Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 1
Date: Nov 19, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control policies, including hand hygiene, linen handling, and enhanced barrier precautions.
Findings
The facility failed to follow its infection control policies and procedures, as evidenced by soiled linens on the floor, staff not washing hands after handling trash, and lack of personal protective equipment for a resident with an indwelling urinary catheter. The facility did not implement required Enhanced Barrier Precautions for residents with urinary catheters.
Deficiencies (1)
Failure to follow infection control policies and procedures for hand hygiene, linen handling, and enhanced barrier precautions.
Report Facts
Residents Affected: 2
Residents Affected: 1
Date of urinary catheter order: Sep 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Director of Nursing | Confirmed linens were soiled and should have been bagged |
| Staff G | Licensed Nursing Assistant | Observed not wearing gloves and not washing hands after handling trash |
| Staff C | Licensed Practical Nurse | Confirmed Resident #49 had an indwelling urinary catheter |
| Staff D | Infection Preventionist | Confirmed residents with indwelling urinary catheters should be on Enhanced Barrier Precautions |
Inspection Report
Routine
Deficiencies: 12
Date: Dec 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, staff competencies, food safety, and vaccination policies at Pleasant Valley Nursing and Rehab Center.
Findings
The facility was found deficient in multiple areas including failure to notify residents' healthcare proxies of medication changes, incomplete care plans for oxygen use, failure to follow physician's orders, inadequate staff competencies and training, improper medication labeling, failure to maintain proper food storage temperatures, incomplete vaccination education and documentation, and failure to follow infection control precautions for COVID-19.
Deficiencies (12)
Failed to inform resident's durable power of attorney of medication change.
Failed to develop comprehensive care plans including oxygen use for residents.
Failed to follow physician's orders for medication administration and G-tube flushing.
Failed to establish policies for cleaning oxygen equipment and monitoring tubing changes.
Licensed nursing staff lacked competencies and skills necessary to care for residents with G-tubes.
Failed to provide documentation of performance reviews and regular in-service education for licensed nursing assistants.
Failed to limit psychotropic medication use to 14 days as recommended.
Failed to label medication with open expiration dates on medication carts.
Failed to store food at proper temperatures in kitchenettes, with repeated refrigerator temperature violations.
Failed to implement and monitor corrective actions for identified gaps in quality assurance and performance improvement activities.
Failed to follow CDC guidance for transmission-based precautions for a resident with COVID-19.
Failed to ensure residents were offered and educated on influenza and pneumococcal vaccinations.
Report Facts
Residents reviewed: 25
Medication administration dates: 13
Temperature readings: 50
Contracted licensed nursing staff: 4
Licensed Nursing Assistants reviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Unit Manager | Confirmed failure to inform DPOA-H of medication change and confirmed medication administration findings |
| Staff E | Licensed Practical Nurse | Observed and confirmed failure to flush G-tube medications and failure to don PPE |
| Staff F | Infection Preventionist/Staff Development | Confirmed lack of onsite training for contracted staff and vaccination education deficiencies |
| Staff H | Human Resources | Confirmed lack of onsite training and performance reviews for staff |
| Staff P | Registered Nurse/Unit Manager | Confirmed care plan deficiencies and medication administration issues |
| Staff O | Administrator | Acknowledged lack of staff training, performance reviews, and quality assurance monitoring |
| Staff G | Food Service Manager | Confirmed refrigerator temperature violations |
| Staff D | Licensed Practical Nurse | Confirmed medication labeling deficiencies |
| Staff M | Maintenance Assistant | Confirmed refrigerator temperature issues |
| Staff A | Unit Manager | Confirmed vaccination documentation deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 2, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including informed consent for antipsychotic medications, PASRR screening, behavioral health services, medication storage and labeling, medical record accuracy, and immunization policies.
Findings
The facility failed to ensure residents or their representatives were fully informed about antipsychotic medication risks and consents for 4 of 5 residents reviewed. PASRR screening was not completed for 2 of 4 residents with mental disorders. Behavioral health consults were not provided for 1 of 5 residents reviewed. Medication carts were found unlocked and medications not stored in original containers. Medical records were incomplete or inaccurate for 4 of 4 residents reviewed. Pneumococcal vaccines were not offered or documented for 3 of 5 residents reviewed.
Deficiencies (6)
Failed to ensure residents or representatives were fully informed of risks of antipsychotic medications and lacked signed or verbal consents for 4 residents.
Failed to ensure PASRR screening was completed for residents with mental disorders for 2 residents.
Failed to provide behavioral health/psychiatry consults for 1 resident reviewed for unnecessary medications.
Medication cart was unlocked and medications were not stored in original containers on 1 medication cart.
Failed to maintain complete and accurate medical records for 4 residents, including incorrect diagnoses and misfiled PASRR documents.
Failed to offer pneumococcal vaccine or document vaccination history/refusal for 3 residents.
Report Facts
Residents reviewed for antipsychotic use: 5
Residents reviewed for PASRR: 4
Residents reviewed for behavioral health consults: 5
Medication carts observed: 5
Residents reviewed for medical records: 4
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Confirmed lack of signed or verbal consents for antipsychotic medications and medication administration documentation issues |
| Staff C | Interim Director of Nursing | Confirmed lack of signed or verbal consents for antipsychotic medications and psychiatric referral documentation |
| Staff A | Social Worker | Confirmed PASRR screening issues and misfiled PASRR documents |
| Staff E | Licensed Practical Nurse | Admitted leaving medication cart unlocked and unattended |
| Staff G | Unit Manager | Confirmed lack of pneumococcal vaccination documentation and follow-up |
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