Pleasant Valley Healthcare Center

Inspectors wroteBased on observation and staff interviews the facility failed to distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure all equipment used for meal deliveries was clean. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 99.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate minimum data set (MDS) assessment. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of hospice. Resident Identifier: #20. Facility census: 99.

Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Infection control breaches occurred during medication administration. This was a random opportunity for discovery during the medication administration facility task. Resident identifier: #12 Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to implement their Abuse Prohibition policy by failing to report all allegations of neglect to appropriate state agencies as required. Resident #398, #399, #8 and #11 made allegations of neglect at the same time regarding Nurse Aide (NA) #73 nor providing care to them when requested. These allegations of neglect were not reported to the appropriate state agencies as required by the facility's policy. This was true for four (4) of five (5) residents reviewed for the care area of abuse during the long term care survey process. Resident identifiers: #398, #399, #8, and #11. Facility census: 97.

Inspectors wroteBased on record review and staff interview, the facility failed to report all allegations of neglect to appropriate state agencies as required. Resident #398, #399, #8 and #11 made allegations of neglect at the same time regarding Nurse Aide (NA) #73 not providing care to them when requested. These allegations of neglect were not reported to the appropriate state agencies as required. In addition, an incident of resident to resident altercation involving Resident #81 abuse was not reported to appropriate state agencies as required. This was true for five (5) of five (5) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: #398, #399, #8, #11 and #81. Facility Census: 97. Findings Included: [...]

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to develop and implement a Medication Regimen Review (MRR) policy that accurately addressed the time frames for steps in the MRR process. The facility also failed to ensure monthly pharmacy medication reviews were completed by the consulting pharmacist. This was true for four (4) out five (5) residents reviewed for unnecessary medications. Resident identifiers: #6, #20, #90, and #41. Facility census: 97.

Inspectors wroteBased on staff interview, resident interview, and record review, the facility failed to ensure facility staff, responsible for presenting the binding arbitration agreements to residents/responsible parties could explain the nature and implications of the proposed binding arbitration agreement to inform their decision on whether or not to enter into such agreements. This had the potential to affect more than a limited number of residents at the facility. Resident identifiers: #87, #248, #2. Facility census: 97.

Inspectors wroteBased on record review, and staff interview, the facility failed to accurately complete section E (Wandering) of the MDS. This is true for one (1) of (22) medical records reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: 89. Facility census: 97.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure 2 of 22 residents reviewed had a person-centered comprehensive care plan developed for Resident #89's wandering and Resident #41's positioning / comfort device. Resident identifiers: #89 and #41. Facility census: 97.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure one (1) of one (1) residents reviewed for the care area of skin conditions, non pressure had the care plan updated for treatment of a diabetic ulcer. Resident identifier: #73. Facility census: 97.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple medications stored in the medication room refrigerators were unlabeled and undated. This practice had the potential to affect a limited number of residents. Facility census: 97.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure a medicaid resident who was in need of routine and/or emergency dental care received needed care as soon as possible. Resident #93 returned from a dental appointment on 11/02/22 and returned with recommendations for teeth extractions, fillings and fittings for a top denture and lower partial. On 11/09/22 the facility confirmed they had not begun the process of setting up this recommended dental work. This was true for one (1) of one (1) residents reviewed for dental. Resident identifier: #93. Facility census: #97.

Inspectors wroteBased on observation, facility documentation review, and staff interview, the facility failed to provide food services in accordance with professional standards. The facility failed to ensure food were dated to indicate when opened. The facility also failed to ensure temperatures for the walk-in freezer were consistently recorded. The practice had the potential to affect a limited number of residents. Facility census: 97.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain current food handler cards as required by County law for one (1) of ten (10) employees reviewed in the Dietary Department. This practice had the potential to affect a limited number of residents who receive their nutrients from the kitchen. Facility census: 97.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for two (2) of 21 sample residents reviewed during the Long-Term Care Survey process. The facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were legally valid. Resident identifiers: #90 and #248. Facility census: 97.

Inspectors wroteBased on facility documentation and staff interview, the facility failed to maintain documentation related to current students training in the facility for COVID-19 vaccination for eight (8) of eight (8) nurse aide and nursing students reviewed for compliance with Covid -19 vaccinations. Facility Census: