Pleasant Valley Manor Care Center

In the surveyor’s words

From the most serious findings on record at Pleasant Valley Manor Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 6, 2022

  Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards when staff did not properly maintained a Liko Viking mechanical lift according to the manufacturer's directions. Staff did not perform daily and routine maintenance checks on the lift, causing the lift to malfunction during a transfer resulting in an injury to one resident (Resident #1). The facility census was 70. Review of the Liko Viking mobile lift instruction guide showed for trouble-free use, certain details should be checked each day the lift is used: move this to the top - Inspect the lift and make sure that there is no external damage. […]

• No harm, potential for more than minimal, patternF552Sep 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF569Sep 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF759Sep 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF761Sep 5, 2025

  Based 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. […]