Above 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 Ridge Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence on staff was found with a swollen, painful knee that was later diagnosed as an acute fracture. Although the injury was unwitnessed and unexplained, the facility did not report it to the state agency as required by policy, citing the provider's assessment that the injury was idiopathic.
A resident with intact cognition and multiple diagnoses experienced discomfort due to a malfunctioning AC unit that was not repaired or replaced in a timely manner, despite reporting the issue to staff and the DOM confirming the problem. Observations verified the AC unit was not blowing cool air, and interviews indicated a lack of follow-up and awareness among facility leadership regarding the complaint.
A resident with a history of leaving the facility without signing out was not accounted for when their empty wheelchair was found outside in the rain. Despite care plan interventions and staff expectations to initiate the elopement process if a resident was missing, the facility did not take immediate action to locate the resident, who was later returned by another resident. Staff and policy reviews confirmed the deficiency in supervision and response.
A resident with MRSA and other conditions experienced a delay in receiving prescribed IV antibiotics due to the unauthorized removal of a PICC line and poor communication between the facility and the ID specialist's office. The resident missed multiple doses of Daptomycin and Teflaro, and the facility failed to send required lab results, leading to a significant delay in care.
A resident with a history of serious infections missed multiple doses of prescribed IV antibiotics due to pharmacy delivery errors and facility inaction. Despite having a policy for medication administration, the facility did not ensure the availability of the medication or contact the pharmacy to rectify the issue.
The facility failed to ensure appropriate storage of medications, affecting a mildly cognitively impaired resident who was found with an unattended plastic medication cup containing two pills. The resident was unsure of the origin, identity, duration, or ownership of the medications. Interviews with two LPNs confirmed that the medications should not have been left unattended, as per the facility's policy.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency in a timely manner for a resident with severe cognitive impairment, legal blindness, and chronic pain syndrome. The resident, who was dependent on staff for all activities of daily living, was found to have a swollen, warm, and painful right knee during incontinence care. Nursing staff notified the provider, obtained orders for a STAT X-ray, and administered pain medication. The X-ray revealed acute nondisplaced oblique fractures of the right knee, but the results were not accessed or reported to the provider until two days later by the Assistant Director of Nursing. Despite the extent of the injury and the lack of a witnessed event or explanation from the resident, the facility did not file a self-reported incident for injury of unknown origin, as the provider deemed the injury idiopathic. Facility policy defined injuries of unknown origin as those not observed, not explained by the resident, and suspicious due to their extent, requiring timely reporting to state officials. The failure to report this incident was identified during a complaint investigation.
Failure to Maintain Working Air Conditioning Unit for Resident Comfort
Penalty
Summary
A deficiency occurred when a resident was not provided with a comfortable environment due to a malfunctioning air conditioning (AC) unit in their room. The resident, who had intact cognition and diagnoses including fascial fibromatosis and paroxysmal atrial fibrillation, reported that the AC unit was not working properly and that the room became hot on warm days. The resident stated they had informed staff, and the Director of Maintenance (DOM) had visited the room and agreed that the unit was blowing warm air. Observations confirmed that the AC unit did not blow cool air, even when set to the lowest and highest settings. Further interviews revealed that the DOM acknowledged the unit needed to be replaced but did not recall previous discussions with the resident and had not returned to address the issue. The Director of Nursing (DON) stated that the expectation was for broken equipment to be fixed or replaced immediately, but was unaware of any complaints regarding non-working AC units in the resident's hall. The Executive Director (ED) indicated that maintaining comfortable temperatures was a high priority and that residents were typically offered a fan or room change if their AC was not working. The facility's policy stated a commitment to providing resident-centered care that meets psychosocial, physical, and emotional needs.
Failure to Identify and Respond to Potential Elopement
Penalty
Summary
The facility failed to identify and appropriately respond to a potential elopement when a resident's empty wheelchair was found on the facility curb during rainy weather. The resident, who had diagnoses including peripheral vascular disease, manic depression, and psychotic disorder, was known to leave the building without signing out despite prior education and care plan interventions. The resident's care plan directed staff to encourage independence while monitoring behaviors, but on the day of the incident, staff discovered the resident's empty wheelchair outside and brought it back inside without immediately locating the resident. The resident was later returned to the facility by another resident in a vehicle, and staff notified the executive director and the resident's guardian after the fact. Medical record review indicated the resident had intact cognition but required staff assistance for wheelchair mobility. Staff interviews revealed that the expectation was for residents to sign out when leaving and for staff to initiate the elopement process if a resident was unaccounted for. However, in this instance, the elopement process was not initiated when the resident was missing, and the facility was unaware of the resident's whereabouts until their return. The facility's policy defined elopement as leaving the premises without authorization or necessary supervision, particularly when the facility is unaware of the resident's departure.
Delay in Administration of IV Antibiotics
Penalty
Summary
The facility failed to ensure timely administration of prescribed intravenous (IV) antibiotics for a resident, leading to a delay in care. Resident #69, who had been admitted with diagnoses including sepsis with methicillin-resistant Staphylococcus aureus (MRSA), chronic obstructive pulmonary disease (COPD), and hepatitis C, was ordered to receive Daptomycin and Teflaro IV antibiotics. However, the resident missed multiple doses of these medications due to the removal of the PICC line without a physician's order and lack of communication between the facility and the infectious disease (ID) specialist's office. The resident's medical records indicated that the PICC line was removed without proper authorization, and there was no documentation of who removed it. This led to the resident missing six doses of Teflaro and five doses of Daptomycin in July. The ID specialist's office was not informed of the discontinuation of the antibiotics, and the facility failed to send required lab results to the specialist's office. Despite multiple outreach attempts by the ID specialist's office, the facility did not respond promptly, resulting in further delays in restarting the antibiotics. Interviews with the Director of Nursing (DON) and other staff confirmed the delay in care and the lack of timely follow-up with the ID specialist's office. The facility's policy required nurses to execute physician orders or ensure a safe hand-off to the next nurse, which was not adhered to in this case. The deficiency was identified during a complaint investigation, highlighting significant lapses in communication and adherence to physician orders, affecting the resident's treatment plan.
Significant Medication Errors in Antibiotic Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident who was receiving intravenous antibiotics. The resident, who had a history of sepsis with MRSA, COPD, chronic hepatitis C, and emphysema, was prescribed Teflaro and Daptomycin. However, the medication administration record revealed that the resident missed multiple doses of both antibiotics over several days in July and September. The errors were partly due to a pharmacy delivery issue, where the pharmacy failed to deliver the correct number of doses and incorrectly processed the refill order, leading to a shortage of Daptomycin. Interviews with facility staff, including a pharmacist and a registered nurse, confirmed the medication errors and the lack of available medication in the stock room. The facility's policy on medication administration was reviewed, which mandates that medications be administered as prescribed by the provider. Despite this policy, the facility did not take action to address the missing medication or contact the pharmacy to resolve the issue, resulting in the resident missing critical doses of their prescribed antibiotics.
Failure to Ensure Appropriate Storage of Medications
Penalty
Summary
The facility failed to ensure appropriate storage of residents' medications, affecting one resident out of 11 reviewed for environmental concerns. Resident #28, who was mildly cognitively impaired and had diagnoses including fibromyalgia, personality disorder, and hypertension, was found alone in their room with a plastic medication cup containing two pills on the over-the-bed table. The resident was unsure of the origin, identity, duration, or ownership of the medications. Interviews with two LPNs confirmed that the medications should not have been left unattended. The facility's policy on medication administration explicitly stated that medications were never to be left unattended.
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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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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.