Pleasant Valley Healthcare and Rehabilitation Cent

In the surveyor’s words

From the most serious findings on record at Pleasant Valley Healthcare and Rehabilitation Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF698Sep 14, 2024

  Based 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]. […]

• Immediate jeopardy, isolatedF600Nov 24, 2023

  Based 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]). […]

• Immediate jeopardy, isolatedF607Nov 24, 2023

  Based 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]. […]

• Actual harm, isolatedF686Jul 17, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Oct 21, 2021

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure expired foods were discarded, food was properly stored in the facility's refrigerator and freezer, and the freezer floor was free from spills. These failures could place all residents who ate from the kitchen at risk for food-borne illness. […]