Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Pleasant Acres Care Center during CMS and state inspections, most recent first.
Kitchen and dietary sanitation lapses were observed in the food prep and storage areas. Surveyors found debris in refrigerator units, ice build up in freezers, and unlabeled food items, and later observed lime build up on the ice machine plus debris on the snack cart and water cart. The DM reported recent kitchen staffing losses had affected completion of some duties, and stated the items observed required cleaning.
Two residents with intact cognition reported or were observed experiencing lapses in dignity, privacy, and respectful communication. During incontinence care for a resident with muscle weakness, anxiety disorder, and respiratory failure, staff opened and left the room door open while the resident lay in bed with pants at the ankles and only a brief over the perineal area, without using a blanket or privacy curtain, and a CNA told the resident to urinate in the brief after the resident expressed a need to void. Another resident with quadriplegia, anemia, and hyperlipidemia reported repeatedly overhearing staff in the hallway talking about him and other residents in a negative manner, and stated that when he confronted a nurse about this, she became upset and short with him for the remainder of her shift.
A resident was observed in the activity room taking multiple tablets with applesauce while no staff were present, even though the chart had no assessment or order allowing self-administration. The facility policy required observation of medication consumption, and the DON stated the resident should have been supervised because she cannot take her pills without assistance.
A resident with disorientation, delirium, muscle weakness, and a history of falls had repeated falls, but the clinical record lacked neuro checks after some of the incidents. The chart showed neuro checks after one fall, including entries that the resident was sleeping or refused, but no documented neuro checks after two other falls; the DON stated neuro assessments should be completed when the resident is sleeping.
Unsafe transfer during toileting care. Staff applied a gait belt to a resident, but an RN and a CNA lifted the resident to standing and back into the wheelchair by placing their arms under the resident’s armpits instead of using the gait belt. The facility policy required gait belt use for residents who cannot independently ambulate or transfer, and the DON stated the staff should have used the gait belt already on the resident.
BiPAP Equipment Cleaning Schedule Not Established: A resident with OSA, respiratory failure, and obesity used a BiPAP at night, but staff had not established or followed a routine cleaning schedule for the tubing or facemask. The resident stated the equipment had never been cleaned, and the care plan and treatment record contained no cleaning or maintenance instructions. The DON confirmed the facility failed to initiate a cleaning schedule for the BiPAP equipment.
Failure to disinfect a glucometer and perform hand hygiene during blood sugar testing and insulin administration. An RN completed a glucose check for a resident while skipping hand hygiene before gloves, exited with soiled gloves, handled the med cart keys, and returned the glucometer to storage without proper cleansing. During insulin administration, staff again handled the cart and insulin pens with soiled gloves and did not properly disinfect the pens, despite facility policies requiring glucometer disinfection after each use and hand hygiene before and after glove use.
The facility failed to follow the menu and prepare food to meet residents' nutritional needs. A dietary staff member used only one 5-pound bag of chicken for a meal requiring 9 pounds, based on incorrect training. The error was confirmed by the Dietary Manager and the Administrator, who acknowledged the expectation to follow recipes accurately, although no specific policy was in place.
The facility failed to notify the LTC Ombudsman about the hospital transfers of two residents with heart-related conditions. The residents were transferred and returned without their names being included in the facility's monthly notification report. The Administrator acknowledged the omission was due to a report error and the absence of a notification policy.
The facility failed to conduct care plan conferences with two residents and their families, as required by regulations. One resident with severe cognitive impairment had no documented care conferences, and their brother/POA was not informed about participation opportunities. Another resident with no cognitive impairment reported not being invited to care conferences. Staff and the administrator acknowledged the oversight, which was contrary to the facility's policy encouraging resident and family involvement in care planning.
A resident with heart failure, anemia, and peripheral vascular disease did not receive physician-ordered medications, including Coumadin, Bupropion, and Calcitriol, due to unavailability. The facility failed to notify the physician of these missed medications, contrary to their policy. The resident had no cognitive impairment, and the issue was acknowledged by the DON.
The facility failed to respond to call lights in a timely manner for two residents, with documented delays ranging from 16 minutes to over an hour. One resident reported frequent waits over 15 minutes, and another's family noted similar issues, especially on weekends. The facility's administrator confirmed that call lights should be answered within 15 minutes, highlighting a deficiency in meeting this standard.
A facility failed to follow infection prevention practices for a resident with a suprapubic catheter on Enhanced Barrier Precautions (EBP). A CMA was observed performing catheter care without a gown, contrary to EBP guidelines requiring gowns and gloves for high-contact activities. Staff interviews revealed confusion about PPE requirements, with the RN/IP unsure about gown necessity and the DON expecting gown use during catheter care. The facility's policy and CDC guidelines stress the importance of PPE to prevent the spread of multidrug-resistant organisms.
Kitchen and Dietary Area Sanitation Lapses
Penalty
Summary
The facility failed to ensure proper sanitary conditions in the kitchen area where staff prepared food for a census of 37 residents. During the initial kitchen walkthrough on 12/16/26 at 10:35 AM, surveyors observed refrigerator units with scattered food debris, freezer units with ice build up, and food items that were not labeled, including ranch dressing, frozen meat, and frozen pizza. During the initial tour, the Dietary Manager reported the facility had recently lost two kitchen staff, which resulted in some duties not being consistently completed. The Dietary Manager also reported that the bottoms of the refrigerator units required cleaning, the freezers needed defrosting, and all food required proper labeling. On 12/18/26 at 12:42 PM, a tour of the ice machine room showed an ice machine with lime build up on the outside, a snack cart with loose debris build up on top and within the drawers, and a water cart with debris and dry liquid build up. The Dietary Manager stated dietary staff were not responsible for cleaning the ice machine, snack cart, or water cart, but also stated that all of these items required cleaning, including the tray on top of the ice machine. The facility policy stated that all food service areas shall be kept clean, sanitary, and free from litter and that daily and weekly inspections were to be conducted for refrigerators, freezers, storage areas, and other food service areas.
Failure to Maintain Dignity, Privacy, and Respectful Communication
Penalty
Summary
The deficiency involves failures to maintain resident dignity, privacy, and respectful communication during care and staff interactions. For one resident with muscle weakness, anxiety disorder, and respiratory failure, whose MDS documented intact short- and long-term memory, surveyors observed incontinence care during which a CNA used a walkie-talkie to request additional wet wipes. When the RN brought the supplies, the resident was lying in bed with pants at the ankles and only a brief covering the perineal area. Staff did not place a blanket over the resident or pull the privacy curtain before the door was opened, and the door was left open with the resident in the same state of undress after the wipes were placed on the bedside table. During the continuation of incontinence care, when the resident stated, "I need to pee," the CNA responded, "Go ahead and go, you still have your brief on." The resident then paused and said, "Never mind, I don't have to go." These actions occurred despite a facility policy stating that residents are to be treated with respect and dignity and that resident privacy is to be maintained. The deficiency also includes staff communication about residents in a manner that could be overheard and was perceived as disrespectful. A resident with quadriplegia, anemia, hyperlipidemia, and a BIMS score of 15 indicating no memory impairment reported that staff were talking about him in the hallway outside his room and that he could hear them. He stated that the nurse talks badly about other residents, and that when he opened his door and confronted her, she became upset and short with him for the rest of her shift. He further reported that this was not the first time he overheard staff talking about him and other residents, and that he felt frustrated at being labeled crabby or as causing issues when he believed he was standing up for himself and other residents. The Administrator acknowledged that staff should not be discussing residents in the hallways.
Unsupervised Medication Self-Administration
Penalty
Summary
The facility failed to ensure safe self-administration of medications for Resident #26 and failed to monitor the resident while she took medications, despite no assessment or order in the medical record authorizing self-administration. During observation on 02/18/2026 at 8:31 a.m., Resident #26 was sitting in the activity room with two medication cups in front of her; one cup contained applesauce with a spoon, and the other contained a variety of tablets. The resident dumped the tablets onto the table, lined them up, and took them with the applesauce while no facility staff were in or around the area. Review of the resident’s chart showed no documentation of an assessment for self-administration and no orders for self-administration of medications. The facility’s Medication Administration policy stated that resident consumption of medications should be observed, and the DON stated in interview that the resident should have had someone watching her take her medications because she cannot take her pills without supervision.
Missing Neurological Checks After Falls
Penalty
Summary
The facility failed to complete neurological checks after a resident fell for 1 of 1 residents reviewed. Resident #11’s MDS documented disorientation, delirium due to a known psychosocial condition, muscle weakness, and a history of falling, and the BIMS score was not assessed. The incident log showed falls on 1/21/26, 1/25/26, 1/27/26, and 2/13/26. The clinical record showed neurological checks documented after the 1/21/26 fall, including repeated entries noting the resident was sleeping or refused checks while in a wheelchair. However, the record lacked documentation of neurological checks after the 1/25/26 and 1/27/26 falls. After the 2/13/26 fall, neurological checks were documented beginning at 10:30 p.m. and continued through 2:00 a.m., with entries noting the resident was sleeping, awake, or exhibiting behaviors. The facility’s Head Injury policy required assessment after a known, suspected, or verbalized head injury, including neurological evaluation for changes in physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech, or slow responses, and the DON stated the neurological assessment should be completed when the resident is sleeping.
Unsafe Transfer During Toileting Care
Penalty
Summary
The facility failed to provide safe transfers for Resident #11 during toileting care. Staff D, a CNA, applied a gait belt to the resident, but Staff B, an RN, and Staff E, a CNA, assisted the resident to a standing position with their arms under the resident’s armpits instead of using the gait belt. After the resident finished using the toilet, Staff B and Staff E again lifted the resident to standing with their arms under the armpits while Staff D provided perineal care, and then Staff B and Staff E assisted the resident back into the wheelchair without using the gait belt. The facility policy titled Use of Gait Belt, dated 2025, stated gait belts are to be used with residents who cannot independently ambulate or transfer for safety. The DON stated the staff should not have been lifting under the resident’s arms and should have used the gait belt already on the resident.
BiPAP Equipment Cleaning Schedule Not Established
Penalty
Summary
The facility failed to implement and practice appropriate infection control measures for a resident’s BiPAP machine by not establishing or following a routine cleaning schedule. Resident #7 had diagnoses of obstructive sleep apnea, respiratory failure, and obesity, and the MDS documented use of a non-invasive mechanical ventilator with a BIMS score of 15. During observation, a BiPAP machine was present on the resident’s bedside table, and the resident stated staff had never cleaned the BiPAP oxygen tubing or facemask, despite having used the device for about a year and a half. Record review showed a physician order for BiPAP use at night, but the care plan and February 2026 treatment record contained no instructions regarding cleaning or maintenance of the BiPAP equipment. The facility’s CPAP/BiPAP Cleaning policy required cleaning in accordance with CDC guidelines and manufacturer recommendations, including routine cleaning of the mask, tubing, and other components. The DON stated the facility failed to initiate a cleaning schedule for the resident’s BiPAP equipment and confirmed that CPAP and BiPAP equipment should have a regular cleaning schedule.
Failure to Disinfect Glucometer and Perform Hand Hygiene During Blood Sugar Testing and Insulin Administration
Penalty
Summary
The facility failed to perform blood sugar testing and administer insulin in a manner that protected a resident from bloodborne pathogens for 1 of 1 residents reviewed. During observation, Staff C, RN, removed Resident #7’s glucometer and testing supplies from the medication cart, entered the resident’s room, and completed the glucose check without performing hand hygiene before donning gloves. After discarding the used disposable supplies, Staff C exited the room wearing soiled gloves while holding the glucometer, returned to the medication cart, removed one glove, failed to perform hand hygiene, retrieved the medication cart keys from a scrub pocket, and unlocked the cart. Staff A then returned the glucometer to the storage container without proper cleansing. Later, Staff A retrieved insulin pens, needles, and supplies and entered the resident’s room to administer insulin. After insulin administration, Staff C again exited the room wearing soiled gloves, removed one glove, failed to perform hand hygiene, retrieved the medication cart keys from a scrub pocket, unlocked the cart, and placed insulin pens in a drawer without properly disinfecting the pens. The facility’s Glucometer Disinfection policy required glucometers to be cleaned and disinfected after each use, and the Hand Hygiene policy stated that staff must perform hand hygiene before donning gloves and immediately after removing gloves. In interview, the DON stated staff were required to disinfect glucometers using disinfecting wipes and to clean insulin pens as needed, and that hand hygiene should be performed before donning gloves and immediately after doffing gloves.
Failure to Follow Menu and Recipe for Nutritional Needs
Penalty
Summary
The facility failed to follow the menu and prepare food to meet the residents' nutritional needs. On a specific date, Staff D, a dietary staff member, used only one bag of diced chicken for a lunch meal intended to serve 36 portions of Chicken Alfredo. The recipe required 9 pounds of chicken, but Staff D used only one 5-pound bag, mistakenly believing it was the correct amount based on training received. This discrepancy was confirmed through observation of the packaging and review of the recipe, which clearly documented the need for 9 pounds of chicken. The Dietary Manager, Staff C, acknowledged the error, confirming that two 5-pound bags were available in each box and that 1.75 bags should have been used for the recipe. The facility's policy on portion control was reviewed, which stated that foods should be served according to standard portion sizes to ensure adequate servings. The Administrator confirmed the expectation that recipes be followed accurately, although there was no specific policy regarding adherence to recipe ingredient amounts. The facility census at the time was 27 residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman regarding the transfer of two residents to the hospital. Resident #4, who had diagnoses of heart failure, anemia, and peripheral vascular disease, was transferred to the hospital on February 5, 2024, and returned on February 19, 2024. The facility's documentation, specifically the Notice of Transfer Form to the Long Term Care Ombudsman for February 2024, did not include Resident #4's name, indicating a failure in the notification process. Similarly, Resident #15, with diagnoses of atrial fibrillation, heart failure, and COPD, was transferred to the hospital on May 25, 2024, and returned on June 3, 2024. The facility's Notice of Transfer Form for May 2024 also lacked Resident #15's name. Interviews with the Administrator revealed that the omission was due to a report that did not include these residents' names, and the facility did not have a policy on notification to the Ombudsman, although they submitted reports monthly.
Failure to Conduct Care Plan Conferences with Residents and Families
Penalty
Summary
The facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team, including the resident and their representative, for two residents. Resident #14, who was documented as having severe cognitive impairment, had no care conferences documented with family or resident present. The resident's brother and power of attorney stated that he was not informed about the possibility of participating in care conferences and expressed a desire to be involved. Resident #19, who had no cognitive impairment, also reported not being invited to care conferences since residing at the facility. Staff B, a registered nurse and infection preventionist, acknowledged that care conferences had not been completed with these residents or their families. The facility's administrator confirmed that care plan conferences had not been conducted in accordance with regulations and that the facility was working to address this issue. The facility's policy encourages resident and family participation in care planning, but this was not adhered to in these cases.
Failure to Administer and Notify Physician of Missed Medications
Penalty
Summary
The facility failed to provide physician-ordered medications and did not notify the physician of missed medications for a resident diagnosed with heart failure, anemia, and peripheral vascular disease. The resident, who had no cognitive impairment, had orders for Coumadin, Bupropion, and Calcitriol. However, the facility's records showed multiple instances where these medications were not available or not administered over several days. Specifically, Coumadin was not available on multiple occasions, and Bupropion and Calcitriol were also noted as not available or on order. The facility's policy requires prompt notification of the provider in case of significant medication errors or adverse consequences. Despite this, the Electronic Health Records did not indicate any physician notification for the missed medications on the specified dates. An interview with the Director of Nursing revealed that there are times when medications do not arrive on time, and it was acknowledged that missed medications should be documented, and the physician should be notified, which was not done in this case.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to ensure timely responses to call lights for two residents, leading to prolonged wait times. Resident #4 reported experiencing delays of over 15 minutes on several occasions. A review of the facility's Alarm Event Report from 12/4/24 to 12/11/24 showed multiple instances where call lights were left unanswered for extended periods, ranging from 16 minutes to over an hour. Specific incidents included a call light on 12/8/24 that was on for 1 hour and 7 minutes and another on 12/9/24 that was on for 51 minutes. Resident #23's family also reported delays in call light responses, particularly on weekends, with waits exceeding 15 minutes. The Alarm Event Report corroborated these claims, showing a call light on 12/7/24 that was on for 55 minutes and another on 12/8/24 for 26 minutes. The facility's administrator acknowledged that call lights should be answered within 15 minutes, indicating a failure to meet this standard during the reported period.
Inadequate Use of PPE During Catheter Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices for a resident with a suprapubic catheter who was on Enhanced Barrier Precautions (EBP). During an observation, a Certified Medication Assistant (CMA) was seen performing catheter care for the resident without wearing a gown, which is required under EBP guidelines. The CMA did wear gloves and a mask, but the absence of a gown during the procedure was noted. The facility's policy on EBP, which requires the use of gowns and gloves during high-contact resident care activities, was not followed in this instance. Interviews with staff revealed a lack of clarity and understanding regarding the requirements for PPE during catheter care. The Registered Nurse/Infection Preventionist was unsure if a gown was necessary, and the Director of Nursing (DON) confirmed that the facility's expectation was for a gown to be worn during all catheter care. The facility's policy and the CDC guidelines both emphasize the importance of using gowns and gloves to prevent the spread of multidrug-resistant organisms, especially for residents with indwelling medical devices.
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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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Nursing homes near Hull
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hegg Memorial Health Center | 7.2 mi | ★★★★★ | 4 | 0 |
| Crown Pointe Estates Care Center | 8.7 mi | ★★★★★ | 0 | 0 |
| Prairie Ridge Care Center | 13.1 mi | ★★★★★ | 0 | 0 |
| Good Samaritan - George | 13.4 mi | ★★★★★ | 19 | 0 |
| Sanford Senior Care Sheldon | 15 mi | ★★★★★ | 8 | 0 |
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