Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Valley Manor Care Center during CMS and state inspections, most recent first.
A facility failed to ensure that three residents, or their representatives, were informed of the risks and benefits of psychotropic medications before use. Records showed psychotropic orders including antidepressants, antianxiety meds, a hypnotic, and an antipsychotic for residents with conditions such as dementia, depression, anxiety, and insomnia, but the charts lacked documentation of consent or discussion of risks and benefits. Staff interviews showed uncertainty about where consents were kept, while the DON and Administrator stated consents should be obtained before starting these meds.
The facility failed to reconcile and return resident funds within the expected timeframe after discharge for three residents, with credit balances remaining in the private pay account and no proof refunds had been made. The facility also failed to notify a resident when the account was within $200 of the SSI resources limit; staff said they were not aware of the exact limit and had not informed the resident or family so the account could be spent down.
Medication Administration Errors Exceeded Allowed Rate: Surveyors found a 16% medication error rate after observing four missed opportunities in 25 medication passes. Two residents were affected: one resident’s Psyllium Husk Powder was mixed with less liquid than ordered, and another resident’s MiraLAX and Psyllium Husk Powder were mixed with incorrect amounts of water while Amantadine was not given because it was not available due to prior authorization issues. The DON stated the medications should have been mixed with at least 120 ml of liquid and available when due.
Expired and discontinued medications, along with loose pills, were found in a medication cart during observation. An opened inhaler for one resident was past the discard timeframe, another resident's Lisinopril was expired, a deceased resident's doxycycline remained in the cart, and a discontinued Lactase package was also present. An LPN stated expired meds should not be used and there should not be loose pills or medication packages wedged behind the cart drawer.
Improper Food Storage and Labeling: Surveyors found expired items in the dry storeroom and multiple unlabeled or undated leftovers in the refrigerator, including pancakes, a yellow liquid mixture, and shredded cheese. A dietary staff member also re-dated a container of sour cream after it had already been opened and used, contrary to facility policy and stated food storage practices.
Failure to offer an appropriate meal substitute: A resident with severe cognitive impairment, DM, HTN, CAD, dementia, and depression refused the lunch entrée and sides, but staff did not present the available substitute choices or ask what the resident wanted. Instead, a CMT brought a PB&J sandwich, which the resident only partially ate and then spit out. The DM and Administrator stated the sandwich was not a suitable nutritional substitute, and the resident said he or she would have chosen one of the listed options if offered.
Therapeutic diet orders were not followed for a resident on a mechanically soft diet with dysphagia and multiple chronic conditions. The resident was served a salmon patty that was not further altered and had no gravy or broth present, despite the meal card requiring all meats to be ground up with gravy or broth added. Dietary staff believed the patty was already mechanically separated, while the ADM and RD stated it needed to be served with gravy or broth for the ordered diet.
The facility failed to properly label, date, and dispose of expired food items in the kitchen, and did not sanitize thermometers between food temperature checks, risking foodborne illnesses for residents. Observations revealed opened cartons and packages with missing or outdated labels, and a Dietary Aide admitted to skipping thermometer sanitization due to a lack of supplies and time constraints.
The facility failed to ensure the proper functioning of a sit-to-stand lift for a resident, leading to safety concerns due to malfunctioning batteries. Additionally, two residents' rooms had unsealed air conditioning units allowing pest entry, and common areas like the shower room and laundry room were not maintained properly. The Director of Nursing and Maintenance Director were unaware of these issues, indicating a lack of communication and oversight.
A facility failed to coordinate care for a resident with end-stage renal disease requiring dialysis. The resident's care plan required dialysis and staff assessments, but the facility did not send or receive necessary information to and from the dialysis center. Interviews confirmed the absence of policies for sharing clinical information, placing the resident at risk for inadequate care.
The facility failed to conduct annual performance reviews and track 12 hours of in-service training for two CNAs. The facility's policy requires regular in-service training and annual performance reviews, but records showed lapses in both areas. The DON acknowledged not tracking training hours and being behind on performance reviews.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three sampled residents reviewed for unnecessary medications, or their representatives, were informed of the risks and benefits of psychotropic medications before those medications were started. The facility policy for Psychotropic Medications stated that residents, families, and/or representatives would be informed of the risks and benefits of these medications. For Resident #1, the record showed diagnoses including anemia, congestive heart failure, renal insufficiency, malnutrition, and COPD, with intact cognitive skills and no behaviors on the quarterly MDS, yet the chart contained no documentation that the resident or representative was informed of the risks or benefits of trazodone before it was started for insomnia. The resident’s care plan also identified use of trazodone for depression and alprazolam for adjustment issues. For Resident #34, the quarterly MDS showed severe cognitive impairment and diagnoses of coronary artery disease, kidney disease, and depression, and the resident was prescribed psychotropic medications including clonazepam for anxiety and insomnia and escitalopram for anxiety, but the medical record had no documentation of informed consent for psychotropic use. For Resident #2, the care plan identified dementia with anxiety and use of olanzapine for mood management and trazodone for agitation, and the physician order sheet showed trazodone and olanzapine orders, but the record did not contain a signed psychotropic consent form from the DPOA before use. During interviews, an LPN said staff thought consents were obtained but did not know where they were kept or who completed them, while the DON and Administrator stated consents should exist and be obtained before psychotropic medications were started, with risks and benefits discussed and documented.
Resident Funds Not Reconciled After Discharge and SSI Limit Notice Not Provided
Penalty
Summary
The facility failed to provide personal funds and a final accounting within 30 days after discharge for three residents. Review of the accounts receivable aging report showed that Resident #68, Resident #69, and Resident #70 each had credit balances remaining in the facility’s private pay account after discharge, with balances of $4,422.14, $4,981.98, and $2,923.04, respectively. During interview, the Business Office Manager stated the facility had changed accounting software and lost old payment data, so it could not prove refunds had been made to these residents. She also stated she was working on refunds with the corporate office and that the expectation from her office was to reconcile all resident accounts within 30 days of discharge. The Administrator stated accounts should be reconciled within two to three months, but that two or three years would be an unacceptable timeline for reimbursement. The facility also failed to notify Resident #21 when the resident was within $200 of the SSI resources limit. Review of the resident fund account balance showed Resident #21 had $8,276.82 in the resident account, which exceeded the SSI resources limit of $6,068.80, and there was no documentation that notice had been sent when the balance was near the limit. During interview, the Social Services Designee stated she was not aware of the exact SSI resources limit and that the facility had not informed Resident #21 or the immediate family that the resident was within $200 of the limit so the account could be spent down.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained under five percent, with surveyors identifying four missed opportunities out of 25 observed medication administrations for a 16% error rate. The census was 62 residents. The facility’s medication administration policy stated that residents are to receive medications on a timely basis and in accordance with physician orders, and that orders are to be followed exactly as written. For Resident #32, the physician order for Psyllium Husk Powder directed that 17 grams be mixed in 8 ounces of liquid in the morning, but during observation the CMT mixed the medication with less than 5 ounces of water in a cup marked as a 5-ounce cup. For Resident #44, the POS included orders for MiraLAX 17 grams daily, Psyllium Husk Powder 2 scoops daily, and Amantadine HCL 100 mg daily. During observation, the LPN mixed MiraLAX and Psyllium Husk Powder with amounts of water that did not match the label directions, and the Amantadine was not administered because the resident did not have it due to waiting for prior authorization. The MAR showed the Amantadine was not administered on 9/1, 9/2, or 9/3, and the DON stated the medications should be mixed with at least 120 ml of liquid and should be available for staff to pass when due.
Expired and Discontinued Medications Found in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles because expired and discontinued medications were found in the medication cart, medication was wedged behind the drawer of the cart, and loose pills were present in the cart. During observation of the front hall medication cart, an opened Arnuity Ellipta inhaler for Resident #33 was found with a fill date of 10/30/24 and a label instructing it to be discarded six weeks after opening. Two loose pills were also found wedged behind the bottom drawer of the cart, along with Resident #20's Lisinopril package with four pills left and expired, Resident #71's doxycycline package with two pills left even though the resident was deceased, and Resident #56's Lactase package with 13 tablets left even though the medication had been discontinued. During interview, the LPN stated that the DON and ADON check medication carts for expired medications, that expired medications should not be used and should be discarded, and that inhalers should be dated when opened and labeled for the correct resident. The LPN also stated there should not be loose pills or medication packages wedged behind the drawer of the medication cart. The DON later stated that nurses are responsible for cleaning the medication carts and medication room and ensuring there are no expired medications, and that there should not be any medication packages or loose pills wedged behind the drawer of the medication cart.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety when surveyors observed expired food items and improperly handled food in the kitchen. In the dry storeroom, surveyors found 2 containers of thickened iced tea that had expired, and later observed strawberry fountain syrup that had been opened and resealed without an open date. In the refrigerator, surveyors found undated leftover pancakes, an undated leftover yellow liquid mixture with no label, and undated leftover shredded cheese left open. Record review showed the facility’s policies required dry foods removed from original packaging to be labeled and dated, refrigerated foods to be covered, labeled, and dated, and leftovers to be stored with the item name, date prepared, and use-by date. During observation, a dietary staff member re-opened a container of refrigerated sour cream and placed a date on it after using it, despite not knowing when it had originally been opened. Interviews with the Dietary Manager, Administrator, and Registered Dietician confirmed that expired items should be discarded immediately and leftovers should be labeled with the product name, preparation date, and use-by date.
Failure to Offer an Appropriate Meal Substitute
Penalty
Summary
The facility failed to provide an alternative appealing option of similar nutritive value to a resident who refused the meal being served. The facility policy on Resident Food Preferences stated that the food services department would offer a variety of foods at each scheduled meal and substitutions with the same nutritive value. A meal substitute list for lunch included hot dogs, chicken noodle soup, cheese puffs, ice cream, side salad, diced pears, yogurt, or chips. The resident involved had severe cognitive impairment, moderate hearing difficulty, clear speech, was usually understood and usually understood communications, and was independent in eating. Diagnoses included coronary artery disease, hypertension, diabetes, dementia, and depression. During lunch in the dining room, the resident ate only cherry cheesecake and did not eat the cheeseburger macaroni casserole, vegetables, or dinner roll. A CMT encouraged the resident to eat, was told the resident did not like the meal, and offered to get a substitute without asking what the resident wanted or providing the available choices. The CMT returned with a peanut butter and jelly sandwich on white bread, which the resident took two bites of and then spit out. The resident later stated that no specific substitute options were offered and that he or she would have chosen one of the listed substitutes if informed. The DM stated that a peanut butter and jelly sandwich was not a suitable nutritional substitute for a lunch meal, and the Administrator stated the same.
Therapeutic Diet Not Followed for Mechanically Soft Meal
Penalty
Summary
The facility failed to ensure a prescribed therapeutic diet was followed for one resident with a mechanically altered diet order. Resident #1 was cognitively intact, dependent on staff for set-up assistance with eating, and had diagnoses including heart failure, kidney disease, diabetes, anxiety disorder, and dysphagia. The resident’s records showed a mechanically altered/mechanical soft diet order, and the meal card specified that all meats were to be ground up with gravy or broth added. During interview, the resident stated the main courses were supposed to be ground up but were not usually prepared that way, making it hard to eat. During lunch observation, the resident was served a salmon patty that was unaltered from its original form and there was no gravy present on the plate or in the bowl. The resident stated this happened all the time and that the salmon could cause choking because it was not prepared properly. Dietary staff stated the salmon patty was already mechanically separated and believed gravy on the side was sufficient, while the Administrator stated the salmon patty needed to be separated and served with gravy or broth for a mechanically soft diet. The RD later stated that a salmon patty cooked and removed from the oven should have gravy or broth on the side or on the entree to be served properly for a mechanically soft diet.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper food storage and handling practices in the main kitchen, which could potentially lead to foodborne illnesses and infections for all 60 residents. During an observation, several food items in the reach-in refrigerators were found to be improperly labeled and dated. Specifically, opened cartons of almond milk, thickened lemon water, orange juice, and iced tea were either missing open dates or had exceeded the manufacturer's recommended usage period. Additionally, an opened package of deli ham was found with a use-by date that had already passed. These observations were verified by a Dietary Aide during the kitchen tour. Furthermore, during a tray line observation, the Dietary Aide was seen taking food temperatures without sanitizing the thermometer before use and between each food item tested. The aide admitted to usually sanitizing the thermometer but had run out of alcohol swabs and was in a hurry. An interview with the Dietary Manager revealed a lack of awareness regarding the need to check manufacturer's instructions for expiration dates. These lapses in food safety protocols highlight the facility's failure to adhere to its own policies on handling leftover foods and monitoring food temperatures.
Facility Fails to Maintain Equipment and Environment
Penalty
Summary
The facility failed to ensure the proper functioning of a sit-to-stand mechanical lift for a resident who was dependent on staff for transfers. The resident, who was cognitively intact and had a history of neuralgia, neuritis, and repeated falls, reported feeling unsafe due to the lift's malfunctioning batteries. Staff interviews confirmed that the batteries frequently ran out during use, requiring staff to fetch replacements, which was not always done promptly. The Director of Nursing was unaware of the issue, indicating a lack of communication and oversight regarding equipment maintenance. Additionally, the facility did not maintain a safe and clean environment in several areas. Two residents' rooms had air conditioning units with unsealed gaps, allowing pests to enter. The Maintenance Director and Housekeeping Supervisor confirmed the presence of flies and damaged window screens, which had not been addressed. The Maintenance Director was unaware of these issues, suggesting a lapse in regular maintenance checks. The facility also failed to maintain cleanliness and safety in common areas. The northeast shower room had a soiled privacy curtain and an electrical outlet falling out of the wall. The laundry room floor was in poor condition, with exposed concrete and minimal tiling. These observations were confirmed by the Housekeeping Supervisor, who acknowledged the need for repairs. The facility administrator was not aware of these environmental deficiencies, indicating a lack of oversight in facility management.
Failure to Coordinate Dialysis Care for a Resident
Penalty
Summary
The facility failed to coordinate care for a resident with end-stage renal disease who required dialysis services. The resident, identified as R32, was admitted with a diagnosis of end-stage renal disease and was severely cognitively impaired, as indicated by a BIMS score of five out of 15. The resident's care plan, updated after a hospital return, noted the need for dialysis and required staff to assess the thrill and bruit each shift. However, the facility did not prepare or send necessary information to the dialysis center, nor did they receive any documentation back from the center after treatments. Interviews with facility staff, including a Certified Medication Technician and the Director of Nursing, confirmed the lack of communication and documentation exchange between the facility and the dialysis provider. The facility did not have policies or procedures in place to ensure the ongoing care of the resident by the dialysis center, including the sharing of clinical information, physician orders, and the resident's response to treatment. This lack of coordination and documentation placed the resident at risk for inadequate or inappropriate care.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to ensure that two of three Certified Nursing Assistants (CNAs) reviewed had received their annual performance reviews and the required 12 hours of in-service training for the last year. The facility's policy mandates that all nurse aide personnel participate in regularly scheduled in-service training classes and that performance reviews are completed at least every 12 months. However, the review of CNA1's employee file showed no performance review for over 13 months, and their in-service training hours were not tracked. Similarly, CNA2's file indicated the last performance review was over 13 months ago, and their training hours were also not tracked. During an interview, the Director of Nursing (DON) admitted to not tracking the training hours and being behind on completing performance reviews.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 756 citations issued within 25 miles in the last 12 months — including the 16 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon View Health And Wellness | 2.9 mi | ★★★★★ | 10 | 0 |
| Ignite Medical Resort Kansas City, Llc | 3.1 mi | ★★★★★ | 11 | 0 |
| Linden Woods Village | 3.6 mi | ★★★★★ | 0 | 0 |
| Northland Rehabilitation & Health Care Center | 4.6 mi | ★★★★★ | 2 | 0 |
| Norterre | 5.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pleasant Valley Manor Care Center.
100% money-back within 48 hours.
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.