Pleasant Valley Rehabilitation and Nursing

Inspectors wroteBased on observation of medication administration, interview, record review and facility document review, the facility failed to ensure an insulin pen was primed and the plunger was held down for a count of five (5) seconds after an administration of insulin, according to manufacturer's instructions for 1 (Resident #11) sampled resident reviewed for medication administration.

Inspectors wroteF0812 F Based on observations and interview, the facility failed to ensure deep fryer was free of debris to prevent potential cross contamination, floor throughout the kitchen and wall air vent were free of grease, and stains, food items stored in the freezer or refrigerator were sealed, covered and dated, expired food items were promptly removed /discarded by the expiration or use by dates, and foods were dated as when received to ensure first in and first out usage to prevent the potential for food borne illness, 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition to prevent food and beverage contamination, staff washed their hands between dirty and clean tasks and before handling clean equipment to minimize the potential for contaminating food items for residents who received meals from 1 of 1 kitchen. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the state survey results were posted in a place readily accessible to residents.

Inspectors wroteBased on observation and interview the facility failed to ensure a homelike environment for 1 (room [ROOM NUMBER]) room on the 200 Hall. The facility also failed to ensure residents meals were removed from serving trays in the dining room to de-emphasize the institutional character of the setting to promote dignity and respect. This failed practice had the potential to affect 2 (Resident's #21 & #42) sample mix residents who received a tray on the 200 Hall during lunchtime Sunday 2/4/24 according to a list provided by the Nurse Consultant on 2/7/24 at 1:01pm.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 (Resident #35) of 5 (Residents #13, #21, #35, #42, #66) sample mix residents that were reviewed for unnecessary medications received a diagnosis prior to receiving an anti-depressant medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 5 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 02/08/2024

Inspectors wroteBased on interview the facility failed to ensure isolation laundry was handled correctly to prevent the spread of infection. This failed practice had the potential to affect 15 (Resident's #1, #6, #7, #11, #20, #21, #25, #27, #36, #37, #42, #50, #53, #54, #64) sample mix residents who depend on the facility to provide laundry services according to a list provided by the Social Services Director on 2/7/24 at 3:48pm.

Inspectors wroteBased on observation and interview the facility failed to ensure a safe environment for 1 (room [ROOM NUMBER]) room on the 200 Hall. This failed practice had the potential to affect 3 (Resident #13, #42, & #53) residents who were ambulatory on the 200 Hall, and the facility failed to ensure the residents were provided a homelike environment for 5 (room [ROOM NUMBER], room [ROOM NUMBER], Room112, room [ROOM NUMBER], and room [ROOM NUMBER]) rooms on the 100 Hall .

Inspectors wroteBased on observation and interview the facility failed to ensure a vial of long-acting insulin was properly labeled with an open date. This failed practice had the potential to affect 1 (Resident #12) sample mix residents according to a list provided by the Nurse Consultant on [DATE] at 1:01pm.

Inspectors wroteBased on record review and interview, the facility failed to ensure an injury of unknown source/origin was reported to the Office of Long-Term Care (OLTC) and other agencies in accordance with state and federal laws for 1of 1 (Resident #2) of 3 sampled residents. This failed practice had the potential to affect 73 residents that reside in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before they handled clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 83) as documented on a list provided by Dietary Supervisor on 10/31/22.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's environment was free from accident hazards for 2 (Resident #19 and Resident #80) of the 7 sample residents (R #6, R #10, R #19, R #61, R #64, R #74, and #80) at the facility, who were ambulatory or propel themselves in a wheelchair, as evidenced by Resident #19 had two bottles of peri wash on his over bed table, and R #80 had 1 (1.5 Liter) bottle of mouthwash, 1 can of aerosol hairspray, four bottles of shampoo and two bottles of hair conditioner on the floor next to his nightstand. This failed practice had the potential to affect 39 residents who ambulated by any means, or self-propelled according to a list provided by the Interim Administrator on 11/3/22

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and immunization records were tracked and documented completely for 6 (Resident #6, R #22, R #25, R #52, R #56, R #61) of 6 sample selected residents who had signed consents for the Pneumococcal vaccine to help protect against Pneumococcal bacteria which could cause serious infections and be potentially fatal. This failed practice had the potential to affect 133 admissions since the facility's last survey on 11/4/21 per the admission Lists provided by the Interim Administrator on 11/3/22.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (Resident #55) of 1 sampled resident had a ventilator as documented on the resident Minimum Data Set (MDS) Assessments.

Inspectors wroteBased on record review and interview, the facility failed to include the recommendations from the Preadmission Screening and Resident Review (PASARR) determination and evaluation report into the Care Plan for 2 (Resident #10 and Resident #28) of 2 sampled residents who had Level 2 screening recommendations.