Pleasant Valley Health Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' private information was not released on social media for 3 (#2, 4 and #5) of 3 sampled residents reviewed for privacy. The DON identified 74 residents resided in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a fall intervention to toilet a resident every hour was implemented for 1 (Resident #85) of 3 sampled residents reviewed for falls.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to ensure a licensed practical nurse (LPN) knew how to prime an insulin pen for 1 (Resident #7) of 6 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, facility policy review, and the manufacturer's guidelines, the facility failed to ensure the medication error rate was 5 percent (%) or less. The facility had 3 medication errors out of 34 opportunities, which yielded a medication error rate of 8.82% for 2 (Resident #76 and Resident #7) of 6 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's supplemental oxygen tubing was stored in a plastic bag when not in use for 1 (Resident #41) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteOn 08/16/24 at 9:35 a.m., the Oklahoma State Department of Health identified the presence of an immediate jeopardy related to the facility failed to evaluate Residents #51 and #18 for the capacity to consent to sexual activity. Resident #18 had known sexually inappropriate behaviors and there was no evidence the facility identified these events as sexual abuse or evaluated the resident's capacity to consent. A Progress Note, dated 06/21/24 at 7:16 p.m., documented Resident #51 was observed with their legs opened and Resident #18 was sitting in front of Resident #51, rubbing on Resident #51's vagina. The nurse told the residents they could not do that. The nurse observed them kissing, went to speak with Resident #51, who was leaned forward while trying to pull their pants down, and Resident #18 had partial of their penis out. The nurse told them they could not do that in the hallway. [...]

Inspectors wroteBased on observation, record review, and interview, the facilty failed to ensure staff members assisted residents with eating in a dignified manner for two (#12 and #75) of nine sampled residents observed during meal service in the assisted dining room. The DON identified 15 residents who required feeding assistance resided in the the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure information to file a formal complaint to the state agency and ombudsman were readily available to 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83.

Inspectors wroteBased on observation and interview, the facility failed to ensure past survey results were readily available to residents to review for 10 of 10 residents that attended the resident group interview. The Administrator reported the census was 83.

Inspectors wroteBased on interview and record review, the facility failed to ensure the results of abuse investigations were submitted to the State within 24 hours for three (#15, 44, and #51) of five residents reviewed for abuse. The Administrator identified 83 residents resided in the facility.

Inspectors wrote2. Resident #44 had diagnoses to include mild intellectual disabilities, vascular dementia, hearing loss, visual loss, behavioral and emotional disorder with childhood onset, schizophrenia, and bipolar. A Quarterly Assessment, dated 07/19/24 documented Resident #44 had moderate cognitive impairment, displayed verbal behavioral symptoms toward others and required some substantial to maximum assistance with ADLs. An Incident Report Form, dated 06/26/24 documented a hospice nurse reported Resident #44 stated a staff member was too rough with Resident #44. The resident had reported they had urinated on themselves in the dining room at lunch and the aide had to take the resident out of the dining room to provide care. Resident #44 stated They just jerked me around . [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans for two (#18 and #51) of 21 residents reviewed for care plans. The Administrator identified 83 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure RN coverage for eight consecutive hours seven days per week. The Administrator identified 83 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow their policy to administer medications via enteral tube for one (#13) of one sampled resident reviewed for medication administration via gastrostomy tube. The Administrator stated 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. A total of 37 medications opportunities were observed, with three errors, for a total error rate of 8.11%. This affected two (#13 and #43) of six residents observed during the medication administration. The Administrator stated 83 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: 1. ensure bare hand contact with food did not occur during the lunch meal service. 2. monitor the dish washing machine to ensure proper sanitation was being conducted.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. handle soiled linens in a manner that prevented cross contamination for one (#14) of one sampled resident observed during wound care; and b. ensure enhanced barrier precautions were utilized when accessing a resident's gastric tube for one (#13) of one sampled resident observed with a gastric tube. The Administrator identified 83 residents resided in the facility. The Resident Matrix, dated 08/12/24, documented four residents with a gastric tube resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for two (#58 and #85) of 21 residents reviewed for assessments. The Administrator identified 83 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician ordered labs were obtained for one (#14) of 12 sampled residents reviewed for lab services. The Administrator identified 83 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored in a sanitary manner and dishes were dried completely before storing them. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plans were updated to meet residents' current needs for three (#14, 19, and #47) of 25 sampled residents whose care plans were reviewed. The facility failed to ensure: a. Res #47's care plan was updated with new fall interventions. b. Res #19's care plan was updated with new dialysis orders. c. Res #47 and #14's care plans had input by the required staff members. d. the facility held the required care plan meetings for Res #47 and #14. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility.

Inspectors wrote3. Res #11 had diagnoses which included abnormalities of gait and mobility, lack of coordination, muscle weakness, difficulty in walking, muscle wasting and atrophy, and morbid obesity. A care plan, dated 09/05/2016, documented the resident used positioning bar for repositioning and transfer related to obesity and arthritis. A care plan, dated 12/01/2017, documented the resident would be free of injuries related to positioning bars. A quarterly assessment dated [DATE], documented the resident's cognition was intact and required minimal to limited assistance with ADLs. A five day assessment, dated 05/24/23, documented the resident's cognition was intact and required limited to no assistance with ADLs. On 07/12/23/ at 4:34 p.m., an observation was made of the resident's bed. Grab bars were observed secured to each side of the resident's bed. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error did not exceed five percent. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to implement an effective pest control program for the facility. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility.

Inspectors wroteBased on record and interview, the facility failed to ensure a resident's DNR form was signed by an individual with the authority to do so for one (#69) of three residents reviewed for advanced directives. The Resident Census and Conditions of Residents form documented 48 residents had advanced directives.

Inspectors wroteBased on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to OHCA for a PASRR Level II evaluation for one (#41) of two residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented 81 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received supervision and assistance to prevent falls for one (#47) of four residents sampled for falls. The administrator identified 54 residents who had fallen in the previous six months.

Inspectors wroteBased on record review and interview, the facility failed to ensure a medication regimen review conducted by the consultant pharmacist and agreed on by the physician was acted on for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 81 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a psychotropic medication was not administered in excessive dosage for one (#42) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents documented 46 residents who resided in the facility received antidepressant medications.