Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 9 | 4 |
| The Parks At Garland Healthcare And Rehab | 2.8 mi | — | 3 | 0 |
| Legend Oaks Healthcare And Rehabilitation Garland | 3.5 mi | — | 4 | 0 |
| Garland Nursing And Rehabilitation | 3.6 mi | — | 7 | 1 |
| Advanced Health & Rehab Center Of Garland | 4.1 mi | — | 16 | 3 |
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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 August 2026) and official state health department websites.