Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Pleasant View Care Center during CMS and state inspections, most recent first.
The facility did not consistently serve meals at safe and appetizing temperatures, with observations showing food items such as chicken and pasta being served below required temperatures and in poor condition. Several residents and family members reported that meals were often cold, dry, or overcooked, and staff interviews confirmed that proper reheating procedures were not followed, leading to unsatisfactory meal quality.
Surveyors observed unsanitary conditions in kitchen and dining areas, including food debris in refrigerators, buildup on equipment, and improper food handling by staff. Staff failed to perform hand hygiene after moving between clean and dirty areas, handled food containers inappropriately, and did not discard food dropped on the floor, all in violation of facility policy.
Staff did not follow the planned menu or provide correct portion sizes for pureed diets, resulting in some residents not receiving all required menu items or full servings during meal service. Staff interviews confirmed that insufficient preparation and omissions occurred, and facility leadership acknowledged that menu and portion expectations were not met.
The facility did not maintain food at safe temperatures, with milk served at 44.4°F and lunch items like Salisbury steak and pureed green beans below the required 135°F. A Dietary Aide and the Administrator acknowledged the temperature discrepancies, which violated the facility's policy.
The facility failed to maintain sanitary practices in the kitchen and during meal service. Staff improperly handled food and utensils without cleaning or performing hand hygiene, contrary to the facility's policy. The kitchen was found in unsanitary conditions, with food debris and mold present. Staff shortages contributed to the lack of cleanliness, and cleaning logs were unavailable.
A facility failed to protect resident information when a CMA left a laptop open with EHR data of 10 residents visible and a paper with a resident's narcotic medication time exposed. The CMA was normally assigned different duties. The facility's policy requires securing PHI, as confirmed by the DON.
The facility failed to maintain the dignity of two residents during meal service. A resident was seated at a table labeled as the 'feeder table' by an LPN, and another resident was transported with their briefs and thigh exposed. Staff acknowledged the need for better coverage and language use. The residents had conditions requiring full assistance with ADLs.
The facility failed to serve correct portions and therapeutic diets to residents. A resident on a pureed diet received an incorrect portion of scalloped potatoes due to staff oversight. Additionally, two residents on renal diets did not receive the prescribed parsley noodles, as they were not prepared. The facility's policy requires adherence to physician-ordered diets, which was not followed.
The facility failed to maintain proper infection control practices, as an RN did not perform hand hygiene during medication administration for two residents, and a CNA improperly transported soiled linen. The RN was unclear about hand hygiene protocols, and the CNA did not follow the facility's policy of placing soiled linen in a bag before transport.
The facility failed to develop comprehensive Care Plans to address the side effects of opioid and antidepressant medications for a resident with heart failure, hypertension, and Non-Alzheimer's Dementia. The Care Plan did not include information regarding the side effects of escitalopram and hydrocodone-acetaminophen, despite the facility's policy requiring such details.
A resident with a history of falls and impaired mobility fell in the shower room after a CNA attempted to transfer her without using a gait belt, resulting in a bruise on her right hand. Multiple staff members confirmed the incident, and the DON acknowledged the failure to follow protocol.
The facility failed to ensure proper infection control practices for two residents. An LPN and two CNAs did not change gloves or wash hands between tasks while providing wound and incontinence care, compromising infection control protocols.
Failure to Serve Palatable and Safe Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink were served at safe, palatable, and appetizing temperatures for several residents. Observations during meal service revealed that food items, such as lemon chicken and garlic parmesan pasta, were served below the expected temperature, with the chicken measuring as low as 117.7°F and the pasta at 98.8°F after tray delivery. The chicken was also observed to be dry, burnt, and difficult to cut, and the pasta was mushy. Staff interviews confirmed that the food did not reach the required temperatures, and the normal reheating process was not followed, as food was placed directly on the hot cart instead of being returned to the oven. Multiple residents and their family members reported dissatisfaction with the food quality and temperature. One resident consistently described the food as cold and dry, while another stated that meals were not always hot and expressed a preference for warmer food. A family member of a resident dependent on renal dialysis reported that the food was often dry, difficult to eat, and that vegetables were overcooked. Another resident's spouse noted inconsistency in food temperature, with meals sometimes arriving hot and other times not. Staff observations and interviews further highlighted procedural lapses, such as food being left on the counter before being placed on room tray carts and difficulties in maintaining appropriate temperatures on the steam table. The Certified Dietary Manager and dietary staff acknowledged that food was not reheated as required and that the chicken appeared dry and tough. The administrator confirmed that the meal service was delayed, and the food was not handled according to standard procedures, resulting in suboptimal food temperatures and quality for residents.
Failure to Maintain Sanitary Food Preparation and Handling Practices
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen and food preparation areas, as evidenced by multiple observations of unclean equipment and improper food handling practices. During an initial walkthrough, surveyors found dried liquid and scattered food debris in refrigerators and freezers in the east dining room kitchenette, as well as white crust lime buildup on the ice machine, coffee machine, and dishwasher in another dining area. Drawers containing utensils and cupboards with small appliances were also found with food debris and dried liquid. The main kitchen refrigerator was similarly observed to have food debris. During meal service, staff were observed engaging in unsanitary practices. One staff member, after pureeing pasta, entered the dirty side of the kitchen, touched the dishwasher handle and dish carts, and then returned to the clean side without performing hand hygiene. The same staff member dropped a covered pan of pasta on the floor, picked it up, and placed it over an open rack of garlic bread in the oven. Another dietary aide was seen making a salad, stacking containers of vegetables and ham in her arms, and using her face to steady the stack, while a different aide plated food, served it to residents, and returned to the kitchen without hand hygiene. Interviews with staff confirmed awareness of proper procedures, such as the need for handwashing after moving between clean and dirty areas and discarding food dropped on the floor, but these procedures were not followed during the observed incidents. The facility's own policies require kitchen cleanliness, proper food storage, and strict hand hygiene, as well as discarding any food that comes into contact with the floor, but these standards were not met during the survey period.
Failure to Follow Planned Menu and Portion Sizes for Pureed Diets
Penalty
Summary
Facility staff failed to follow the planned menu for residents requiring pureed diets during meal preparation and service. Observations showed that staff did not use the correct number of servings or portion sizes as indicated on the menu and by facility policy. Specifically, during the preparation of pureed lemon chicken, only one piece of garlic bread was used to thicken four servings of chicken, instead of the required four pieces. Staff also did not prepare enough pureed chicken to provide the full portions for each resident, and the correct scoop sizes were not consistently used during service. Staff interviews confirmed that these deviations occurred due to time constraints and oversight. During meal service, residents on pureed diets did not consistently receive all menu items. For example, one resident did not receive the full portion of pureed meat, and nine trays were served without garlic bread. Staff acknowledged that the omission of garlic bread and insufficient portions of pureed meat were due to forgetting and running out of prepared food. The dietary aide relied on the extended menu but did not ensure all items were served as planned, and the cook did not prepare enough pureed food to meet the menu requirements. The Certified Dietary Manager and Administrator both confirmed that the facility's expectation was for staff to follow the menu completely, including serving the correct portions and all menu items to residents on pureed diets. Facility policy required therapeutic diets to be individualized and to coincide with the menu extensions, but these standards were not met during the observed meal service. The deficiency was identified through review of menus, observations, staff interviews, and policy review.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at safe and appetizing temperatures, as observed during a survey. On August 13, 2024, a Dietary Aide was seen pouring milk for a resident from a jug that was at 44.4 degrees Fahrenheit, exceeding the facility's policy requirement for cold foods to stay below 41 degrees Fahrenheit. On August 14, 2024, a temperature check of lunch items revealed that the Salisbury steak was at 128 degrees Fahrenheit and the pureed Salisbury steak was at 115 degrees Fahrenheit, both below the required 135 degrees Fahrenheit for hot foods. The pureed green beans were at 134.5 degrees Fahrenheit, also below the required temperature. The facility's policy, dated 2021, mandates that temperatures should be periodically checked to ensure compliance with these standards. The Administrator confirmed that staff should adhere to these temperature guidelines.
Sanitation Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen and during meal service, as observed by surveyors. Staff C, a Dietary Aide, improperly handled food by using the same tongs to remove aluminum foil, plate sandwiches, and pour stew, without cleaning the tongs between uses. Staff D, an Activities Assistant, picked up a cup from the floor with bare hands and handled utensils without performing hand hygiene. Staff F did not change gloves or perform hand hygiene while preparing a resident's meal. Staff E, a cook, used a disher to scoop pureed food into steam pans without cleaning it between uses. These actions were contrary to the facility's General Food Preparation and Handling policy, which requires the use of clean utensils to avoid manual contact with prepared foods. Additionally, the initial kitchen walkthrough revealed unsanitary conditions, including a thick layer of grease and food debris on the shelf above the stove, food debris on a cart with clean dishes, and an accumulation of food debris and dried liquids on the kitchen floor, walk-in fridge, and freezer. Mold was found around the caulk and wall in front of the dishwashing sink. Staff A, the Head, admitted to not having mopped or swept the previous day due to staff shortages and was unable to provide cleaning logs. The facility's policy requires the kitchen to be kept neat and orderly, with surfaces and equipment cleaned and sanitized as appropriate.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information from unauthorized access, as observed during a survey. On August 13, 2024, a Certified Medication Aide (CMA), identified as Staff H, left a laptop open with Electronic Health Record (EHR) information of 10 residents visible while attending to a resident in her room. Additionally, a sheet of paper with a resident's narcotic medication administration time was left exposed. Staff H mentioned that she was usually assigned different duties. The facility's policy, effective since November 28, 2016, mandates the protection of Protected Health Information (PHI) in compliance with applicable laws and regulations. On August 15, 2024, the Director of Nursing (DON) confirmed that staff are expected to secure EHR medical records when leaving the cart unattended.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to uphold the dignity of two residents during meal service. One resident, who was seated at a table referred to as the 'feeder table' by a Licensed Practical Nurse (LPN), was not addressed by name. This resident had a history of cerebral palsy, epilepsy, autistic disorder, and was wheelchair-dependent, with a Minimum Data Set (MDS) indicating they were rarely or never understood but had adequate hearing. The use of the term 'feeder table' was noted as inappropriate and not in line with maintaining resident dignity. Another resident was observed being transported to the dining area with their briefs and upper left thigh exposed, as their pants were cut for comfort by a family member. The resident had a BIMS score indicating moderately impaired cognition and required assistance with all Activities of Daily Living (ADLs). Staff acknowledged that they should have used a pad or sheet to cover the resident to maintain dignity, as they had access to such items. The Director of Nursing (DON) confirmed that staff should be mindful of their language and ensure residents are covered appropriately.
Failure to Serve Correct Portions and Therapeutic Diets
Penalty
Summary
The facility failed to serve the appropriate portions and therapeutic diets to residents, as observed during a survey. Specifically, a resident on a pureed diet was served an incorrect portion of pureed scalloped potatoes. The cook, Staff E, prepared the pureed scalloped potatoes using a blender and referenced a pureed disher conversion chart, which directed the use of a #6 (5 1/3 oz) disher and a #8 (4 oz) disher. However, during lunch service, Staff G, a Dietary Aide, only used the #6 disher to plate the pureed scalloped potatoes, forgetting to use the #8 disher as required. This resulted in the resident receiving an incorrect portion size. Additionally, the facility failed to provide the correct therapeutic diet for two residents who were ordered renal diets. The menu review indicated that residents on renal diets should receive 4 oz of parsley noodles, but Staff E admitted to not preparing parsley noodles for the lunch service, citing it as an oversight. The facility's policy, as outlined in a document titled 'Therapeutic Diets' dated 2021, mandates that diets be offered as ordered by the physician or designee. The administrator confirmed that staff should adhere to the scoop diagram and menu items, which was not followed in these instances.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration for two residents. On one occasion, a Registered Nurse (RN) assisted a resident with drinking water during medication administration and then proceeded to handle the medication cart and other items without performing hand hygiene. The RN admitted to not washing her hands after the medication pass and was unclear about the proper hand hygiene protocol. The facility's Medication Pass Policy and Quality Assurance Audit for Medication Pass both emphasized the importance of proper sanitation and hand hygiene, which were not adhered to in this instance. Additionally, the facility did not follow proper procedures for handling soiled linen. A Certified Nurse Aide (CNA) was observed carrying uncontained, soiled linen from a resident's room to the soiled utility room, allowing the linen to come into contact with his uniform and gait belt. The facility's Linen Handling policy required soiled linen to be placed in a plastic bag before transport, which was not followed. The Director of Nursing confirmed that staff should adhere to the policy for linen removal.
Failure to Address Medication Side Effects in Care Plan
Penalty
Summary
The facility failed to develop comprehensive Care Plans to address the side effects of opioid and antidepressant medications for one resident. Resident #13, who has diagnoses of heart failure, hypertension, and Non-Alzheimer's Dementia, was taking escitalopram for depression and hydrocodone-acetaminophen for pain. The Care Plan, revised on 2/10/24, did not include information regarding the side effects of these medications. This deficiency was identified through a clinical record review and staff interview, which confirmed that the side effects should have been listed on the Care Plan as per the facility's policy.
Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to ensure that residents were safe from accidents and hazards, specifically in the case of Resident #33. Resident #33, who had a history of falls, impaired mobility, and impaired cognition, fell in the shower room after a CNA attempted to transfer her from the shower chair to the wheelchair without using a gait belt. The resident sustained a bruise on her right hand as a result of the fall. The CNA admitted to not using a gait belt during the transfer, which is against the facility's protocol for transferring residents. The incident was corroborated by multiple staff members, including the DON and an RN, who confirmed that the resident was found on the wet shower floor, fully clothed and wearing gripper socks. The DON acknowledged that the CNA did not use a gait belt and stated that the CNA would be re-educated and disciplined. The facility's educational checklist clearly states that a gait belt should be used during transfers, which was not followed in this instance, leading to the resident's fall and injury.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to ensure that staff used adequate infection control practices to decrease the transmission of pathogens for two residents. Resident #34, who had multiple wounds requiring daily dressing changes, was observed being treated by an LPN who did not change gloves between different tasks and did not wash hands after completing the care. This resident had a history of urinary tract infections, renal insufficiency, and was at risk for developing pressure ulcers. The LPN applied betadine solution, wrapped the heels, and handled various items without changing gloves or washing hands, thereby compromising infection control protocols. Similarly, Resident #1, who required assistance with incontinence care and had a sore on her upper thigh, was attended to by two CNAs who also failed to follow proper hand hygiene practices. The CNAs did not change gloves between tasks and did not wash hands after completing the care. This resident had diagnoses including heart failure, anxiety disorder, schizophrenia, intellectual disabilities, and Down Syndrome. The CNAs handled the resident's brief, bedpan, and applied barrier cream to an open sore without changing gloves or washing hands, further breaching infection control standards.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Onawa | 6.7 mi | ★★★★★ | 0 | 0 |
| Carl T Curtis Health Education Center Nursing Home | 10.3 mi | ★★★★★ | 7 | 0 |
| Maple Heights | 18.2 mi | ★★★★★ | 17 | 0 |
| Pioneer Valley Living And Rehab | 21.3 mi | ★★★★★ | 7 | 0 |
| Embassy Rehab And Care Center | 21.3 mi | ★★★★★ | 9 | 0 |
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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.