Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Health Care Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments were not evaluated for their capacity to consent to sexual activity, leading to an immediate jeopardy situation. Despite documented incidents of inappropriate sexual behavior, the facility failed to assess or document the residents' ability to consent, nor were care plans updated to address these behaviors. The facility's inaction resulted in a deficiency with potential for more than minimal harm.
The facility failed to ensure dignified mealtime assistance for two residents with cognitive impairments. Staff members were observed standing over residents while feeding them, contrary to the facility's policy that requires staff to be seated. The CNA involved was unaware of this policy, and the DON confirmed the expectation for staff to be seated during feeding assistance.
The facility did not ensure that information on filing complaints and contacting the Ombudsman was accessible to residents. During an interview, ten residents were unaware of how to contact the Ombudsman or report complaints. The information was posted on a bulletin board but was placed too high for easy access. The Administrator admitted the forms needed to be lowered.
The facility failed to make past survey results readily accessible to residents. Ten residents were unaware of where to find these reports. The survey results were placed in a binder on a bulletin board, mounted five feet above the floor, and attached to a chain, limiting access. The Administrator acknowledged the issue with the binder's height.
The facility failed to report abuse investigations and incidents involving three residents within the required timeframe. A resident with cognitive deficits reported verbal abuse by a CNA, but the incident was reported late. Another resident with intellectual disabilities experienced rough handling and alleged molestation, with delays in notifying the Nurse Aide Registry. A third resident with Alzheimer's was involved in unreported altercations and inappropriate behavior. The DON acknowledged the lack of reporting, citing residents' rights.
The facility failed to conduct thorough investigations into abuse allegations and resident altercations. A resident reported rough handling by staff, but the investigation was incomplete. Another resident was involved in multiple altercations without proper incident reporting or investigation. Additionally, an LPN allegedly used inappropriate language towards a resident, but the investigation was insufficient, and the incident was not reported to the nursing board.
Two residents with cognitive impairments exhibited inappropriate behaviors, including sexual misconduct and aggression, but their care plans were not updated to address these issues. Despite multiple documented incidents, the care plans lacked interventions or strategies to manage the behaviors, as confirmed by the DON.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, affecting 83 residents. On several occasions in May, June, and July, RN coverage was insufficient, with hours worked ranging from 4.93 to 7.80 hours. Human Resources confirmed that the DON or ADON should cover these gaps, but this did not happen on the specified dates.
A facility failed to follow its policy for administering medications via enteral tube for a resident with a gastrostomy tube. A CMA was observed crushing medications into a powder without diluting them before administration, contrary to the policy requiring dilution and flushing with water. The CMA admitted to not following the procedure due to forgetting a spoon, despite being aware of the correct method.
The facility's medication error rate was 8.11%, exceeding the acceptable threshold of 5%. Two residents were affected: one was not instructed to chew a prescribed aspirin, and another did not receive Mylanta due to its unavailability and had issues with Potassium Chloride ER administration. These errors highlight a failure in medication administration protocols.
The facility failed to prevent bare hand contact with food during meal service for a resident with dementia, as a CNA used bare hands to serve bread. Additionally, the dishwashing machine was not properly monitored, resulting in inadequate chlorine levels for sanitation. The dietary manager resorted to using disposable serving items due to the issue.
The facility failed to prevent cross-contamination by improperly handling soiled linens and not using enhanced barrier precautions for a resident with a gastric tube. A CNA did not bag soiled items before transporting them, and a CMA did not don a gown when accessing a resident's gastrostomy tube, despite facility policies requiring these actions. Staff were unclear about the meaning of indicators for PPE use.
The facility failed to accurately code Resident Assessments for two residents. One resident, admitted to hospice care, had their hospice status omitted from the Annual Resident Assessment. Another resident, discharged home with family, was incorrectly documented as discharged to a hospital. These inaccuracies were confirmed by MDS Coordinators during reviews.
A resident with a stage four pressure wound did not receive a physician-recommended HBA1C test due to it being listed as a recommendation rather than an order. The test was pending for several months, and the oversight was only identified and addressed after a review by the facility's administration.
Failure to Evaluate Capacity for Consent in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to evaluate two residents for their capacity to consent to sexual activity, leading to an immediate jeopardy situation identified by the Oklahoma State Department of Health. Resident #18, who had a history of sexually inappropriate behaviors and was diagnosed with unspecified dementia, was observed engaging in sexual activity with Resident #51, who had severe cognitive impairment due to Alzheimer's Disease. Despite these observations, there was no documentation of an evaluation of their capacity to consent, nor were there care plans or assessments addressing their sexual activity. The facility's policy on Abuse, Neglect, and Exploitation, which includes guidelines for preventing sexual abuse and ensuring residents' capacity to consent, was not adhered to. The policy requires establishing a safe environment and documenting determinations of capacity to consent to sexual contact. However, the facility did not provide evidence of such evaluations or incident reports to the state health department, even after multiple incidents involving Resident #18's inappropriate sexual behaviors were documented in behavior notes. The Director of Nursing (DON) acknowledged that both residents had severely impaired cognitive abilities, yet no interventions were put in place to address the risk of sexual abuse or to update the residents' care plans to reflect their sexual behaviors. The facility's inaction in assessing and documenting the residents' capacity to consent to sexual activity, despite clear indications of cognitive impairment, resulted in a deficiency with the potential for more than minimal harm.
Removal Plan
- All staff are inserviced on sexual behaviors with residents with decreased BIMS and when to report incidents.
- Designee began assessing all BIMS greater than 9 in the facility for any sexual abuse from resident #18. All residents assessed had not had any form of sexual abuse while in the facility.
- Compliance with reporting allegations of abuse/neglect/exploitation policy has been reviewed with all staff. All staff have been inserviced and all new hires will continue to be inserviced upon hire.
- MDS updated Resident #18 care plan for sexual behaviors. Monitoring order in place every shift.
- Designee will review 24 hour reports and will report any new behaviors in morning meetings.
- Nurse Practitioner to evaluate and treat Resident #18. Resident evaluation to consent to sexual activity and sexual consent form was completed on Resident #18 and Resident #51.
- DON reviewed all behavior notes assessing for any resident to resident sexual abuse. No other instances were found.
- Resident #18 and Resident #51 were educated on sexual activity.
- Nursing staff will initiate the Evaluation for Sexual Consent Form upon any observed sexual behaviors between residents.
- Follow up regarding Resident #18 sexual consent, family consented to companionship but not the act of sex itself. Follow up regarding Resident #51: Family consented to companionship but not the act of sex itself.
Failure to Maintain Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to ensure that staff members assisted residents with eating in a dignified manner, as observed during meal service in the assisted dining room. Two residents, one with vascular dementia and obsessive-compulsive behavior, and another with unspecified dementia and mild neurocognitive disorder, were not assisted in accordance with the facility's policy. The policy, revised in July 2024, mandates that staff should be seated while feeding residents to promote and maintain dignity. However, during observations, staff members were seen standing over the residents while feeding them, which is contrary to the policy. Resident #12, who had severe cognitive impairment and was dependent on staff for eating, was fed by a CMA who stood over them, giving bites of food and drinks while standing. Similarly, Resident #75, who required supervision or touching assistance for eating, was fed by a CNA who also stood over them, despite an empty chair being available. The CNA was unaware of the policy regarding the positioning of staff while assisting residents with meals. The DON confirmed that staff should be seated while assisting residents with eating, indicating a lapse in adherence to the facility's policy.
Inaccessible Complaint and Ombudsman Information
Penalty
Summary
The facility failed to ensure that information on how to file a formal complaint with the state agency and contact the Ombudsman was readily accessible to residents. During a group interview with ten residents, it was revealed that none of them were aware of who their Ombudsman was or where to find information on how to contact them or report a complaint to the state survey office. The residents speculated that the information might be posted on a bulletin board in C Hall. Upon inspection, the bulletin board did contain the necessary information, but it was placed too high, with the bottom of the forms approximately 5 feet above the floor, making it difficult for residents to access. The Administrator acknowledged that the forms needed to be lowered to be more accessible to all residents.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that past survey results were readily available for residents to review. During a resident group interview, ten residents reported that they were unaware of where to find previous survey results and did not know they could access these reports. An observation revealed that the survey results were placed in a binder on a bulletin board in C Hall, mounted approximately five feet above the floor. The binder was attached to a chain, allowing it to be lowered only to about three feet above the floor, making it difficult for residents to access without assistance. The Administrator acknowledged that the binder might be positioned too high and needed to be relocated to a more accessible location.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility failed to report the results of abuse investigations to the State within the required 24-hour timeframe for three residents. Resident #15, who had a cognitive communication deficit and chronic kidney disease, reported verbal abuse by a CNA on July 3, 2024. However, the incident was not reported to the administration until July 8, 2024, and the final report was submitted on July 11, 2024. The delay was attributed to the CNA forgetting to report the incident in a timely manner. Resident #44, diagnosed with multiple conditions including mild intellectual disabilities and schizophrenia, reported rough handling by a staff member on June 26, 2024. Although the initial report was filed on the same day, the Nurse Aide Registry was not notified until July 2, 2024. Additionally, another incident involving an allegation of molestation by a CNA was reported late to the Nurse Aide Registry on August 20, 2024, after management became aware of the incident on August 19, 2024. Resident #51, with Alzheimer's Disease and severe cognitive impairment, was involved in several incidents that were not reported to the State. These included altercations with other residents and inappropriate sexual behavior with another cognitively impaired resident. Despite these events being documented in progress notes, no incident reports were filed with the State or other required agencies. The DON acknowledged that these incidents were not reported, citing the residents' rights as a reason for not taking further action.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving Resident #44, who reported that a staff member was too rough while providing care. The investigation was incomplete as it did not include interviews with all potential witnesses or other residents who might have been affected by the staff member involved. The Director of Nursing (DON) acknowledged the lack of a comprehensive investigation, admitting that not all necessary interviews were conducted to ensure the safety of all residents. Resident #51 was involved in multiple incidents of resident-to-resident altercations, including aggressive behavior and inappropriate sexual conduct. Despite these incidents being documented in progress notes, there were no corresponding incident reports or investigative notes in the clinical record. The DON confirmed that no investigations were initiated for these incidents, as they were not reported, highlighting a failure in the facility's process for handling resident altercations. Resident #14 reported an incident where an LPN allegedly used inappropriate language and gestures towards them. Although the LPN was initially suspended, the investigation was insufficient as it did not include interviews with other staff or residents who might have witnessed the incident. Furthermore, the facility did not report the LPN to the Oklahoma State Board of Nursing, as required by their abuse policy. The facility's failure to conduct a thorough investigation and report the incident to the appropriate authorities constitutes a deficiency in their handling of abuse allegations.
Failure to Revise Care Plans for Behavioral Issues
Penalty
Summary
The facility failed to revise care plans for two residents, #18 and #51, who exhibited significant behavioral issues. Resident #18, diagnosed with unspecified dementia, displayed inappropriate sexual behaviors on multiple occasions, including exposing themselves and attempting to touch others inappropriately. Despite these documented incidents, Resident #18's care plan did not include any interventions or strategies to address these behaviors. The care plan was last updated on 08/06/24, but it did not reflect the resident's ongoing behavioral issues. Similarly, Resident #51, diagnosed with Alzheimer's Disease and malignant neoplasm of the bronchus and lung, exhibited aggressive and inappropriate behaviors, such as yelling, swatting at other residents, and attempting to pull another resident out of a chair. Additionally, Resident #51 was involved in inappropriate sexual behavior with Resident #18. Despite these incidents, Resident #51's care plan did not address these behaviors or include any interventions. The Director of Nursing confirmed that the care plan did not cover the resident's behavioral issues.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required. This deficiency was identified through observation, record review, and interviews. The facility, which housed 83 residents, did not meet the required RN coverage on multiple occasions in May, June, and July. Specific dates were noted where RN coverage fell short, with hours worked ranging from 4.93 to 7.80 hours instead of the mandated eight hours. Human Resource personnel confirmed that on days without adequate RN coverage, the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would need to cover, but this did not occur on the listed dates.
Failure to Follow Medication Administration Policy via Enteral Tube
Penalty
Summary
The facility failed to adhere to its policy for administering medications via enteral tube for a resident with a gastrostomy tube. The policy required flushing the tube with water before and after administering medications, diluting medications appropriately, and using a clean oral syringe. However, during an observation, a Certified Medication Aide (CMA) prepared medications for a resident by crushing tablets into a fine powder and placing them into a plastic water cup without adding any liquids. The CMA then administered the medications through the gastrostomy tube without diluting them, contrary to the facility's policy. The CMA was observed using an eight-ounce container of tap water to flush the tube, mixing parts of the Jevity with the medications, and repeating the process until all medications and Jevity were administered. The CMA admitted to not diluting the medications due to forgetting to bring a spoon, despite being aware of the correct procedure. This incident involved a resident who had multiple medications prescribed, including clopidogrel bisulfate, lactulose, and Jevity, among others, to be administered via the gastrostomy tube.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8.11%. This deficiency was identified during a survey where 37 medication administration opportunities were observed, and three errors were noted. Two residents were affected by these errors. Resident #43, who had a physician's order for a chewable aspirin to be taken daily for atherosclerotic heart disease, was not instructed to chew the aspirin as required. Instead, the medication was placed in a cup with other medications, and the resident swallowed it without chewing, as confirmed by the Certified Medication Aide (CMA) involved. Additionally, Resident #13, who had orders for medications to be administered via a gastrostomy tube, did not receive Mylanta as prescribed due to its unavailability. The CMA also failed to administer Potassium Chloride ER as ordered, citing that the medication could not be crushed and there were no alternative orders for administration through the gastrostomy tube. These actions and inactions contributed to the facility's failure to adhere to the required medication administration protocols, leading to the noted deficiency.
Deficiencies in Food Handling and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper food handling practices during lunch meal service, as observed with a resident diagnosed with unspecified dementia and mild neurocognitive disorder. The resident, who required supervision or assistance for eating, was served by a CNA who used bare hands to pick up and offer a slice of bread to the resident. The CNA was unaware of the policy regarding bare hand contact with food and later stated they would need to ask another staff member about it. The Director of Nursing mentioned that staff were allowed to touch food with bare hands if they sanitized their hands first, although this was not adhered to during the incident. Additionally, the facility did not adequately monitor the dishwashing machine to ensure proper sanitation. A dietary aide tested the chlorine level in the dishwashing machine, which showed a reading of 10 ppm, below the required 50-100 ppm. The dietary manager confirmed the inadequate chlorine level and called maintenance for assistance. In the meantime, the dietary manager decided to use paper serving containers and plastic utensils for lunch service due to the improper sanitation of dishes.
Infection Control Deficiencies in Linen Handling and Barrier Precautions
Penalty
Summary
The facility failed to handle soiled linens properly, leading to potential cross-contamination. During an observation, a CNA provided incontinent care to a resident with cognitive communication deficit and persistent mood disorder. The resident was found with stool on their buttock and back, and the CNA removed the soiled shirt and sling, tossing them on the ground instead of bagging them as per the facility's policy. The CNA later placed the soiled items on the lid of a soiled linen barrel in the hallway without bagging them, contrary to the facility's laundry services policy. Additionally, the facility did not ensure the use of enhanced barrier precautions when accessing a resident's gastric tube. A CMA administered medications and nutritional supplements to a resident with a gastrostomy tube and ESBL resistance without donning a gown, as required by the facility's enhanced barrier precautions policy. The CMA was unaware of the meaning of the green star on the resident's door, which indicated the need for enhanced barrier precautions. This lack of understanding was also evident among other staff members, as an LPN was unsure of the PPE requirements and the significance of the green star.
Inaccurate Resident Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to ensure accurate coding of Resident Assessments for two residents. Resident #58, diagnosed with dysphagia following a cerebral infarction, was admitted to hospice care as per a physician's order. However, the Annual Resident Assessment did not document the hospice care received, despite the MDS Coordinator acknowledging that the life expectancy less than six months section was marked, but hospice care was not. Similarly, Resident #85, who had a displaced intertrochanteric fracture of the left femur, was discharged home with family, as noted in a Nurses' Note. However, the Discharge Resident Assessment inaccurately documented the discharge status as a short-term general hospital, which was confirmed by MDS Coordinator #2 upon review.
Failure to Obtain Physician-Ordered Lab Test
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were obtained for a resident with a stage four pressure wound on the left heel. The Wound Care Physician recommended an HBA1C test in the Wound Evaluation and Management Summary notes starting from May 15, 2024. However, subsequent notes on multiple dates indicated that the HBA1C was pending, and there was no documentation that the test was ever obtained. The issue arose because the HBA1C was listed under recommendations rather than orders, leading to the wound care nurse not seeing it. The Administrator confirmed that the test was only ordered on August 15, 2024, after the oversight was identified.
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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 Muskogee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| York Manor Nursing Home | 0.7 mi | ★★★★★ | 24 | 0 |
| Broadway Care & Rehab Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Muskogee Nursing Center | 1.2 mi | ★★★★★ | 1 | 1 |
| Eastgate Village Care & Rehab Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Brentwood Extended Care & Rehab | 4 mi | ★★★★★ | 0 | 0 |
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