Pleasant Valley Healthcare and Rehabilitation Cent

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #1) reviewed for pressure ulcers. -The facility failed to complete weekly head-to-toe skin assessments from 05/20/26 to 06/17/26. During this time, the resident developed a sacral wound first identified on 06/15/26 with an area of 28.71 cm2 and 5% necrotic tissue. The notes on 07/06/26 revealed the sacral wound area had increased 49.50 cm2, while the necrotic tissue escalated to 75%. On 07/09/26, the resident was sent to the hospital after becoming unresponsive. The hospital documented she had a foul smelling necrotic sacral wound with bone exposure, bacteremia, and sepsis. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility kitchen reviewed for environment .The facility failed to maintain an effective pest control system to prevent the presence of flies in the facility's only kitchen. This failure could place residents at risk for an unsafe environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for 1 of 3 residents (Resident #10) reviewed for treatment of pressure ulcers. The facility failed to follow Resident #10's physician orders to ensure the resident had heel protectors on while in bed on 06/04/26. This failure could place residents at risk of developing new or worsening pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 medication carts (Hall 400 nurses' medication cart) reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the Hall 400 nurses' medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.

Inspectors wroteBased on observation, interview and record review the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 (Resident #85) residents reviewed for food and nutrition services. The facility failed to ensure that Resident #85 received his breakfast meal tray. This failure could place residents at risk of not meeting the nutritional needs of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure the seal on the walk-in freezer door was replaced properly. This failure could place residents at risk of not having essential equipment maintained and in working order.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 medications carts (Nurses cart for hall 400) reviewed for infection control practices.1. LVN G failed to disinfect the glucometer machine after checking blood sugars for unknown residents. 2. LVN G failed to discard the used glucometer strip in biohazard container and had left the used glucometer attached with a used strip with dried blood on the drawer of 400 nurse's cart. These failures could place residents at risk of exposure to infectious agents and could lead to the development of infection.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure all treatment and care was provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of 7 residents reviewed for quality of care. LVN B, LVN C and LVN E failed to ensure Resident #1's change of condition of a rash on his extremities was followed up on 12/16/25, 12/17/25 and 12/18/25; subsequently no plan of care orders was obtained until Treatment Nurse F called NP G on 12/18/25 at 1:23 pm, for nystatin and Benadryl orders for moisture related dermatitis. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #43) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #43 received treatment immediately after she complained of having symptoms of a urinary tract infection. The resident suffered pain that increased with each shift until treatment was administered. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the facility provided, food and drink that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for dietary services. Facility failed to provide palatable, attractive, and appetizing food and drink to residents. These failures could place 77 residents who reside at the facility and eat meals prepared and served by the facility's kitchen at risk of contracting a foodborne illness, discourage residents to eat and drink, impaired nutrition and hydration status and or the recovery from, illness or injury. Findings Included: Observations during follow up visits to the kitchen on 4/24/25 beginning at 11:30am included the following: Cook Q did not use measuring cup to measure out the precise amount of milk to put in the blender while preparing the pureed food. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #51) of three residents reviewed for PASRR Screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screen for Resident #51. The resident did not receive a PASRR Level II assessment Evaluation. This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #22) of 1 resident reviewed for incontinence care. 1. The facility failed to ensure CNA N did not double-brief Resident #22. 2. The facility failed to ensure CNA O thoroughly cleaned the vaginal area of Resident #22. This failure placed residents at risk for the development and/or worsening of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to, store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. Facility failed to utilize proper personal hygiene practices (e.g., proper hand washing and the appropriate use of gloves) to prevent contamination of food. These failures could place 77 residents who reside at the facility and eat meals prepared and served by the facility's kitchen at risk of contracting a foodborne illness. Findings Included: Observations during follow up visits to the kitchen on 4/24/25 beginning at 11:30am included the following: Cook Q left the prep area with gloves on and put trash in the recycle can then returned to prep and continued to prepare the food with the same gloves. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two of six residents (Resident #30 and #180) observed for infection control. MA K used her ungloved hand to pick medication from the medication cart and administered it to Resident #30. CNA L failed to perform hand hygiene while providing incontinence care to Resident #180 The failures could place the residents at risk for infection.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for Dialysis Care. 1)The facility failed to follow Resident #1's Dialysis Communication: Special instructions/progress note dated Thursday [DATE] for Resident #1 to go to the hospital for a permacath placement because she was not able to be dialyzed that day. 2)LVN A failed to notify Resident #1's Doctor or NP about the Dialysis Center's special instructions for Resident #1 to go to the hospital on [DATE]. 3)LVN A failed to properly assess and document Resident #1's vital signs on [DATE], before leaving for dialysis and after she returned from dialysis. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of six residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's vital signs check in the EMR before she left and after she returned for dialysis on [DATE]. The facility failed to ensure LVN A completed documentation on [DATE] about the special instructions from Resident #1's Dialysis Center for her to go to the hospital for a permacath placement. The facility failed to ensure LVN A documented notifying Resident #1's Doctor/NP about the need to go to the hospital per the Dialysis Communication sheet on [DATE] and the outcome of what the Doctor/NP said. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #16) of 8 residents reviewed for Resident Rights. The facility failed to ensure Resident #16 was accommodated with a call light to meet her needs in order to call for assistance when she needed it. This failure could place residents at risk of not being able to call for staff assistance, which could cause delays with getting ADL care, pain management and other healthcare needs leading to health decline and decreased psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 13 of 13 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on interview and record review the facility failed to have a governing body appointing the administrator who was licensed by the state, where licensing was required, responsible for the management of the facility and reported to and accountable to the governing body for one (facility) of one reviewed for Administrator. The facility failed to appoint an Administrator who was responsible for the management and operations of the facility. Some of the facility staff were not aware of who the facility Administrator was, and the identified Administrator was not actively involved in the day-to-day operations and management of the facility. Subsequently, the OM delayed reporting alleged Abuse/neglect to the identified Administrator and HHSC within the required timeframes. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (hall 400 nurses' cart) and 2 of 2 Residents (# 16 and #37) reviewed for pharmacy services. 1. The facility failed to ensure the hall 400 nurses medication cart contained accurate narcotic record for Residents #37 and #16. 2. The facility failed to ensure a bottle of Benadryl tablets that were expired were removed from the 400 Hall medication cart. This failure could place residents at risk for drug diversion, delay in medication administration and at risk of receiving medications that were ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress and to protect the resident's right to be free from neglect for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for neglect. The facility failed to ensure that one or more residents were free from neglect when LVN A and CNA C did not provide services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress to one or more residents. Cumulative effects from LVN A and CNA C individual failures to provide oversight of care delivery to Resident #1 for 8 hours on [DATE] 10:00 PM - 6:00 AM ([DATE]). During the 8-hour span, Resident #1 committed suicide. An Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and records review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) of 28 residents reviewed for provision of care and services by staff. The facility failed to ensure staff implemented abuse and neglect policies and procedures during the provision of care and services to residents. The facility failed to implement abuse and neglect policies and procedures by immediately removing or suspending LVN A and CNA C from the care of any resident during the investigation of potential abuse or neglect to protect other residents from harm. LVN A and CNA C worked [DATE] 10:00 PM - 6:00 AM. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:30 PM. [...]