Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Nursing Home during CMS and state inspections, most recent first.
The facility failed to treat residents with dignity during meal service by standing while feeding residents and not serving all residents at the same table simultaneously. This caused frustration and discomfort among the residents, as confirmed by observations and interviews with staff and residents.
The facility failed to maintain a clean and homelike environment, with issues such as missing trim, damaged drywall, a broken medication cart, dusty medical equipment, and peeling drywall. These deficiencies were confirmed through staff interviews and affected residents with specific medical needs.
The facility failed to check the CNA Registry and conduct required background checks for five of six sampled staff members, including an RN, a cook, a nurse aide, a maintenance supervisor, and a care partner. The Business Office Manager admitted to not checking the CNA Registry for non-nursing employees, and the Director of Nursing and the Administrator were unaware of the requirement to check the CNA Registry for all employees.
The facility failed to provide written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. This affected three residents, who were transferred to the hospital or emergency room without the necessary documentation. Staff interviews revealed inconsistencies in filling out transfer forms and notifying the Ombudsman.
The facility failed to complete a Level I PASARR for two residents with mental disorders, including Alzheimer's Disease, schizoaffective disorder, dementia, depression, and schizophrenia. The required documentation was missing from their medical records, despite confirmation from the DON and Administrator that PASARRs should be completed upon admission.
The facility failed to develop and implement comprehensive care plans for five residents, neglecting to address hospice care, pressure ulcers, oxygen and CPAP usage, and the use of cane rails. These deficiencies were identified through observations, interviews, and record reviews.
The facility failed to follow professional standards of care for four residents by not obtaining necessary physician's orders for blood sugar monitoring and CPAP machine use, and by not adhering to timing guidelines for blood sugar checks before meals.
The facility staff failed to ensure dependent residents received necessary services to maintain good personal hygiene. One resident had unaddressed chin whiskers and partially removed fingernail polish, while another had uncombed hair and facial hair. Staff interviews revealed inconsistencies in shaving and nail care practices, with reliance on Hospice for these services. The facility's policies were found to be inadequate in specifying the frequency of these activities or addressing resident preferences.
The facility failed to assess residents for entrapment risk and ensure bed dimensions were appropriate before installing bed rails. Two residents had bed rails installed without proper assessments or physician's orders, and staff interviews revealed a lack of understanding and adherence to procedures. Observations confirmed the improper installation of bed rails, putting residents at risk.
The facility had a 20% medication error rate, affecting four residents. Errors included improper administration of eye drops, incorrect handling of Lidocaine patches, crushing a non-crushable medication, and failing to instruct a resident to swish and spit after using an inhaler.
The facility failed to store medications securely, leaving them unattended on dining tables for residents without proper supervision or orders for self-administration. Additionally, opened vials and insulin pens were not properly dated, violating facility policies.
The facility failed to ensure that food and drink served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot and cold foods were not served at appropriate temperatures, and pureed foods were not made to the proper consistency. These issues affected three residents, who reported dissatisfaction with the food temperature and consistency.
The facility failed to store, prepare, and serve food according to professional standards, with multiple areas of the kitchen not cleaned properly, expired and undated food items, and inadequate hand hygiene and sanitation practices among dietary staff. Observations and interviews revealed inconsistent cleaning routines, improper food labeling, and a lack of adherence to hand hygiene protocols.
The facility failed to assist a resident in maintaining hydration status by not providing water in the resident's room, despite the care plan indicating the need for a water jug at all times. Observations and interviews revealed that the resident often felt extremely thirsty and had dry, scaly skin and chapped lips. Staff confirmed the resident was not on fluid restriction, but water was not consistently available.
The facility failed to ensure the Dietary Manager had the appropriate competencies and skills, as the DM lacked certification and completed training. The facility relied on a consulting dietician who visited monthly and regional support quarterly, leading to a deficiency in managing dietary services with qualified personnel.
The facility failed to follow infection control standards for catheter care when a resident's urinary catheter drainage bag was observed touching the floor and hooked on a trash can. Staff interviews confirmed that the drainage bag should not be in contact with the floor or contaminated surfaces.
Failure to Treat Residents with Dignity During Meal Service
Penalty
Summary
The facility failed to treat residents with dignity and respect during meal service. Specifically, staff members were observed standing while feeding residents who required assistance, which is against the facility's policy of treating residents with dignity. This was observed with two residents who required substantial assistance with eating due to their medical conditions, including Guillain-Barre syndrome and stroke. The Administrator and Activity Director were both seen standing while feeding these residents, which they later acknowledged was inappropriate behavior. Additionally, the facility did not serve meals to all residents at the same table simultaneously, causing frustration and discomfort among the residents. Multiple residents expressed dissatisfaction with the meal service process, noting that it was uncomfortable to watch their tablemates eat while they waited for their own meals. Observations confirmed that residents at the same table were served at different times, sometimes with significant delays between servings. Interviews with staff members, including the Dietary Aide and Dietary Manager, revealed inconsistencies in the meal service process. The Dietary Aide admitted to not serving all residents at one table at the same time and tried to make it fair by serving those who had been in the dining room the longest. The Dietary Manager acknowledged that residents at the same table should be served together but cited challenges in monitoring when residents arrived in the dining room. The Administrator and Director of Nursing also confirmed that they would expect all residents at the same table to receive their meals simultaneously.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable homelike environment, as evidenced by several observations and interviews. The nurses' station had missing trim and damaged drywall, and the medication cart was in disrepair with black duct tape holding it together. Additionally, a pillar near the dining room entrance had significant paint gouges, and the chair at the nurses' station was heavily worn with missing leather. Resident #22's oxygen concentrator and CPAP machine were found to be dusty, and Resident #200's room had a peeling drywall seam on the ceiling. Room [ROOM NUMBER] A had scuff marks and gouges on the wall with missing paint and exposed plaster. These deficiencies were confirmed through staff interviews, where it was acknowledged that the medication cart and chair were in poor condition and that the walls and ceiling should not have been in disrepair. Resident #22, who had moderate intact cognition and was on oxygen therapy for sleep apnea, was directly affected by the unclean oxygen concentrator and CPAP machine. Resident #200, who had multiple diagnoses including Guillain-Barre Syndrome, strokes, and cognitive communication deficit, was admitted to the facility recently and was found to have a peeling drywall seam in their room. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the various areas of disrepair and lack of cleanliness observed during the survey.
Failure to Conduct Required Background Checks and CNA Registry Verification
Penalty
Summary
The facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator, which is a marker given by the federal government to individuals who have committed abuse or neglect. This deficiency affected five of six sampled staff members, including an RN, a cook, a nurse aide, a maintenance supervisor, and a care partner. The facility's policy, dated January 2017, mandates that the CNA Registry and other background checks be conducted prior to hiring any staff. However, the review of employee files showed that these checks were not performed for the sampled staff members, and the Business Office Manager admitted to not checking the CNA Registry for non-nursing employees. Additionally, the Director of Nursing and the Administrator were unaware of the requirement to check the CNA Registry for all employees, not just nursing staff. During interviews, the Business Office Manager mentioned that the facility no longer maintained hard copy personnel files on-site and that all documents were uploaded into an online system. This system may have overwritten some records, leading to missing background checks for some employees. The Administrator confirmed that background checks should be completed before hiring but was unsure if the CNA Registry should be checked for all employees. This lack of adherence to the facility's policy and the failure to conduct necessary background checks resulted in the deficiency noted by the surveyors.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. This deficiency affected three residents. For Resident #2, there was no documentation of a bed-hold letter or a letter explaining the reason for the transfer to the hospital for surgery. The resident had intact cognitive skills and required assistance with daily activities, with diagnoses including diabetes mellitus, breast cancer, depression, and an abscess of the left great toe. For Resident #39, the facility did not document a bed-hold letter or a letter explaining the reason for the transfer to the emergency room after the resident experienced facial burning, itching, and swelling. The resident had moderately impaired cognitive skills and was independent with toilet use, personal hygiene, and transfers, with diagnoses including dementia, anxiety, and depression. Interviews with staff revealed that transfer forms were not consistently filled out with the resident's appeal rights, and the Ombudsman was not notified of transfers and discharges. Resident #46, who was severely cognitively impaired and had diagnoses including weakness, Parkinson's disease, disorientation, dependence on renal dialysis, and diabetes, was sent to the emergency room without the necessary transfer paperwork. The LPN only sent a copy of the resident's medication list, diagnosis, allergies, and code status. The facility did not have a policy for transfers, discharges, or notifying the Ombudsman, and the Administrator was unaware of the requirement to notify the Ombudsman monthly of transfers and discharges.
Failure to Complete PASARR for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure staff completed a Level I Preadmission Screen and Resident Review (PASARR) for two residents, which is a federal requirement to evaluate individuals for possible mental disorders or intellectual disabilities. Resident #33, who was admitted on 8/17/22, had diagnoses including Alzheimer's Disease and schizoaffective disorder but did not have a Level I PASARR in their medical record. The resident's care plan indicated behaviors of paranoia and required reassurance, and the Quarterly Minimum Data Set (MDS) showed severe cognitive impairment. The Social Services Designee confirmed the absence of the PASARR in the resident's medical record during an interview on 4/8/24. Similarly, Resident #22, who had diagnoses including dementia, depression, and schizophrenia, also did not have a PASARR available in their medical record. The resident's care plan, dated 1/31/24, indicated mental health and behavioral needs, and the Quarterly MDS showed moderate intact cognition with hallucinations and delusions. The Director of Nursing (DON) and the Administrator both confirmed that PASARRs should be completed upon admission and available in all residents' medical records, but the required documentation was missing for these two residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for five of twelve sampled residents. Specifically, the care plans did not address hospice care for one resident, pressure ulcers for another, and the use of oxygen and a CPAP machine for a third resident. Additionally, the care plans did not include the use of cane rails for two residents. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors. Resident #3, who was admitted with hospice services, did not have hospice care addressed in their care plan. The resident confirmed that hospice provided showers and catheter changes, but this was not reflected in the care plan. Similarly, Resident #6, who had a pressure ulcer, did not have this condition addressed in their care plan despite physician orders for wound care and the resident's own acknowledgment of the sore. The MDS Coordinator and the Director of Nursing both confirmed that pressure ulcers should be included in the care plan. Resident #22, who required oxygen therapy and used a CPAP machine, did not have these needs addressed in their care plan. The resident confirmed the use of these devices, and observations corroborated their presence. Additionally, Residents #34 and #39, who used cane rails for mobility, did not have this equipment included in their care plans. The MDS Coordinator, Director of Nursing, and Administrator all acknowledged that these elements should have been included in the care plans.
Failure to Follow Professional Standards of Care
Penalty
Summary
The facility failed to ensure staff followed professional standards of care for four of 12 sampled residents. For Resident #46, the staff administered insulin without checking blood sugar levels due to the absence of a physician's order for blood sugar monitoring. The Licensed Practical Nurse (LPN) used nursing judgment to administer insulin, despite the resident having severe cognitive impairment and multiple diagnoses, including diabetes. The facility's Director of Nursing (DON) and Administrator acknowledged that an order for blood sugar checks should have been obtained when insulin was prescribed. For Resident #22, the facility did not have physician's orders for the use of a Continuous Positive Airway Pressure (CPAP) machine or for changing the oxygen tubing. The resident, who had intact cognition and was on oxygen therapy, reported that the oxygen tubing was changed monthly instead of weekly. The Administrator confirmed that physician's orders should include instructions for changing oxygen tubing and filters for CPAP machines. Residents #18 and #35 had orders for blood sugar checks before meals, but staff did not consistently follow the timing guidelines. Blood sugars were obtained too close to mealtime, contrary to the facility's policy that blood sugars should be checked 30 minutes to an hour before meals. The Administrator and DON confirmed that staff should adhere to the timing guidelines for blood sugar checks to ensure proper insulin administration and resident safety.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility staff failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, staff did not ensure nail care was completed for one resident and shaving was completed for two residents. The facility's policies on nail care and shaving were found to be inadequate, as they did not specify the frequency of these activities or address specific resident preferences. Observations and interviews revealed that Resident #33 had 1/4 inch chin whiskers and partially removed fingernail polish, which the resident expressed dissatisfaction with. Despite the resident's requests, these issues were not addressed in a timely manner. Similarly, Resident #3 had uncombed hair and facial hair, and the resident could not recall the last time they were shaved. The resident expressed a desire to be shaved, but this was not done promptly. Interviews with staff indicated that shaving was typically done on shower days, and there was reliance on Hospice for nail care and shaving, which did not occur frequently enough to meet the residents' needs. The Administrator and Director of Nursing acknowledged that residents should be shaved if they do not like chin whiskers and that staff should talk to the family for non-alert and oriented residents. However, the facility's current practices and policies were insufficient to ensure consistent and timely personal hygiene care for the residents.
Failure to Assess and Install Bed Rails Properly
Penalty
Summary
The facility staff failed to assess residents for the risk of entrapment from bed rails prior to their installation and did not ensure that the bed's dimensions were appropriate for the residents' size and weight. Additionally, the staff did not complete quarterly assessments or obtain a physician's order before installing bed rails for two residents. The facility also lacked a policy on entrapment assessments, which contributed to these deficiencies. Resident #22 had bilateral assist bars installed without a physician's order, and the only bed rail assessment found was signed months after the resident's admission. Resident #39's care plan did not address the use of cane rails, and no entrapment assessment was completed for this resident either. The only bed rail assessment for Resident #39 was completed months after the resident's admission. Interviews with facility staff revealed a lack of understanding and adherence to proper procedures for bed rail assessments and installations. The Maintenance Supervisor admitted to not knowing what entrapment assessments were and did not measure the mattresses to bed frames or look for gaps. The Director of Nursing did not think physician's orders were needed for cane rails and expected entrapment assessments to be completed with changes in side rails, beds, or mattresses. The Administrator also acknowledged that residents with side rails should probably have a physician's order and that therapy should complete side rail assessments and measurements. Observations confirmed that both residents had cane rails installed on their beds without proper assessments or physician's orders. Resident #22 expressed that the rails were for positioning, while Resident #39 mentioned using the rails very little. The facility's failure to follow its own policies and procedures for bed rail use and entrapment assessments led to these deficiencies, putting residents at risk of harm from improper bed rail installations.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure staff administered medications with a medication error rate of less than five percent. Observations, interviews, and record reviews revealed that staff made five medication errors out of 25 opportunities, resulting in a 20% error rate. This affected four residents. Specific deficiencies included improper administration of eye drops without applying lacrimal pressure, incorrect handling and application of Lidocaine patches, and crushing a medication that should not be crushed, leading to incomplete ingestion by the resident. For Resident #21, the LPN administered eye drops without applying lacrimal pressure and failed to follow proper procedures for removing and applying Lidocaine patches. The patch was not removed the previous night, and the area was not cleaned before applying a new patch. For Resident #33, the LPN also failed to apply lacrimal pressure after administering eye drops for glaucoma. The LPN admitted to not knowing the correct duration for applying lacrimal pressure. For Resident #27, the LPN crushed Metoprolol Tartrate, which should not be crushed, and mixed it with a drink, resulting in the resident not consuming the entire dose. For Resident #43, the LPN did not instruct the resident to swish and spit out water after using a Dulera inhaler, leading the resident to swallow the water instead. The facility's policies and procedures were not followed, and the staff lacked knowledge about proper medication administration techniques.
Medication Management Deficiencies
Penalty
Summary
The facility failed to store medications in a locked storage area, leaving medications in pill cups on dining tables for residents. This was observed with multiple residents, including one who had a cup of pills left in front of them at the dining room table and another who had six medications left in a pill cup while eating breakfast. These residents did not have orders for self-administration of medications, nor were there any assessments for self-administration in their medical records. Staff did not maintain observation of the medications, leaving them unattended and accessible to unauthorized individuals. Additionally, the facility failed to properly manage and label medications. An opened vial of tuberculin purified protein derivative was found without a date, and another vial was found with an expired date. An opened insulin pen was also found without a date. The facility's policy required that all refrigerated liquid medications be labeled with the date they were opened, but this was not followed. The Administrator and DON acknowledged that the medications should have been dated and discarded appropriately. The facility's failure to ensure medications were stored securely and properly labeled led to deficiencies in medication management. Staff interviews revealed that medications were sometimes left with residents without proper supervision, and there were no assessments or orders for self-administration. The facility's policies were not adhered to, resulting in medications being left unattended and improperly managed.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food and drink served to residents were palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot and cold foods were not served at appropriate temperatures, and pureed foods were not made to the proper consistency. Specifically, oatmeal was served cold, and other foods were often not warm when served. Additionally, pureed foods were found to be either too thin or lacking in taste, failing the required consistency tests. These issues affected three of twelve sampled residents, who reported dissatisfaction with the food temperature and consistency. Resident #22, who had moderate cognitive impairment and required assistance with eating, reported that oatmeal was often served cold. Resident #39, who also had moderate cognitive impairment and was independent with eating, mentioned that food was frequently served cold and that the facility had changed its kitchen supplier, resulting in smaller portions and repetitive meal options. Resident #34, who was cognitively intact but required substantial assistance with eating, expressed a desire for more varied food options and noted that food was often barely warm when served. Observations on specific dates showed that food temperatures were not consistently checked before serving. For instance, pork loin, potatoes, and green beans were found to be excessively hot on the steam table, but no temperatures were recorded when the food was plated and served. A test tray revealed that the pork loin was below the required serving temperature, and pureed pineapple and corn were not at the correct consistency or temperature. Interviews with the dietary manager and administrator confirmed that food temperatures should be checked before and during meal service, but this was not consistently done, leading to the deficiencies observed.
Deficiencies in Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards of food service safety. Observations revealed multiple areas of the kitchen were not cleaned and sanitized properly, including a grease trap full of grease and food, stove tops covered with dried food particles, and a microwave with food particles and crumbs inside. Additionally, the trash can lid was stuck in the up position, and trash was overflowing. Interviews with the Dietary Manager and staff indicated a lack of a cleaning sign-off sheet and inconsistent cleaning routines, contributing to the unsanitary conditions observed in the kitchen. The facility also failed to properly label and date food items, leading to the presence of expired and undated food in storage areas. Observations showed various food items in the walk-in cooler, spice shelf, and free-standing refrigerator that were either undated or past their expiration dates. Interviews with the Dietary Manager and staff revealed inconsistent practices regarding the labeling and dating of food, with some staff not adhering to the facility's policies on food storage and handling. This inconsistency in food labeling and dating practices increased the risk of serving expired or contaminated food to residents. Furthermore, the facility did not ensure proper hand hygiene and sanitation practices among dietary staff. Continuous observations showed dietary aides and cooks frequently handling food and serving residents without washing their hands or sanitizing between tasks. The reuse of plate covers without proper sanitation was also noted. Interviews with the Dietary Manager and staff indicated a lack of training and adherence to hand hygiene protocols, which compromised the overall food safety and sanitation standards in the facility. Additionally, the facility failed to maintain and document sanitizer solution levels and the cleanliness of the ice machine, further contributing to the deficiencies in food service safety.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to assist Resident #6 in maintaining hydration status by not providing water in the resident's room. The resident, who had severe cognitive impairment and required assistance with various activities, was on a pureed diet with thickened liquids due to a condition affecting the autonomic nervous system. Despite the care plan indicating that the resident should have a water jug in the room at all times, observations on multiple occasions revealed that the resident did not have water available. The resident expressed feeling extremely thirsty and reported that staff often forgot to bring water, leading to dry and scaly skin, chapped lips, and a persistent headache. Interviews with staff confirmed that the resident was not on fluid restriction and should have access to water. However, it was noted that the water glass was kept at the nurses' station because it required thickener, and there was no glass available at the time of observation. The Director of Nursing and the Administrator both acknowledged that residents should have access to fluids unless restricted by a physician's order. Despite this, the facility did not provide a policy on hydration, contributing to the deficiency in care for Resident #6.
Deficiency in Dietary Management Competency
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) had the appropriate competencies and skills to carry out the functions of the food and nutrition services. The DM admitted to not having any dietary certification, was currently enrolled in college out of state, and did not have any completed training certificates. Additionally, there was no one in the facility who was certified in dietary management. The facility dietician, who was contracted to come in once a month, had not provided any training to the facility staff. The facility administrator confirmed that the DM was working on his/her certification and that there was no certified dietary manager currently in the building. The facility relied on a consulting dietician who visited monthly and regional support who came quarterly. The dietary managers participated in corporate training over the phone every other week. Despite these measures, the lack of a certified dietary manager on-site and the infrequent presence of the consulting dietician contributed to the deficiency in ensuring the dietary services were managed by qualified personnel.
Failure to Follow Infection Control Standards for Catheter Care
Penalty
Summary
The facility failed to follow infection control standards and guidelines for catheter care when staff did not ensure that a urinary catheter drainage bag was kept off the floor for one of the sampled residents. The resident, who had no cognitive impairment and required substantial assistance with toileting and personal hygiene, was observed on two separate occasions with the catheter drainage bag touching the floor and hooked on the edge of a trash can. The resident's care plan indicated a self-care performance deficit related to multi-system degeneration of the autonomic nervous system, and the resident had an indwelling catheter with a physician's order to change it monthly and as needed. Interviews with staff, including a Nurses Aide and a Licensed Practical Nurse (LPN), confirmed that the catheter drainage bag should not be touching the floor or hanging on a contaminated surface. Both staff members acknowledged that they assist the resident with transfers and toileting and should ensure the drainage bag is off the floor before leaving the room. The Administrator and Director of Nursing (DON) also confirmed that indwelling urinary catheter drainage bags should not be touching the floor or hanging on a contaminated surface.
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Illustrative
What surveyors actually found near you
We read the 92 citations issued within 25 miles in the last 12 months — including the 2 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rock Port
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Auburn | 17.8 mi | ★★★★★ | 10 | 0 |
| The Ambassador Sidney Inc | 23 mi | ★★★★★ | 6 | 0 |
| Garden View Care Center | 23.9 mi | — | 45 | 2 |
| Accura Healthcare Of Shenandoah | 24 mi | ★★★★★ | 16 | 0 |
| Tiffany Heights | 24.6 mi | ★★★★★ | 15 | 0 |
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