Pleasant Valley Healthcare And Rehabilitation Center

Penalties

• Sep 14, 2024 — Fine ($19,928)
• Nov 24, 2023 — Fine ($33,465)

Inspection findings

1. Jun 4, 2026 Health · 6 findings
   • Not serious Scope/severity D

     F0658 Resident Assessment and Care Planning Deficiencies

     Ensure services provided by the nursing facility meet professional standards of quality.

     Corrected Jun 5, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jun 5, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0800 Nutrition and Dietary Deficiencies

     Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

     Corrected Jun 5, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 5, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 5, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Jun 5, 2026 · CMS health inspection

2. Dec 19, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 20, 2025 · CMS health inspection

3. Apr 25, 2025 Fire Safety · 14 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected May 13, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected Jun 16, 2025 · CMS fire safety

   • Not serious Scope/severity D Complaint

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Apr 28, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Apr 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Apr 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Apr 28, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 28, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 28, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 13, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0325 Smoke Deficiencies

     Have properly installed hallway dispensers for alcohol-based hand rub.

     Corrected May 13, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected May 13, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 13, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected May 13, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 13, 2025 · CMS fire safety

4. Sep 14, 2024 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Sep 15, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Sep 15, 2024 · CMS health inspection

5. Mar 14, 2024 Health · 11 findings
   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0565 Resident Rights Deficiencies

     Honor the resident's right to organize and participate in resident/family groups in the facility.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0837 Administration Deficiencies

     Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

     Corrected Mar 15, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0325 Smoke Deficiencies

     Have properly installed hallway dispensers for alcohol-based hand rub.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 13, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Mar 13, 2024 · CMS fire safety

6. Nov 24, 2023 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Nov 25, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Nov 25, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 07/01/2022
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• PETERSON, SKYLER — adp of the snf, NOT APPLICABLE, since 07/03/2025
• PETERSON, SKYLER — managing control - governing body, NOT APPLICABLE, since 07/01/2022
• PETERSON, SKYLER — operational/managerial control, NOT APPLICABLE, since 07/01/2022
• SHARMA, NEERAJ — operational/managerial control, NOT APPLICABLE, since 07/01/2022
• SHARMA, NEERAJ — managing control - governing body, NOT APPLICABLE, since 07/01/2022
• SHARMA, NEERAJ — adp of the snf, NOT APPLICABLE, since 07/03/2025
• WRIGHT, LABAN — corporate officer, NOT APPLICABLE, since 07/01/2022
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 07/01/2022
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 04/18/2022
• PRIMROSE HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 07/03/2025
• PRIMROSE HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 07/01/2022