Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant Valley Healthcare And Rehabilitation Cent during CMS and state inspections, most recent first.
Kitchen Pest Control Failure: The facility failed to maintain an effective pest control program in its only kitchen. Surveyors observed the back kitchen door propped open with a rock and flies near the food prep area. The Acting Dietary Mgr, other staff, and the Admin stated the door should not be left open because flies and rodents could enter, and the facility’s pest control policy required a pest-free environment with frequent treatment, monitoring, and prompt reporting of pest problems.
Failure to follow a resident's heel protector orders was identified for a resident with severe cognitive impairment, left foot drop, and muscle contracture who was dependent on staff for all ADLs. Staff observed the resident in bed without heel boots, and interviews showed a CNA had not used them, an LVN was unaware of the order, and the ADON and DON acknowledged staff responsibility for ensuring the devices were in place while the resident was in bed.
Expired medications were found in the Hall 400 nurses' medication cart during observation. The LVN, ADON, DON, and pharmacist each reported checking the cart at different intervals, but all missed two bubble packs of Dicyclomine with an expired date. The facility policy stated outdated medications are to be immediately removed from stock and disposed of per medication destruction procedures.
A resident with cerebral infarction, seizures, asthma, and severe cognitive impairment did not receive his breakfast tray after admission. Interviews showed the LVN assumed the kitchen had made a mistake, one CNA passed only what was on the cart and did not recognize the new resident, and another CNA knew of the new admission but did not verify the tray pass while feeding another resident. The RD and Administrator stated new admission diet tickets were supposed to be implemented for meal tickets, and the facility had no policy regarding residents receiving daily meals.
Walk-in freezer door seal not maintained. Ice buildup was observed along the freezer door frame, threshold, and on food boxes inside the freezer, and the door would not close easily. The acting Dietary Manager said Maintenance was responsible for the freezer and was unsure whether the seal had been replaced, while the Administrator stated staff were expected to report major kitchen repairs and noted freezer problems could affect food quality if temperatures were not kept within range.
Infection Control Lapse With Contaminated Glucometer: A glucometer with a used test strip and dried blood was found in a nurses’ cart drawer, and an LVN stated she had not disinfected the reusable equipment after use or discarded the strip in the biohazard container. The ADON and DON stated staff were expected to clean reusable equipment after use and dispose of contaminated strips properly, and the facility policy required common-use equipment to be cleaned and disinfected before use on another patient.
A resident with multiple health conditions developed a rash on several areas of his body, which was documented by several LVNs over multiple days without timely follow-up or treatment orders. Communication lapses between nursing staff and failure to adhere to the facility's change of condition policy led to a delay in notifying the NP and obtaining appropriate medications, resulting in the resident experiencing ongoing itchiness and discomfort.
A resident with multiple chronic conditions reported UTI symptoms to an LVN, but her complaint was not documented or communicated to subsequent shifts, resulting in delayed assessment and treatment. The resident's pain increased over several shifts, and appropriate interventions were not initiated until surveyors intervened. Facility staff interviews confirmed failures in documentation, communication, and adherence to policy.
Surveyors found that staff did not consistently follow recipes or measure ingredients accurately when preparing and serving meals, resulting in food that was bland, of improper consistency, and not always appetizing. Dietary staff acknowledged the importance of following recipes, but observations and taste tests confirmed deficiencies in meal preparation and presentation.
A resident with a history of stroke, anxiety disorder, depression, and PTSD did not receive an accurate PASRR Level I screening, resulting in the absence of a required Level II evaluation. The screening was entered incorrectly by a previous staff member and not verified by the current MDS Nurse, despite facility policy requiring follow-up and appropriate evaluation for residents with mental health diagnoses.
A resident with multiple chronic conditions and total incontinence did not receive proper incontinence care, as staff failed to change her as frequently as required, double-briefed her, and did not thoroughly cleanse her perineal area. These actions were not in accordance with facility policy and placed the resident at risk for urinary tract infection.
Staff failed to follow proper hand hygiene and glove use protocols in the kitchen, including not changing gloves after handling trash before returning to food preparation. This was observed during kitchen operations and confirmed in staff interviews, revealing inconsistent understanding and application of the facility's hand hygiene policy.
Staff failed to follow infection control protocols during medication administration and incontinence care for two residents. A medication aide administered a tablet that had fallen on the medication cart after picking it up with an ungloved hand, and a CNA did not perform hand hygiene after changing gloves while providing incontinence care. Both staff members acknowledged awareness of infection control requirements, and the facility's policy mandates proper hand hygiene to prevent infection spread.
A resident with renal failure was not dialyzed due to a swollen access site, and the facility failed to follow the dialysis center's instructions to take her to the hospital for a permacath placement. Instead, they attempted to arrange a vascular doctor appointment, which was delayed. The resident returned to the facility without dialysis, and her vital signs were not properly assessed or documented. She was later found unresponsive, leading to a code blue and hospitalization, where she eventually passed away.
A resident with multiple health conditions, including renal insufficiency, did not have her vital signs documented in the EMR before and after a dialysis session. LVN A failed to document special instructions from the dialysis center and did not notify the resident's doctor about the need for hospital admission for permacath placement. The facility lacked clear documentation processes, leading to incomplete records and potential risks to the resident's care.
Kitchen Pest Control Failure
Penalty
Summary
The facility failed to maintain an effective pest control program in its only kitchen. During observation, the back kitchen door was propped open with a marble rock, and flies were seen in the kitchen near the food preparation area. The acting Dietary Manager stated that leaving the back door open created a risk because the kitchen was not secured and flies or rodents could enter, and that the door was the entrance for all grocery deliveries, which presented a pest problem when it was open. During interviews, staff stated the kitchen exit door should never be propped open and that leaving it open created a risk for flies and rodents entering the facility. The Administrator also stated the back kitchen door should not be propped open and noted that groceries were delivered through the same door. Record review showed the facility’s undated pest control policy required an environment free of pests, frequent treatment through a pest contract, additional visits when a problem was detected, staff monitoring of the environment, and prompt reporting of pest problems.
Failure to Follow Heel Protector Orders
Penalty
Summary
The facility failed to ensure services provided or arranged matched the comprehensive care plan and professional standards of quality for one resident with pressure ulcers. Resident #10 was a female with diagnoses including Alzheimer's disease, left foot drop, and muscle contracture, and her quarterly MDS reflected a BIMS score of 2 with severe cognitive impairment and total dependence on staff for ADLs. Her care plan dated 06/04/26 stated she wore bilateral heel boots while in bed, with interventions to apply bilateral heel boots while in bed and float heels. Physician orders directed staff to offload heels with pillows while in bed every shift and to apply bilateral heel boots while in bed every shift for heel protection. On 06/04/26, observations at 9:46 AM and again at 10:42 AM showed Resident #10 lying in bed without heel protectors on, and no heel protectors were seen in the room. During interviews, a CNA stated she had not seen any heel protectors for the resident and had not used them, instead placing a pillow under the resident's heels. An LVN stated she was not aware of the heel protector order and had not been told the resident had them. An ADON stated CNAs, nurses, and she were responsible for ensuring the heel protectors were placed on the resident while in bed and verified, and the DON stated the resident did have heel boots and if they were not present they were probably being washed. The facility policy stated nursing staff shall implement pressure-reducing devices as appropriate and confirm all orders have been implemented as ordered.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for 1 of 3 medication carts reviewed, the Hall 400 nurses' medication cart. During observation, two bubble packs of Dicyclomine capsules, one containing 30 pills and the other containing 18 pills, were found in the cart with an expiration date of 03/31/2026. The medication was identified as being used to treat functional bowel/irritable bowel syndrome by relaxing the muscles in the stomach and intestines to reduce cramping and spasms. During interview, the LVN responsible for the cart stated she checked the cart daily for expired medications and had missed the expired medication that morning. The ADON stated nurses were expected to check their carts weekly and that ADONs checked behind them weekly; he said he had last audited the cart on 5/29/2026 and also missed the expired medications. The DON stated nurses were expected to check carts every shift, ADONs were responsible for weekly checks, and the pharmacist had last checked the cart on 06/02/2026 but also missed the expired medications. The facility policy stated outdated medications are to be immediately removed from stock and disposed of according to medication destruction procedures.
Missed Breakfast Tray for New Admission
Penalty
Summary
The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs for 1 of 1 residents reviewed for food and nutrition services, Resident #85. Resident #85 was admitted on 06/04/2026 with diagnoses including cerebral infarction, seizures, and asthma, and his admission MDS showed a BIMS score of 05, indicating severe cognitive impairment. The record also noted that he usually was understood when expressing ideas and wants, and usually understood verbal content, though he had difficulty communicating some words or finishing thoughts. Resident #85 stated that he received his dinner tray on the evening of admission but did not receive his breakfast tray the following morning. During interviews, an LVN stated he received report of the new admission and believed the kitchen had made a mistake when the resident did not get a tray; he also stated the CNA was supposed to notify him if a resident missed a tray. A CNA stated she passed trays on Hall 100 and only passed what was on the cart, and she did not know there was a new resident in the room because she did not read the names on the doors. Another CNA stated she knew there was a new resident but did not check the morning tray pass because she was feeding another resident and later learned the resident had not eaten. The RD stated staff had been in-serviced on following up on new admissions to make sure diet cards were implemented, and the Administrator stated nursing implemented the diet ticket for new admissions and took it to the kitchen so meal tickets could be added; the facility did not have a policy regarding residents receiving daily meals.
Walk-in freezer door seal not maintained
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen reviewed for food and nutrition services. During observation, ice buildup was seen along the walk-in freezer door frame, threshold, and on boxes of food items on the shelves inside the freezer. The acting Dietary Manager stated that Maintenance was responsible for ensuring the freezer was clean and said she noticed the ice buildup that day and would request maintenance to replace the seal around the door or freezer. On the following day, ice buildup was still present along the door frame and the freezer door would not close easily. The acting Dietary Manager stated the Maintenance Director had cleared the ice the day before, but ice had accumulated again, and she did not know whether the seal had been replaced. The Administrator stated kitchen staff were expected to report major repairs, including the freezer, stove, or dishwasher, to the Maintenance Director and himself, and he acknowledged that if the freezer was not working it could affect food quality if temperature was not kept within range.
Infection Control Lapse With Contaminated Glucometer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 3 medication carts reviewed, specifically the nurses’ cart for hall 400. During an observation on 06/03/26 at 1:21 PM, a glucometer with a used test strip was found in the drawer of the 400 nurses’ cart. During a later interview and observation, the LVN stated the strip was in the drawer and had dry blood on it. She said she was supposed to use disinfectant wipes to clean the glucometer after use and discard the used strip into a biohazard container, but she could not explain why this had not been done and could not recall when she had received training on the care and disinfection of reusable equipment. The ADON observed that the strip had blood and stated staff were expected to disinfect reusable equipment after use and discard contaminated items in the biohazard container. The DON also stated staff were expected to maintain clean equipment, disinfect reusable equipment after use, and dispose of used strips in the biohazard containers attached to the nurses’ carts. The facility’s Infection Control policy, dated October 2022, stated that if common use of equipment for multiple patients is unavoidable, the equipment should be cleaned and disinfected before use on another patient.
Failure to Timely Assess and Treat Resident Rash Due to Breakdown in Communication and Policy Adherence
Penalty
Summary
The facility failed to ensure that a resident received timely assessment and treatment for a rash, as required by professional standards of practice and the facility's own change of condition policy. The resident, who had a history of stroke, moderate cognitive impairment, incontinence, and was at risk for skin breakdown, developed a rash on multiple areas of his body. Documentation shows that the rash was first noted by nursing staff, who recorded the presence of itchy, reddish areas on the resident's extremities and notified the nurse practitioner (NP) via telephone message. However, no treatment orders were obtained at that time, and there was no documentation of follow-up or monitoring instructions from the NP. Over the next two days, multiple licensed vocational nurses (LVNs) documented the ongoing presence of the rash and the resident's complaints of itchiness, but did not obtain new treatment orders or ensure that the NP was contacted again. Communication between shifts was inconsistent, with some nurses stating they had reported the rash to the next shift or to the treatment nurse, while others denied receiving such reports. The treatment nurse was not notified of the rash until she independently assessed the resident and observed the skin condition, at which point she contacted the NP and obtained orders for topical and oral medications. Interviews with staff revealed confusion and lack of clarity regarding the process for reporting and following up on changes in resident condition. The facility's policy required prompt communication of unusual signs and symptoms to the physician and documentation of all attempts to reach the physician, as well as ongoing assessment and documentation until the condition stabilized. In this case, the policy was not followed, resulting in a delay of several days before the resident received appropriate treatment for his rash.
Delay in Treatment and Documentation for Resident with UTI Symptoms
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, heart failure, diabetes, and blindness reported symptoms of a urinary tract infection (UTI) but did not receive timely assessment, documentation, or treatment according to professional standards and the facility's own policies. The resident, who was cognitively intact and able to communicate her needs, informed an LVN during the evening shift that she believed she had a UTI. The LVN reported the complaint to the physician, who instructed the nurse to monitor the resident and obtain a urine analysis, but did not provide any new orders at that time. The LVN failed to document the resident's complaint, assessment, or the physician's instructions in the progress notes or on the 24-hour report, resulting in a lack of communication to subsequent shifts. Over the next several shifts, the resident's pain and symptoms increased, but no further assessment or intervention was initiated until surveyors became involved. The resident repeatedly reported feeling ill and experiencing pain, but staff did not follow up or reassess her condition. The medication administration record did not reflect any pain or new interventions, and the care plan, which included monitoring and administering antibiotics as ordered, was not implemented. The lack of documentation and communication between staff members led to a delay in the resident receiving appropriate treatment for her UTI. Interviews with facility staff, including the ADON, LVNs, physician, and DON, confirmed that the resident's complaint was not properly documented or communicated, and that the expected process for responding to a change in condition was not followed. The facility's policy required prompt assessment, documentation, and communication of changes in condition, as well as implementation of interventions and monitoring. The failure to adhere to these procedures resulted in the resident experiencing increased pain and delayed treatment for her UTI.
Failure to Provide Palatable and Properly Prepared Food
Penalty
Summary
Surveyors observed that the facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature. During kitchen observations, staff did not use measuring cups to accurately measure ingredients such as milk and chicken when preparing pureed food. Additionally, the wrong scoop size was used for serving, and pureed cornbread was found to be bland and of an overly thick consistency, making it difficult to eat. These issues were confirmed through taste tests and direct observation of meal preparation. Interviews with dietary staff, including the cook, dietary aide, dietary manager, and dietitian, revealed that recipes were not consistently followed, which could result in food that does not taste good or is not prepared in the correct quantity. The dietary manager and aide acknowledged the importance of following recipes to ensure meal quality. Review of the facility's policy indicated that menus and recipes are intended to meet residents' nutritional needs and preferences, but the observed practices did not align with these guidelines.
Failure to Ensure Accurate PASRR Screening and Evaluation
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level I screening for one resident, resulting in the resident not receiving a required PASRR Level II evaluation. The resident, a male with a history of stroke, anxiety disorder, depression, and post-traumatic stress disorder (PTSD), had a care plan indicating risks for re-traumatization and depression. Despite these diagnoses, the PASRR Level I screening completed in 2023 indicated that the resident did not have a serious mental illness, and no Level II evaluation was conducted as required for residents with such conditions. Interviews revealed that the PASRR Level I was entered incorrectly into the electronic system by a previous employee, and the current MDS Nurse did not verify its accuracy. The MDS Nurse acknowledged that the error could have resulted in the resident not receiving appropriate services. The Director of Nursing was unaware of the inaccuracy until informed and indicated that further evaluation would be pursued. Facility policy requires follow-up on all PASRR Level I screenings and obtaining Level II evaluations when indicated, but this was not followed in this case.
Failure to Provide Proper Incontinence Care and Prevent UTI
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bowel and bladder did not receive appropriate incontinence care to prevent urinary tract infections. The resident, a female with diagnoses including heart failure, kidney failure, diabetes, stroke, and Alzheimer's disease, was found to be wearing two soaked disposable briefs, a practice known as double-briefing, which is not permitted by facility policy. Certified Nursing Assistant (CNA) N admitted to double-briefing the resident due to being in a hurry and also reported not changing the resident as frequently as required, only twice during her shift instead of every two hours. Both CNAs involved were unsure when the resident was last changed, and the resident was observed to be soaked with urine that had penetrated her clothing and wheelchair towel. Additionally, CNA O, who was responsible for cleaning the resident, did not thoroughly cleanse the vaginal area, failing to open the labia major and minor as required for proper perineal care. CNA O acknowledged this lapse, attributing it to nervousness, and recognized that inadequate cleansing could lead to infection. The facility's policy requires thorough cleaning from front to back and checking for incontinence at least every two hours, but these procedures were not followed. The Director of Nursing confirmed that CNAs are trained and checked for competency in incontinence care and that double-briefing and untimely care are not acceptable practices.
Failure to Follow Proper Hand Hygiene and Glove Use in Food Service
Penalty
Summary
The facility failed to ensure proper food safety practices in the kitchen, specifically regarding personal hygiene and glove use among dietary staff. During observations, a cook was seen leaving the food preparation area with gloves on, disposing of trash, and then returning to food preparation without changing gloves. This action was confirmed in an interview, where the cook acknowledged the importance of changing gloves after touching items such as trash cans to prevent resident illness. Additional interviews with dietary staff revealed inconsistent understanding of when gloves should be changed, with one aide stating gloves would only be changed if they ripped, rather than after potential contamination. The facility's hand hygiene policy outlines specific situations requiring handwashing or use of alcohol-based hand rub, including after contact with potentially contaminated surfaces and before handling food. Despite this policy, staff actions did not align with these standards, as observed during the survey. The deficiency was identified in the context of the kitchen, which serves meals to all 77 residents in the facility.
Failure to Maintain Infection Control During Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents observed for infection control practices. In one instance, a medication aide prepared medications for a female resident with dementia, heart failure, and diabetes. During medication preparation, a tablet fell onto the medication cart, and the aide picked it up with her bare hand and placed it in the medication cup, later administering it to the resident. The aide acknowledged she was not supposed to pick up or administer medication that had fallen on the cart due to potential contamination, despite having been in-serviced on infection control. In another instance, a certified nursing assistant provided incontinence care to a female resident with vascular dementia, dysphagia, and a feeding tube. The assistant performed initial hand hygiene and donned gloves before care, but after changing gloves during the process, she did not perform any form of hand hygiene. The assistant admitted she was aware of the requirement to clean her hands after glove removal but failed to do so, citing that she had forgotten her hand sanitizer and did not use the resident's bathroom sink. The facility's policy requires staff to follow hand hygiene procedures to prevent the spread of infection.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, leading to a deficiency. The resident, a 67-year-old female with a history of renal failure, was not dialyzed on a scheduled day due to a swollen access site. The dialysis center instructed that the resident be taken to the hospital for a permacath placement, but this instruction was not followed by the facility. Instead, the facility attempted to arrange an appointment with a vascular doctor, which was not immediately available due to contractual issues. The resident returned to the facility from the dialysis center without having received dialysis. The Licensed Vocational Nurse (LVN) on duty failed to notify the resident's doctor or nurse practitioner about the dialysis center's instructions and did not properly assess or document the resident's vital signs upon her return. The resident was later found unresponsive in her room, leading to a code blue situation where CPR was initiated, and she was transported to the hospital. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and the dialysis center's instructions. The facility's failure to act on the dialysis center's recommendation and the lack of timely assessment and documentation of the resident's vital signs contributed to the deficiency. The resident's condition deteriorated, resulting in her being placed on a ventilator in the ICU and eventually passing away.
Incomplete Documentation of Dialysis Care and Vital Signs
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was reviewed for medical records. Specifically, the facility did not ensure that LVN A documented the resident's vital signs in the electronic medical record (EMR) before and after the resident's dialysis session. Additionally, LVN A did not document the special instructions from the resident's dialysis center, which indicated that the resident needed to go to the hospital for a permacath placement. Furthermore, there was a failure to document the notification to the resident's doctor or nurse practitioner about the need to go to the hospital, as per the dialysis communication sheet. The resident involved was a female with a moderate cognitive impairment and multiple active diagnoses, including renal insufficiency, hypertension, and diabetes mellitus. She required hemodialysis three times a week. On the day in question, the resident was not dialyzed due to a bruised access site, and it was communicated that she needed to go to the hospital for a permacath placement. However, this information was not documented by LVN A, who misplaced the paper with the resident's vital signs and did not enter them into the EMR. Interviews with facility staff revealed that there was a lack of clarity and consistency in the documentation process. The Director of Nursing (DON) and the Administrator acknowledged the importance of documenting vital signs and communication with the dialysis center. However, there was no scheduled time for checking vital signs, and the documentation was not completed in a timely manner. The facility's policies on medical records and dialysis care were not effectively implemented, leading to incomplete documentation and potential risks to the resident's care.
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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 Garland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beltline Healthcare Center | 1.3 mi | ★★★★★ | 4 | 0 |
| The Parks At Garland Healthcare And Rehab | 2.8 mi | ★★★★★ | 13 | 0 |
| Legend Oaks Healthcare And Rehabilitation Garland | 3.5 mi | ★★★★★ | 10 | 0 |
| Avir At Garland | 3.6 mi | ★★★★★ | 15 | 1 |
| Advanced Health & Rehab Center Of Garland | 4.1 mi | ★★★★★ | 14 | 2 |
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