Inspection Reports for
Pleasant Valley Manor Care Center
6814 SOBBIE RD, LIBERTY, MO, 64068-9555
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
61% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 7
Date: Sep 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food service, and financial practices at Pleasant Valley Manor Care Center.
Findings
The facility was found deficient in multiple areas including failure to inform residents or their representatives about risks and benefits of psychotropic medications, failure to provide timely refunds and notifications related to resident funds, medication errors exceeding acceptable rates, improper medication storage and expired medications, failure to provide suitable meal substitutes and properly prepared therapeutic diets, and inadequate food storage and labeling practices.
Deficiencies (7)
Failed to ensure residents or their representatives were informed of risks and benefits of psychotropic medications for three sampled residents.
Failed to provide personal funds and final accounting within 30 days upon discharge for three residents and failed to notify one resident when within $200 of SSI resource limit.
Medication error rate was 16%, exceeding the 5% threshold, due to missed medication administrations and improper medication preparation.
Failed to discard expired medications and biologicals, had loose pills and wedged medication packages in medication carts.
Failed to provide an alternative appealing meal option of similar nutritive value to a resident who refused the served meal.
Failed to ensure therapeutic diet foods were prepared properly; main entree was not mechanically altered with gravy or broth as ordered.
Failed to store, prepare, and serve food in accordance with professional standards including failure to discard expired food, label and date leftovers, and properly date incoming food products.
Report Facts
Residents affected: 3
Residents affected: 4
Medication error rate: 16
Medication errors: 4
Facility census: 62
Credit balance: 4422.14
Credit balance: 4981.98
Credit balance: 2923.04
Resident account balance: 8276.82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding psychotropic medication consent forms |
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication consents and medication preparation |
| Administrator | Administrator | Interviewed regarding psychotropic medication consents, resident funds reconciliation, and meal substitutions |
| Business Office Manager | Business Office Manager | Interviewed regarding resident funds and refunds |
| Certified Medication Technician A | Certified Medication Technician | Observed and interviewed regarding medication preparation and resident meal refusal |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication preparation and expired medications |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, labeling, and meal substitutions |
| Dietary A | Dietary Staff | Interviewed regarding food storage and meal preparation |
| Registered Dietitian | Registered Dietitian | Interviewed regarding therapeutic diet preparation and food storage |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 7
Date: Sep 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, care coordination, staff training, environmental conditions, and food safety at Pleasant Valley Manor Care Center.
Findings
The facility was found deficient in multiple areas including malfunctioning mechanical lifts, unsealed air conditioning units allowing pest entry, unclean and unsafe shower and laundry areas, failure to coordinate dialysis care with outside providers, lack of annual performance reviews and in-service training for some CNAs, and improper food storage and thermometer sanitation practices. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (7)
Failure to ensure the sit to stand mechanical lift was functioning properly before use for one resident.
Air conditioning units for two residents had unsealed gaps allowing pests to enter the rooms.
Laundry room floor was exposed, unsealed concrete with minimal floor tiles.
Northeast shower room was unclean and unsafe, including a soiled privacy curtain and a loose electrical outlet.
Failure to coordinate resident care with outside dialysis provider, lacking documentation and communication.
Two CNAs lacked annual performance reviews and tracking of required in-service training hours.
Food stored in the kitchen was not properly labeled or dated, and thermometer was not sanitized between uses.
Report Facts
Residents affected: 60
Residents affected: 28
Residents affected: 3
Residents affected: 3
CNA performance review delay: 13
In-service training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Named in deficiency related to lack of annual performance review and in-service training |
| Certified Nursing Assistant 2 | CNA | Named in deficiency related to lack of annual performance review and in-service training |
| Director of Nursing | DON | Interviewed regarding knowledge of lift battery issues, dialysis care coordination, and staff training |
| Maintenance Director | MD | Interviewed regarding knowledge of mechanical lift and air conditioning unit conditions |
| Dietary Aide 1 | DA | Observed and interviewed regarding food storage and thermometer sanitation |
| Dietary Manager | DM | Interviewed regarding food safety practices and expiration date awareness |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Sep 25, 2023
Visit Reason
The inspection was conducted due to a complaint alleging abuse by a Certified Nurse Aide (CNA A) towards Resident #1, specifically that CNA A pushed the resident's lips shut during care on September 9, 2023.
Complaint Details
The complaint involved an allegation that CNA A pushed Resident #1's lips shut and was rough during care on 9/9/23. The allegation was substantiated by resident and staff interviews. The facility delayed reporting to authorities and did not notify law enforcement, citing no serious injury. The investigation started two days after the allegation was reported internally.
Findings
The facility failed to timely report the suspected abuse to law enforcement and the Department of Health and Senior Services. The investigation was delayed until September 11, 2023, and the Administrator did not consider the allegation serious enough to report within two hours or to law enforcement. Resident #1 and staff interviews confirmed the abuse allegation, and the agency staff CNA A was removed from the facility.
Deficiencies (2)
Failed to timely report suspected abuse to law enforcement and state authorities as required by policy and regulation.
Failed to appropriately investigate allegations of abuse in a timely manner.
Report Facts
Facility census: 69
Date of abuse allegation: Sep 9, 2023
Date investigation started: Sep 11, 2023
Date DHSS report received: Sep 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported abuse allegation to DON and spoke with resident and family |
| CNA A | Certified Nurse Aide | Alleged perpetrator of abuse towards Resident #1 |
| Administrator | Facility Administrator | Responsible for investigation and reporting; delayed reporting to authorities |
| DON | Director of Nursing | Received abuse allegation on 9/10/23; delayed reporting and investigation |
| Assistant DON | Assistant Director of Nursing | Conducted staff interviews as part of investigation |
| Social Services Director | Social Services Director | Interviewed residents during abuse investigation |
| CNA B | Certified Nurse Aide | Reported abuse allegation against CNA A to RN A |
Inspection Report
Routine
Census: 76
Deficiencies: 11
Date: Jun 22, 2023
Visit Reason
The inspection was conducted to evaluate compliance with resident dignity, safety, care planning, medication management, environment, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, maintain a safe and homelike environment, ensure proper care planning and medication review, maintain safe bed rails and entrapment assessments, and provide appropriate catheter care. Several residents were observed with unmet needs related to privacy, positioning, hygiene, and safety.
Deficiencies (11)
Failure to honor residents' dignity including privacy during care, clothing assistance, and responding to residents' needs.
Failure to maintain a homelike environment including temperature control and excessive noise from door alarms.
Failure to check CNA Registry for non-certified staff to prevent employment of individuals with abuse history.
Failure to develop and implement complete care plans addressing fall risk, oxygen use, hospice services, side rails, and smoking.
Failure to provide appropriate positioning during meals for residents dependent on staff assistance.
Failure to provide adequate care and assistance for activities of daily living including hygiene and nail care.
Failure to ensure safe environment including accessible call lights, secured medications, and safe catheter care.
Failure to ensure proper catheter care and secure catheter drainage bags off the floor.
Failure to complete entrapment assessments for residents with side rails and failure to obtain informed consent.
Failure to ensure monthly pharmacist medication regimen reviews are completed, reviewed, and acted upon timely.
Failure to regularly inspect bed frames, mattresses, and bed rails for safety and proper attachment.
Report Facts
Residents affected: 4
Facility census: 76
Medication regimen reviews: 2
Medication regimen reviews: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in catheter care and call light accessibility findings |
| CNA B | Certified Nurse Aide | Named in catheter care findings |
| CNA H | Certified Nurse Aide | Named in catheter bag and resident care findings |
| CNA J | Certified Nurse Aide | Named in catheter bag and resident care findings |
| Director of Nursing | Director of Nursing | Provided statements on care expectations and deficiencies |
| Administrator | Administrator | Provided statements on facility policies and deficiencies |
| Staffing Coordinator | Staffing Coordinator | Provided statements on registry checks |
| Maintenance Director | Maintenance Director | Provided statements on bed rails and entrapment assessments |
| Physical Therapist | Physical Therapist | Provided statements on side rails and hospice beds |
| Licensed Practical Nurse A | Licensed Practical Nurse | Provided statements on alarm noise and catheter care |
| Medication Technician A | Medication Technician | Provided statements on alarm noise |
| RN B | Registered Nurse | Provided statements on alarm noise |
Inspection Report
Routine
Census: 72
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with facility policies and regulatory requirements regarding the provision of care and assistance for activities of daily living, specifically focusing on showering dependent residents.
Findings
The facility failed to ensure that staff provided at least two showers per week to five dependent residents out of eight sampled. Observations, interviews, and record reviews showed many residents received fewer showers than the facility policy required, with some residents reporting feeling unclean and embarrassed due to infrequent showers.
Deficiencies (1)
Facility failed to provide at least two showers per week to dependent residents as required by policy.
Report Facts
Residents affected: 5
Residents sampled: 8
Showers received by Resident #10 in April: 1
Showers received by Resident #10 in March: 4
Showers received by Resident #10 in February: 2
Showers received by Resident #11 in January: 3
Showers received by Resident #11 in February: 1
Showers received by Resident #11 in March: 1
Showers received by Resident #12 in March: 2
Showers received by Resident #13 in January: 3
Showers received by Resident #13 in March: 1
Showers received by Resident #14 in January: 2
Showers received by Resident #14 in February: 2
Showers received by Resident #14 in March: 3
Showers received by Resident #14 in April: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurses Aide A | Certified Nurses Aide | Reported being agency staff and described shower assignments |
| Certified Nurses Aide B | Certified Nurses Aide | Reported issues with showers when short staffed and resident preferences |
| Certified Nurses Aide C | Certified Nurses Aide | Reported skipping showers if short staffed and re-offering showers |
| Director of Nursing | Director of Nursing | Returned from retirement recently, unaware showers were not being completed, described shower sheet checks |
| Administrator | Administrator | Expected showers to be provided weekly, preferably twice a week |
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