PLEASANT VALLEY MANOR, INC

Nursing Home Inspector

4227 MANOR DRIVE
STROUDSBURG, PA 18360
Monroe County
Phone: 570-992-4172
Provider Number: 395491
Last Inspection: 09/22/2017

About the Nursing Home

Number of Beds: 174
Number of Residents: 165
Beds Available: 9
Percent Occupancy: 95%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

34

Facility
35

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

34

2017
32

2016
32

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/22/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 10/25/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Potential 3 10/25/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 10/25/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 10/25/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 10/25/2017
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 10/25/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 10/25/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 10/25/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 10/25/2017
 

10/28/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 12/28/2016
 
Failed To: Provide proof that residents' personal money that is deposited with the nursing home is secure. Widespread : Potential 4 12/28/2016
 
Failed To: Maintain comfortable and safe temperature levels. Pattern : Minimal 4 12/28/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 12/28/2016
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 1/12/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Pattern : Minimal 4 12/28/2016
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 12/28/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 12/28/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 12/28/2016
 

9/25/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 11/10/2015
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 11/10/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 10/30/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 10/30/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 10/30/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 10/30/2015
 
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 11/10/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 11/10/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 10/30/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 8/3/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 8/3/2017
 

3/10/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Potential 3 4/17/2017
 
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Minimal 4 4/17/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 4/17/2017
 

11/10/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 12/28/2016
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 12/28/2016
 

4/25/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 5/23/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 5/23/2016
 

3/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 4/25/2016
 

1/27/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 unknown
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 unknown
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 unknown
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 3/2/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 unknown
 

8/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 10/30/2015
 

6/11/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 unknown
 

4/29/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 unknown
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Widespread : Potential 4 unknown
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 unknown
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 unknown
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 165 114.00 110.03
Registered Nurses 0.49 0.66 0.94
Licensed Practical / Vocational Nurses 0.81 0.93 0.85
Certified Nursing Assistants 2.47 2.19 2.26
Total Staff Hours 3.77 3.78 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 3 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 96 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 92 95
of long-stay residents experiencing one or more falls with major injury 1 1 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 5 7 7
of long-stay residents who received an antianxiety or hypnotic medication 18 14 22
of long-stay residents who received an antipsychotic medication 14 12 15
of long-stay residents who self-report moderate to severe pain 9 6 6
of long-stay residents who were physically restrained 5 1 0
of long-stay residents whose ability to move independently worsened 28 22 20
of long-stay residents whose need for help with daily activities has increased 14 13 15
of long-stay residents with a catheter inserted and left in their bladder 0 2 1
of long-stay residents with a urinary tract infection 4 1 3
of low risk long-stay residents who lose control of their bowels or bladder 67 62 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 92 89 83
of short-stay residents who had an outpatient emergency department visit 17 12 10
of short-stay residents who made improvements in function 65 59 64
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 14 16 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90 85 82
of short-stay residents who were rehospitalized after a nursing home admission 27 23 20
of short-stay residents who were successfully discharged to the community 35 48 52
of short-stay residents with pressure ulcers that are new or worsened 0 0 0