Pleasant Valley Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Pleasant Valley Nursing and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF726Dec 1, 2023

  Based 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). Finding include: Observation on 11/29/23 at 7:10 a.m. of Resident #71's G-tube medication administration with Staff E (Licensed Practical Nurse (LPN)) revealed that Staff E did not flush the G-tube prior to administering the first medication and did not flush between the medications. Interview on 11/29/23 at 10:00 a.m. with Staff E confirmed that he/she did not flush before administering medications or between the medications. […]

• No harm, potential for more than minimal, patternF730Dec 1, 2023

  Based 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). Findings include: Interview on 11/30/23 at 2:51 p.m. with Staff O (Administrator) revealed that the facility was aware that staff performance reviews and in-service education had not been done. Review on 12/1/23 of the facility's Active Employee list revealed that Staff Q and Staff R had been employees since 2019. Review on 12/1/23 of Staff Q's employee file revealed that there was no annual performance review completed in the past 12 months and no in-service training. […]

• No harm, potential for more than minimal, patternF865Dec 1, 2023

  Based on interview and record review, it was determined that the facility failed to implement and monitor corrective actions for identified gaps in systems. Findings include: Review on 11/30/23 of 5 residents for influenza and pneumococcal vaccination revealed that 3 of 5 medical records did not contain documentation that residents were offered and received education for influenza and pneumococcal vaccination. Cross reference F883 Influenza and Pneumococcal Immunizations. Interview on 11/30/23 at 2:51 p.m. with Staff O (Administrator) revealed that the facility had identified issues offering and educating residents for influenza and pneumococcal vaccinations and the issue was in Quality Assurance. […]

• No harm, potential for more than minimal, patternF880Dec 1, 2023

  Based on record review, observation, interview, and policy review it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 6 of 8 residents reviewed for infection control (Resident Identifiers are #36, #79, #88, #71, #91, and #9). Findings Include: Resident #88 Review on 11/28/23 of Resident #88's medical record revealed they had a Foley catheter since admission on 10/30/23. Observation on 11/28/23 at approximately 12:15 p.m. of Resident #88 revealed no EBP signage or PPE available outside of the resident's room. Interview on 11/29/23 at approximately 9:35 a.m. […]

• No harm, potential for more than minimal, patternF883Dec 1, 2023

  Based 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). Findings include: Resident #91 Review on 11/30/23 of Resident #91 medical record revealed that Resident #91 was admitted to the facility in October 2023, discharged to the hospital on 10/30/23, and returned on 11/10/23. […]