharge for a resident with a urinary catheter. The resident had diagnoses including neurogenic bladder, paraplegia, a stage IV pressure ulcer of the left buttocks, osteomyelitis, anxiety, and depression, and had intact cognition with a BIMS score of 15 out of 15. The resident used a urinary catheter and required moderate staff assistance with transfers, bathing, and toileting. The resident’s record showed a physician order on 10/17/25 for a UA with C&S to be done Monday early AM and sent to the lab Monday AM. Nursing notes documented cloudy urine and mucus on 10/12/25 and 10/16/25, then foul smell, mucus, hematuria, cloudy appearance, and urine retention on 10/18/25, with the catheter intact. The UA specimen was not obtained until 10/20/25 at 12:04 a.m., when it was placed in a cooler on ice for lab pickup. The resident stated she had been telling staff for about 2 weeks before discharge that she thought she had a UTI, that staff knew she was having symptoms and did nothing until the day before discharge, and that when she spoke to Staff A on 10/17/25 she was told they would deal with it on Monday. The final UA results from 10/20/25 showed turbid urine, blood, positive nitrites, 3+ leukocytes, greater than 50 WBCs, moderate bacteria, mucus, budding yeast, and WBC clumps. The culture grew more than 100,000 CFU Klebsiella pneumoniae and 20,000 to 25,000 CFU Enterococcus faecalis, indicating a UTI requiring treatment with at least 2 different antibiotics. The resident stated that on 10/24/25 she felt very ill with fever of 101, rapid heart rate, flank pain, and thick foul-smelling urine with mucus, and that her urologist prescribed an antibiotic based on her symptoms on 10/25/25. She also stated she had not received the results of the UA done on 10/20/25. Staff interviews showed confusion about why the specimen was delayed, that the order was entered as a provider-written order without provider authorization, and that the facility’s ARNP denied being informed of the resident’s UTI symptoms or authorizing the order as described.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound dressing changes for a resident with multiple venous ulcers and a history of sepsis, renal insufficiency, and an ESBL-positive urinary tract infection. The resident required substantial assistance with activities of daily living and was on contact precautions due to infection risk. Facility policy required staff to don isolation gowns and gloves, perform hand hygiene, disinfect reusable equipment, and conduct wound care in the resident's room. Observations and interviews revealed that nursing staff did not consistently follow these protocols. One nurse was observed changing the resident's dressing at the nurse's station, failing to clean the wound, neglecting hand hygiene, and placing used items, including scissors, back into the medication cart without disinfection. Another nurse, during wound care in the resident's room, failed to change gloves or perform hand hygiene between tasks, used the same gauze to cleanse multiple wounds, and did not disinfect scissors between uses. The nurse also left the room wearing the isolation gown and handled supplies and equipment without appropriate glove changes or hand hygiene. Staff interviews confirmed a lack of adherence to infection control procedures, with admissions of forgetting to disinfect scissors and not always changing gloves or performing hand hygiene as required. The Director of Nursing stated that the expectation was for wound care to be completed in the resident's room with proper use of personal protective equipment, hand hygiene, and disinfection of reusable supplies, in accordance with facility policy. However, these practices were not consistently followed, as evidenced by direct observation and staff statements.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants and evidence of vermin within resident rooms. One resident with intact cognition reported seeing ants in her room over the past month and described an incident involving a mouse and baby mice in her bed, which she reported to staff. Observations in her room revealed no visible ants but did find debris resembling mouse droppings and food items stored on night stands, including fruit and bottled water. Another resident, also with intact cognition, confirmed the presence of a mouse in his room and pointed out a mouse trap placed along the wall. Multiple CNAs interviewed acknowledged hearing about or previously seeing mice in the facility, particularly in rooms where residents kept food, but none reported recent sightings of ants or mice themselves. The facility's pest control contract had lapsed after the last service in December, and the administrator was unaware that services had stopped until contacting the provider during the survey. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents, but this was not maintained, as evidenced by resident and staff reports, physical observations, and the lack of current pest control services.
Failure to Manage Pressure Ulcer and Nutritional Needs
Penalty
Summary
The facility failed to notify the physician of pressure ulcer deterioration and implement nutritional orders to promote healing for a resident with a Stage 3 pressure ulcer. The resident, who had severely impaired cognition and was at moderate risk for pressure ulcers, was admitted with a surgical wound and skin tears but no pressure ulcers. Despite being identified as at risk, the facility did not implement a care plan for wound management or address the resident's protein calorie malnutrition. The resident developed a Stage 3 pressure ulcer on the right gluteus, which was not properly managed. The facility did not notify the physician of the wound's deterioration or the heavy saturation of the dressing. Nutritional recommendations from the dietician, including high-protein supplementation, were not implemented. The facility also failed to transcribe and implement orders from the wound clinic, including increased protein intake and specific wound care instructions. The resident's condition worsened, leading to hospital admission for a complicated wound infection and urinary tract infection. The facility's documentation was inconsistent, with missing wound assessments and failure to follow up on physician orders. The lack of proper wound care and nutritional support contributed to the deterioration of the resident's pressure ulcer, resulting in further complications and hospital readmission.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that met the individual preferences of a resident, who was one of seven residents reviewed. The resident, who had intact cognition, was diagnosed with diabetes, congestive heart failure, peripheral vascular disease, and anxiety. The resident required substantial assistance for various activities but was able to feed herself and express her preferences. Despite her preference for a vegetarian diet, the facility did not consistently accommodate her dietary choices, leading to instances where she did not receive meals aligned with her preferences. On one occasion, the resident received a hot dog for lunch, which she did not care for, and requested a peanut butter and jelly sandwich instead. Although she eventually received the sandwich, there were times when her requests for meal substitutions were not fulfilled, resulting in her skipping meals. The resident reported an incident where she received a supper tray with beef, requested a substitution, but was not provided with an alternative, leading her to skip the meal entirely. The facility's interim off-site Registered Dietician was unaware of the resident's vegetarian preference and expressed concern about the resident missing meals, especially given her insulin-dependent diabetes and other health conditions. The facility's policy required that all residents' diets be served according to the physician's order, but the alternate menu provided did not have the authorization of a Registered Dietician, indicating a lapse in adherence to dietary protocols.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during multiple surveys. The deficiencies included insufficient nursing staff (F725), inadequate activities of daily living (ADL) care for dependent residents (F677), poor quality of care (F684), issues with the nutritive value, appearance, and temperature of food (F804), unsanitary food procurement, storage, preparation, and serving (F812), and lapses in infection prevention and control (F880). These deficiencies were noted during recertification and complaint surveys conducted over several periods, indicating a persistent issue with the facility's quality management processes. During an interview, the Administrator acknowledged that the QAPI team meets at least quarterly, aiming for monthly meetings to address issues. However, there was no plan in place for improving previous survey deficiencies when the current Administrator assumed her position, which contributed to the recurrence of these issues. The facility's QAPI Management Plan, revised in January 2024, outlines the responsibilities of the QAPI Committee, including monitoring and evaluating improvement plans, but it appears these measures were not effectively implemented, leading to the repeated deficiencies.
Staffing Shortages and Resident Incident
Penalty
Summary
The facility failed to employ sufficient numbers of staff to meet the needs of its residents, as evidenced by a review of the Facility Assessment and staff schedules. The assessment indicated that three Certified Nursing Assistants (CNAs) were required for both the first and second shifts when the census was 30 or more. However, the staff schedules from August 1 to September 2, 2024, showed that there were only two CNAs for either partial or whole shifts on multiple occasions. Interviews with staff members confirmed that they often felt understaffed, which affected their ability to complete their duties effectively. The facility's administrator acknowledged the staffing issues, citing staff turnover and call-ins as contributing factors. In a specific incident involving Resident #16, who had diagnoses including depression and chronic obstructive pulmonary disease, the facility's understaffing contributed to a situation where a CNA, Staff F, became overwhelmed and acted inappropriately. The resident, who was dependent on staff for various activities of daily living, was involved in a verbal altercation with Staff F, who then threw a box of gloves that indirectly hit the resident. This incident occurred on a day when the facility was short-staffed, with only three staff members present, including Staff F, Staff H (an RN), and Staff N (a CNA who was unable to assist with lifting due to pregnancy). The facility's administrator was aware of the potential for staff burnout and attempted to manage it by monitoring staff energy levels and attitudes. However, the ongoing staffing shortages and high turnover rates contributed to a stressful work environment, which may have exacerbated the situation leading to the incident with Resident #16. The administrator noted that they tried to limit overtime and fill shifts with available staff, but the challenges persisted, impacting the quality of care provided to residents.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the minimum qualifications of having a national certification for food service management and safety within the required timeframe. The Dietary Manager was hired on 6/21/22, but as of the report date, the facility lacked records of her education or certification. The Administrator acknowledged that the Dietary Manager had attempted to take the certification test but faced interruptions, including a test shutdown and being called into work due to a cook cancellation. The test was rescheduled for the following week. Additionally, the facility did not have a policy indicating the necessary certification for Dietary Managers. The dietician, who works remotely, was never on-site, and the facility was unable to produce a schedule for her.
Deficiency in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that food was properly prepared and appropriate to meet the needs of residents on a pureed diet. During an observation, the Dietary Manager (DM) did not measure the beef before blending it for four residents, and the resulting puree was not measured before being served. Similarly, carrots were blended without measuring the volume afterward, and an incorrect scoop size was used to serve them. Additionally, chocolate chip cookies were blended with an unknown quantity of milk and served without measuring, and bread and gravy were not prepared or served as part of the meal. The DM explained that she had been trained by different managers who taught her two different methods for pureeing food, one of which involved using a total volume chart to determine serving sizes, which she does not use. The facility's undated policy on pureed food preparation directed staff to portion out items before blending and to use only nutritive liquids for consistency, but it did not provide guidance on measuring foods after blending to ensure adequate serving sizes. This lack of adherence to proper procedures and the absence of clear policy guidelines contributed to the deficiency in food preparation for residents requiring pureed diets.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, leading to potential cross-contamination during meal preparation and service. Observations revealed that staff did not perform adequate hand hygiene, as evidenced by a staff member wearing gloves while handling various kitchen items and then plating food without changing gloves. Another staff member washed dirty dishes and then prepared a drink mix without washing hands. Additionally, the facility's kitchen had uncovered garbage cans, which were previously identified as an issue, and the cleaning solution used for sanitizing surfaces lacked the appropriate chemical concentration. Further inspection of the kitchen storage areas showed several food items in the freezer that were opened, unsealed, and undated, including cookie dough, chicken nuggets, ravioli, pizza crust, sausage patties, and sausage links. In the dry goods pantry, almond extract was found with a broken lid, unsealed, and undated. The facility's policy, titled HACCP Procedures Manual, directed staff to use proper hand washing and handling techniques to prevent infections but lacked specific instructions regarding garbage can coverage, chemical sanitization, and proper labeling and dating of opened food items.
Deficiency in Serving Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a safe temperature and ensure it was palatable, as evidenced by multiple findings. A review of the Resident Council Minutes from May 2024 revealed complaints about food sometimes being cold. During an interview, a resident described the vegetables as overcooked and the hamburger as tasting like sandpaper, noting that the food was not warm when delivered to his room. An observation of a test tray showed that the mashed potatoes were at 135.5 degrees Fahrenheit, boiled carrots at 125.0 F, and roast beef at 120.5 F, with the carrots and roast beef noted to be lukewarm and the carrots having a mushy consistency. The Dietary Manager stated that she expected food holding temperatures to be around 145 F and acknowledged that additional steps might be needed to keep room trays warm. The facility's undated HACCP Procedures Manual indicated that the minimum acceptable holding temperature for all hot foods should be 135 F and directed staff to prevent soggy, overcooked vegetables.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control protocols by not implementing Enhanced Barrier Precautions (EBP) during wound care for two residents and while emptying a urinary catheter collection bag for another resident. Resident #15, who was cognitively intact and dependent on staff for various activities, had a care plan that required EBP due to wounds. However, during wound care, staff did not wear gowns as required, despite the presence of an EBP sign and adequate PPE supplies outside the room. Staff D, LPN, and Staff E, CNA, both failed to don gowns while performing wound care, which was against the facility's infection control policy. Resident #87, also cognitively intact and dependent on staff, had wounds on the back and required wound care. Although the care plan did not specifically address EBP, the presence of an EBP sign and PPE supplies indicated the need for such precautions. Staff D, LPN, did not wear a gown while performing wound care, and admitted during an interview that a gown should have been worn. The facility's policy required the use of a gown and gloves for wound care, which was not followed in this instance. Resident #86, who had an indwelling catheter and required EBP, did not receive care in accordance with these precautions. Staff B, CNA, emptied the urinary catheter collection bag without donning a gown, despite the EBP sign and available PPE. Interviews with staff confirmed the expectation to wear gowns and gloves for such procedures, which was not adhered to. The facility's policy clearly outlined the need for gown and glove use during high-contact care activities, including those involving catheters, which was not followed in this case.
Failure to Provide Range of Motion Exercises for Quadriplegic Resident
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) exercises for a resident with quadriplegia, leading to a deficiency in maintaining the resident's current level of ROM. The resident, who has intact cognition, is dependent on staff for activities of daily living due to limited mobility and requires assistance for transfers, bathing, dressing, and personal hygiene. The care plan for the resident did not include directives for staff to perform ROM exercises, and both the occupational and physical therapy discharge summaries lacked recommendations for a restorative or functional maintenance program. Interviews with the resident and staff revealed that the resident was not receiving any therapy or ROM exercises, which was a source of frustration for the resident. The Director of Nursing acknowledged the absence of a restorative nursing program and the need for staff to provide ROM exercises for residents unable to perform them independently. A physical therapy assistant confirmed that no recommendations for restorative nursing were made due to the lack of such a program at the facility, despite the necessity of passive ROM exercises to prevent contractures.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to ensure that a physician provided orders for a resident's immediate care and needs following a change in condition. Resident #33, who had diagnoses including multiple sclerosis, muscle weakness, and difficulty walking, was noted to have 2+ pitting edema in both lower legs and feet during skilled evaluations. Despite the facility's policy requiring physician notification and intervention for such conditions, there was no documentation indicating that the physician was informed of the edema or that any follow-up interventions were implemented. The resident's care plan included monitoring for edema and notifying the physician, yet this was not adhered to. The physician's progress notes did not address the resident's recent edema, and the resident reported only meeting the physician once without examination. Interviews with the Director of Nursing confirmed the lack of documentation and follow-up regarding the resident's edema, highlighting a failure in communication and adherence to the facility's policy for managing changes in a resident's condition.
Failure to Provide Required Immunizations
Penalty
Summary
The facility failed to provide pneumococcal and influenza immunizations as required for two out of five residents reviewed. Resident #10's immunization record indicated the last pneumococcal vaccine was administered on 8/27/22, with no record of the vaccine being offered or declined since then. Similarly, Resident #19's record showed the last influenza vaccine was administered on 10/07/22, with no subsequent record of the vaccine being offered or declined. During an interview, the MDS Coordinator admitted to not having a permission form for Resident #10 and was unsure if the resident refused or was not offered the vaccine. Additionally, there was no declination or acceptance form for Resident #19's influenza vaccine. The facility's policy requires all residents to receive annual influenza vaccines and pneumococcal immunizations unless contraindicated or refused, with documentation to be placed in the medical record.
Resident Abuse Due to Staff Overwhelm and Understaffing
Penalty
Summary
The facility failed to protect a resident from physical abuse when a staff member threw a box of gloves toward the resident. The incident involved Resident #16, who had diagnoses including depression, chronic pain, and chronic obstructive pulmonary disease, and was dependent on staff for various activities of daily living. The resident had intact cognition with a BIMS score of 15 out of 15. The facility's policy on abuse, revised in August 2020, defined abuse as the willful infliction of injury or punishment resulting in harm or mental anguish, and stated a zero-tolerance approach. On the day of the incident, the facility was understaffed, and tensions were high among the staff. Staff F, a CNA, became frustrated with Resident #16's verbal aggression and threw a box of gloves at the resident, which hit the bed before making contact with the resident's head. The resident was not physically hurt but was upset by the incident. Multiple staff members, including Staff H, RN, and Staff N, CNA, witnessed the event and provided statements indicating that Staff F was overwhelmed and stressed due to the staffing situation and personal issues. Interviews with staff revealed that Staff F had been experiencing personal and professional stress, which contributed to her actions. The facility's administrator acknowledged the challenges in managing staff burnout and the need to monitor staff well-being. Despite the incident, Staff F was described as a good aide who generally provided good care, but the situation highlighted the impact of understaffing and stress on staff behavior and resident safety.
Failure to Separate Staff After Allegation of Abuse
Penalty
Summary
The facility failed to immediately separate a staff member from residents following an allegation of abuse involving a resident. The incident involved a resident with intact cognition, who was dependent on staff for various activities of daily living, including toileting hygiene and transferring. The resident was involved in an altercation with a Certified Nursing Assistant (CNA), who became frustrated and threw soapy washcloths and a box of gloves at the resident, with the gloves reportedly hitting the resident in the head. The facility's policy mandates the suspension of staff accused of abuse pending investigation, but this was not followed. The incident occurred during a time when the facility was understaffed, contributing to heightened stress levels among staff. The CNA involved in the incident admitted to being verbally abused by the resident and reacted by throwing a box of gloves, which she claimed did not hit the resident. However, other staff members and the resident's roommate provided accounts that suggested the gloves did make contact with the resident. Despite the altercation, the CNA continued to care for another resident before being asked to leave the facility. The facility's administrator acknowledged the failure to immediately separate the staff member from residents, as required by their policy. The administrator admitted that the CNA should have been removed from the facility immediately following the incident. The report highlights the facility's policy of zero tolerance for abuse and the expectation that residents should be free from abuse in their home environment.
Failure to Prime Insulin Pen and Follow Physician Orders
Penalty
Summary
The facility failed to properly prime an insulin pen before administering insulin to a resident. During a medication pass, an LPN administered insulin to a resident without priming the pen, which involves wasting 2 units before dialing the prescribed dosage. The LPN was unaware of the need to prime the pen, and the facility's diabetic management policy did not include instructions on priming insulin pens. The Director of Nursing confirmed that priming is necessary and mentioned plans for educating the nursing staff. Another deficiency involved the failure to follow physician orders for a resident who was readmitted after hospitalization. The resident, who was cognitively intact, had orders for insulin, glucose monitoring, and Vitamin D that were not transcribed correctly upon their return. The orders were only added four days later, and the resident did not recall missing any medications. The Director of Nursing acknowledged that the facility had several new admissions that week and only one floor nurse to double-check orders, which contributed to the oversight. The facility's policy requires that all physician orders be entered into the electronic medical record immediately and reviewed by a licensed nurse. However, the process was not followed correctly, leading to the delay in implementing the physician's orders for the resident. The Director of Nursing noted that the current pharmacy does not enter orders into the system, and there was a plan to have the pharmacy enter orders initially, with nurses double-checking them afterward.
Inadequate Bathing Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate bathing care for two residents, Resident #32 and Resident #6, as observed during a survey. Resident #32, who has quadriplegia and is dependent on staff for all activities of daily living, reported receiving only two baths since admission, despite the facility's policy requiring at least two baths per week. Staff interviews revealed that the lack of sufficient staffing often led to missed baths, and Resident #32 was not known to refuse showers. The Director of Nursing confirmed that baths should be documented in the electronic health record, but inconsistencies in documentation and staffing shortages were noted. Similarly, Resident #6, who has paraplegia and multiple sclerosis, was assessed as needing staff assistance for bathing. The review of bath documentation showed that five scheduled baths were missed over two months. Resident #6 reported that the facility's staffing issues were the reason for missed showers, and staff confirmed that bath schedules were color-coded and required documentation. However, the completion of baths was inconsistent, particularly during night shifts, due to staffing shortages.
Failure to Act on Lab Results and Edema in Residents
Penalty
Summary
The facility failed to carry out necessary interventions for two residents, leading to deficiencies in care. Resident #17, who was cognitively intact and had multiple diagnoses including type 2 diabetes mellitus and coronary artery disease, had a lab result indicating a high white blood cell count, suggestive of a potential infection. The lab results were available on August 31, 2024, but the facility did not act on them until September 2, 2024, when the resident's condition worsened, showing signs of lethargy and fluctuating vitals. The delay in response resulted in the resident being sent to the emergency room for further evaluation and treatment, where they were diagnosed with acute cystitis. Resident #33, who had multiple sclerosis and muscle weakness, was identified with 2+ pitting edema in both lower legs and feet during skilled evaluations in June 2024. Despite the care plan directing staff to document and notify the physician about edema, there was no documentation of physician notification or any follow-up interventions related to the edema. This lack of action indicates a failure to adhere to the care plan and ensure timely medical intervention. Interviews with staff revealed lapses in communication and follow-up procedures. Staff D, an LPN, acknowledged that lab results should have been reviewed and acted upon promptly, but they were not addressed until after the weekend. The Director of Nursing admitted to being unaware of the missed lab results and the lack of documentation regarding Resident #33's edema. These oversights highlight deficiencies in the facility's processes for monitoring and responding to changes in residents' conditions.
Failure to Complete Dressing Changes as Ordered
Penalty
Summary
The facility failed to complete dressing changes as ordered for a resident with a stage 4 pressure ulcer on the coccyx/left buttock. The resident, who was cognitively intact and dependent on staff for various activities, had a care plan that included administering treatments as ordered and monitoring for effectiveness. Despite this, the Treatment Administration Records (TAR) indicated that a dressing change was missed on one occasion, and the resident reported that dressings were not changed on weekends, leading to the wound getting larger. Observations and interviews confirmed that dressing changes were not consistently performed as ordered, particularly over weekends. Staff interviews revealed that an LPN noticed the same dressing on the resident after returning from a weekend off, indicating that changes were not made during her absence. The LPN admitted to not always documenting these findings but reported them to the Director of Nursing (DON). The DON acknowledged being informed of the issue weeks prior and had completed re-education. The facility's policy on skin management did not address the completion of dressing changes as ordered, contributing to the deficiency.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to adhere to the Care Plan for a resident who required mechanical lift assistance for transfers. The resident, who had diagnoses including depression, chronic pain, and chronic obstructive pulmonary disease, was assessed as dependent on staff for various activities of daily living, including transferring. The Care Plan specified the use of a mechanical lift with the assistance of two staff members for transfers. However, on one occasion, two CNAs transferred the resident without using the mechanical lift, resulting in all three individuals falling into the bed. The resident confirmed that this method of transfer occurred, although not frequently. Interviews with staff revealed that the mechanical lift was not used as required, and this was reported to the nurses. A Certified Medication Aide also heard about the improper transfer method and noted that the resident questioned why the lift was not used consistently. The facility's Administrator acknowledged that the resident was supposed to use the mechanical lift and stated that transferring without it was unacceptable. However, she was unaware of the incident until it was brought to her attention.
Failure to Provide Meals According to Resident Needs
Penalty
Summary
The facility failed to provide meals in accordance with the needs and preferences of a resident who required assistance with eating. The resident, who underwent dialysis on Mondays, Wednesdays, and Fridays, reported missing supper on one occasion and often not receiving food after returning from dialysis. The resident typically returned between 4-5 PM and ate in his room, requiring assistance from staff after they finished assisting in the dining room. However, due to insufficient staffing, the resident's meal was sometimes left at the nurses' station, and he would only receive a peanut butter and jelly sandwich after using his call light. Interviews with staff confirmed that the resident was occasionally forgotten for meals, and a CNA had to request a peanut butter and jelly sandwich for him. The Dietary Manager noted that the resident usually took a sandwich to dialysis and returned in time for dinner, but required assistance with eating. The manager expected CNAs to retrieve the resident's tray from the kitchen, but acknowledged that a former cook frequently forgot about the resident. The facility's undated food preparation policy directed staff to use portion-control methods to ensure correct quantities were served, but did not address the specific needs of residents requiring assistance with meals.
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What surveyors actually found near you
We read the 192 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pleasant Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Summit Of Bettendorf | 2.8 mi | ★★★★★ | 3 | 0 |
| Bettendorf Health Care Center | 3.7 mi | ★★★★★ | 23 | 0 |
| Avenues At Quad Cities | 4.7 mi | ★★★★★ | 0 | 0 |
| The Vistas At Bettendorf | 4.9 mi | ★★★★★ | 14 | 0 |
| Silvis Center For Nursing Rehab & Care | 4.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.