Pleasant Valley Nursing and Rehab Center

Inspectors wroteBased on interview and record review, it was determined that the facility failed to implement a comprehensive care plan for 1 of 3 residents reviewed for accidents in a final sample of 18 residents (Resident identifier is #26).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were not administered for 1 medication in a total of 30 medication administrations observed. (Resident identifier is #89.)

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure medications were appropriately labeled on 3 of 3 medication carts observed and 1 of 2 medication rooms observed. (Resident identifiers are #24, #50, #7, #35, #42, and #54.)

Inspectors wroteBased on observation, interview, and policy review, it was determined that the facility failed to follow the facility's infection control policies and procedure for hand hygiene, linen handling, and enhanced barrier precautions. Findings Include: Observation on 11/19/24 at 10:33 a.m. of the Skilled Medical Unit (SMU) revealed a pile of soiled bed linens on the floor beside the bed where two Licensed Nursing Assistants (LNAs) were providing care. Interview on 11/19/24 at 10:35 a.m. with Staff F (Director of Nursing) confirmed that the linens were soiled and revealed they should have been put in a plastic bag for transport and not put on the floor. Observation on 11/20/24 at 11:48 a.m. of the SMU meal service revealed Staff G (LNA) exited a resident's room carrying a full clear trash bag. Staff G was not wearing gloves. Staff G disposed of the trash bag in the soiled utility room. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to ensure that licensed nursing staff had the competencies and skills necessary to care for residents with a Gastrostomy Tube (G-tube) for 4 of 4 contracted licensed staff reviewed for staffing (Staff Identifiers are E, I, J, and K).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide documentation of performance reviews and regular in-service education for 2 of 2 Licensed Nursing Assistants (LNAs) reviewed for staffing (Staff Identifiers are Q and R).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to implement and monitor corrective actions for identified gaps in systems.

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure a resident was offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza vaccination for 3 of 5 residents reviewed for vaccinations (Resident Identifiers are #49, #85, and #91).

Inspectors wroteBased on record review, and interview it was determined that the facility failed to inform the resident's activated durable power of attorney for healthcare (DPOA-H) of a change in medication for 1 of 1 resident reviewed for notification of change in a final sample of 25 residents (Resident identifier is #16).

Inspectors wroteBased on interview, observation, and record review it was determined that the facility failed to follow physician's orders for 2 residents in a final sample of 25 residents (Resident Identifiers are #71 and #91). Finds include: Professional reference: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . [...]

Inspectors wroteBased on observations, interviews, and record review, it failed to establish policies for Oxygen (O2) services to include cleaning of O2 equipment for 2 of 2 residents reviewed for respiratory care in a final survey sample of 25 residents (Resident Identifiers are # 41 and #87). Finds include: Resident #41 Observation on 11/28/23 at 9:30 a.m. revealed that there was an O2 concentrator next to Resident #41's bed with a nasal cannula attached to it. The O2 tubing had no marking indicating the date the tubing was put into use. O2 was in use at this time by Resident #41 and the tubing was clear and appeared clean and not soiled. Observation on 11/29/23 at 12:16 p.m. revealed Resident #41's O2 tubing with no date for initiation of tubing. O2 was in use at this time by Resident #41. Review on 11/29/23 at approximately 12:45 p.m. [...]

Inspectors wroteBased on record review, interview, and observation, it was determined that the facility failed to limit psychotropic medication to 14 days for 1 of 5 residents reviewed for unnecessary medications in a final sample of 25 residents (Resident Identifier is #77).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to label medication with open expiration dates when applicable in 1 of 3 medication carts reviewed (Resident Identifiers are #20 and #56).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in 1 of 3 kitchenettes reviewed.

Inspectors wroteBased on record review, observation, interview, and policy review it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for Transmission Based Precautions (TBP) for 1 of 8 residents reviewed for infection control (Resident Identifier is#9). Findings Include: Resident #9 Review on 11/30/23 of Resident #9's medical record revealed they were positive for COVID-19 since 11/23/23 and on TBPs. Observation on 11/30/23 at approximately 10:20 a.m. of Resident #9's room revealed Staff E (LPN) entered Resident #9's room without donning gloves, gown, and eye protection. Interview on 11/30/23 at approximately 10:25 a.m. with Resident #9 revealed that staff sometimes don gloves, gowns, and eye protection when entering the room, but not always while on precaution. Interview on 11/30/23 at approximately 10:30 a.m. [...]

Inspectors wroteBased on record review and interview, it was determined the facility failed to develop a comprehensive care plan which included a resident's need for Oxygen (O2) for 2 of 2 residents reviewed for O2 use in a final sample of 25 residents (Residents Identifiers are #41 and #87).