Pleasant Valley Manor Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 15 sampled residents reviewed for unnecessary medications (Resident #1, #2 and #34), and/or their representative were informed of the risks and benefits of taking psychotropic medications, this included anti-depressant medications, anti-anxiety medications, hypnotic medications (sleep aid), and anti-psychotic medications (for the treatment of mood and behaviors associated with mental health conditions). This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 62. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for three residents (Resident #68, #69, and #70) and failed to notify one resident (Resident #21) when they were within $200.00 of the Supplemental Security Income (SSI) resources limit. This affected four of 15 residents sampled. Facility census was 62. Request for a policy covering resident funds upon discharge was not provided by the facility.1. Review of the facility's accounts receivable aging report, dated [DATE], showed the following residents had money in the facility's operating account: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication rate under five percent for two sampled residents (Resident #32 and #44) when there were four missed opportunities out of 25, leaving a medications error rate of 16%. The facility census was 62 residents. Review of the facility Medication Administration policy, updated on 7/15/21, showed all resident shall receive medications on a timely basis and in accordance with established policies. Medication orders are to be followed exactly per the physician. If there is any concern regarding the order the physician should be contacted prior to administering the medication. 1. Review of Resident #32 POS (Physician Order Sheet), dated September 2025, showed an order for Psyllium Husk Powder, give 17gm daily for constipation. Instructions read: Mix in 8oz of liquid.in the A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to discard expired medications and biologicals stored within the medication cart, failed to ensure medication was not wedged behind the drawer of the medication cart, which affected four of 15 sampled residents (Resident #33, #20, #71 and #56), and failed to ensure there were no loose pills in the medication cart. The facility census was 62. Record review of the facility's undated policy for Storage of Medications showed:- The purpose of this procedure is to ensure that medications are stored in a safe, secure and orderly manner.- Medications are bubble packaged when they are received. Over the counter may be in a bottle with the label intact and the date the bottle is opened.- Drug containers having soiled, illegible, worn, makeshift, incomplete, damaged or missing labels should be returned to the pharmacy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired food items in the dry storeroom and leftovers in the refrigerator, failed to date and label food items in a refrigerator, and failed to properly date incoming food products stored in the dry storeroom. This had the potential to affect all residents by putting them at risk for a food borne illness. The facility census was 62. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an alternative appealing option of similar nutritive value to one resident (Resident #35) who refused food being served. This affected one resident of 15 residents sampled. The facility's census was 62. Record review of facility policy Resident Food Preferences, revised July 2017, showed the food services department will offer a variety of foods at each scheduled meal and substitutions with the same nutritive value Record review of meal substitutes for lunch, dated 9/2/25, showed: Hot dogs, chicken noodle soup, cheese puffs, ice cream, side salad, diced pears, yogurt or chips.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff prepared foods per the prescribed therapeutic diet needs of individual residents when they did not ensure the main entree for a resident was mechanically altered with accompanying gravy or broth for one resident (Resident #1) out of 15 sampled. The facility census was 62. The facility did not provide the requested policies on therapeutic diets and pureed food preparation. Record review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/1/25, showed:- Resident was cognitively intact;- Resident dependent on staff for set up assistance for eating;- Diagnosis: [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food stored in the main kitchen was labeled, dated, disposed of upon expiration, and the thermometer was properly sanitized in-between taking temperatures of the food. These failures had the potential to increase the prevalence and spread of foodborne illnesses and infection for all 60 facility residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure the sit to stand mechanical lift was functioning properly before use for one of three residents (Resident (R) 5) who utilized the sit to stand lift; ensure the air conditioning unit for two of two residents (R51 and R17) was sealed to prevent pests from entering the rooms; ensure the laundry room floor was a cleanable surface; and ensure the northeast shower room was clean and safe for the residents utilizing the room of 28 sample residents. This failure had the potential to affect the 60 residents' right to reside in a safe, clean, and comfortable environment.

Inspectors wroteBased on record review and interview, the facility failed to coordinate resident care with other health care providers who provide care for one of three residents (Resident (R) 32) with care provided by an outside health care agency of 28 sample residents. The facility's failure to provide ongoing communication with the outside health care provider places the resident at risk for inadequate or inappropriate care.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure two of three Certified Nursing Assistants (CNA) 1 and CNA2 reviewed had received annual performance reviews along with 12 hours of in-service training for the last year. This deficient practice had the potential to allow CNAs to not receive the in-service training based on the outcome of the performance review.

Inspectors wroteBased on interview and record review, the facility failed to report to law enforcement (LE) and the Department of Health and Senior Services (DHSS) when the facility Director of Nursing (DON) became aware on 9/9/23 that there was an allegation of abuse by Certified Nurse Aide (CNA) A towards Resident #1. This affected one of five sampled residents (Resident #1). The facility census was 69. Review of the facility Abuse Prevention Policy, dated 11/2017, showed: -All allegations of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury occurred, will be reported immediately in compliance with state law and regulation. -Any and all identified types of allegations will be investigated. The DON/designee will be responsible for conducting an investigating and reporting the results to the proper authorities. [...]

Inspectors wroteBased on interview and record review, the facility Administrator and Director of Nursing (DON) failed to investigate allegations of abuse from Resident #1 when the DON was made aware on 9/9/23 that CNA A held Resident #1's mouth closed with his/her fingers. This affected one of one sampled residents. The facility census was 69. Review of the facility Abuse Prevention Policy, dated 11/2017, showed: -All allegations of suspected abuse/neglect/exploitation as defined in this policy, whether or not an actual injury occurred, will be reported immediately in compliance with state law and regulation. -Any and all identified types of allegations will be investigated. The DON/designee will be responsible for conducting, investigating and reporting the results to the proper authorities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they cared for residents in a dignified way that a reasonable person would expect when they failed to respond to residents yelling out, provide privacy during catheter peri-cares, provide clothing assistance to resident with belly exposed, notify a visually impaired person they were leaving, did not cover a catheter bag, and did not provide residents access to call buttons. This affected four of 16 sampled residents (Residents #10, #48 , #57, and #179). The facility census was 76. The facility policy, dignity, dated February 2021, showed: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 2. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain the building in a homelike environment. The facility failed to provide an environment with comfortable sound levels when a door alarm went off multiple times throughout the day. The facility also failed to monitor and maintain air temperatures in the 71 degrees Fahrenheit and 120 degrees Fahrenheit. The facility failed to replace broken blinds, mount mirror to wall, and replace light bulb in a resident room. The facility census was 76. The facility did not provide a policy on homelike environment. 1. Review of resident #66's annual Minimum Data Set (MDS), a federally mandated instrument completed by facility staff, dated 4/11/23 showed: [...]

Inspectors wroteBased on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected four of ten sampled staff (Dietary Aide A, Housekeeper A, Dietary Aide B, and Laundry Aide A). The facility census was 76. Review of the facility policy, Abuse Prevention Policy, dated 11/2017., showed: -To ensure screening and training of potential employees, have procedures in place for prevention, to identify alleged abuse/neglect/exploitation, procedures in which to investigate and protect residents, and immediate resorting of any alleged, suspected or witnessed abuse/neglect/exploitation to any resident. -Screening: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's for five sampled residents (Resident #12, #57, #48, #10 and #18). The facility census was 76. Review of the facility's Comprehensive, Person-Centered Care Plan Policy, revised December 2016, showed: - The comprehensive, person-centered care plan will: o Include measurable objectives and timeframe's; o Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; o Included the resident's stated goals upon admission and desired outcomes; o Incorporate identified problem areas; o Reflect treatment goals, timetables and objectives in measurable outcomes; [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide appropriate positioning for four of 16 sampled residents (Resident #72, #38, #55, and #4) while eating. The facility census was 76. Facility did not provide a policy on positioning during meals. Facility policy titled activities of daily living (ADL), supporting, dated March 2018, showed: -Residents will be provided care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided three of 16 sampled residents (Resident #28, #48 and #55), that were unable to do their own activities of daily living (ADLs tasks done in a day to care for oneself such as bathing, toileting, personal hygiene, etc), the necessary care and services to maintain good personal hygiene. The facility census was 76. Review of the facility provided policy Activities of Daily Living dated March 2018 showed in part: -Residents will be provided with care, treatment and services as appropriate to mainitain or improve their ability to carry out activities of daily living. -Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintian good nutrition, grooming and personal and oral hygiene. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for three sampled residents when staff did not ensure call lights were accessible to Resident #12, #13 and #57. The facility failed to ensure Resident #31 did not have access to medication that he/she did not have an order for. The facility census was 76. Review of the facility's Answering the Call Light Policy, revised March 2021, showed: - Staff are to be sure the call light is plugged in and fuctioning; -When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident; - Staff are to check on residents that may not be able to use their call light frequently. 1. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/7/23, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used proper infection control techniques when performing catheter care for Resident #57 and when staff failed to ensure that catheter drainage bags for Resident #57 and Resident #179 were secured and not touching the floor. The deficient practice affect two of 16 sampled residents. The facility census was 76. Review of the facility's Indwelling Catheter Care policy, revised 7/13/21, showed: -Hold the catheter at the insertion site to prevent tugging and clean the catheter tubing by wiping from the insertion site away from the resident; -Use one cloth per swipe. Review of the facility's Perineal Care Policy, revised 7/12/21, showed: -For female residents, separate the skin folds; -Cleanse moving from the front to the back; -Wash each side of the skin folds and in the center over the urethral opening; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to review the risk and benefits with the resident or the resident representative and obtain informed consent prior to installation, and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for four of 16 residents sampled (Residents #10, #12 , #13 and #59). The facility census was 76. Review of the facility policy titled Entrapment Assessment, dated 10/12/18, showed: -The facility desires to remain a restraint free facility and prefers not to use side rails -If situation indicates side rails are required the following areas shall be monitored to ensure that entrapment with the side rail did not occur. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of psychotropic medications for four of 16 sampled residents (Resident #4, #31, #24, and #65). The facility census was 76. Review of the facilty's Drug Regimen Review Monitoring, revised, on 6/24/21, showed: -It is the facilty policy to ensure each resident receives medications in a manner that follows best practice; -A pharmacist shall review the resident's medical record monthly and make recommendations; -The recommendations shall be given to the director of nursing; -The Director of Nursing (DON) shall review the recommendations and contact the physician within five working days; -After orders are received they will be processed in a timely manner. 1. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to complete entrapment assessments for four of 16 sampled residents with side rails (Residents #10, #12, #13, and #59, ) to ensure the environment remained safe and free of accident hazards. The facility census was 76. Facility policy titled entrapment assessment, dated 10/12/18, showed: -Facility desires to remain a restraint free facility and prefers not to use side rails -If situation where side rails are required the following areas shall be monitored to ensure that entrapment with the side rail did not occur. -The maintenance department (or designee) will complete the side rail entrapment review -The review will be done quarterly Facility policy titled proper use of side rails, revised December 2016, showed: [...]