Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%
with medication opportunities of 36 for 2 of 5 residents (Resident #22 and #31) and 1 of 3 staff (MA C)
reviewed for medication administration errors, in that:
Residents Affected - Some
MA C administered late medications to Resident #22 and #31 resulting in an 13% medication
administration error rate.
This failure could place residents at risk for not receiving therapeutic effects of their medications and
possible adverse reactions.
The findings included:
Record review of Resident #22's face sheet, dated 01/19/23, reflected the resident was admitted on [DATE].
The resident was diagnosed with Types 2 diabetes, dysphagia (difficult with eating and swallowing), visual
loss, insomnia, cerebral infarction (stroke), and chronic pain.
Record review of Resident #22's medication administration schedule/MAR, for January 2023, revealed,
Pantoprazole 40 mg 1 tablet scheduled at 0630, Nateglinide 120 mg 1 tablet scheduled at 0700,
Amlodipine 10mg 1 tablet scheduled at 8am, Carvedilol 12.5 mg 1 tablet scheduled at 8am, Clonidine
0.1mg 1 tablet scheduled at 8am, Stool softener 100 mg 1 tablet scheduled at 8am, Fluticasone propionate
- nasal spray scheduled for 8am, Hydralazine 25 mg 1 tablet scheduled at 8am, Acidophilus with pectin 1
capsule scheduled at 8am, Saline nasal spray and Metformin 500 mg 1 tablet scheduled at 8am.
An observation on 01/17/23 at 9:50am revealed MA C prepared, dispensed and administered to Resident
#22 the following medications: Pantoprazole 40 mg 1 tablet, Nateglinide 120 mg 1 tablet, Amlodipine 10mg
1 tablet, Carvedilol 12.5 mg 1 tablet, Clonidine 0.1mg 1 tablet, Stool softener 100 mg 1 tablet, Fluticasone
propionate - nasal spray, Hydralazine 25 mg 1 tablet, Acidophilus with pectin 1 capsule, Saline nasal spray
and Metformin 500 mg 1 tablet.
Record review of Resident #31's face sheet, dated 01/19/23, revealed an admission date of 01/01/21, with
diagnoses which included: Dysphagia (difficulty in swallowing), Hypertension (High blood pressure),
cerebrovascular disease (diseases that affect the heart and blood vessels), chronic obstructive pulmonary
disease (a condition involving constriction of the airway), and pain.
A record review of Resident #31's medication administration schedule/MAR, for January 2023, revealed,
Amlodipine Besylate 10mg,1 tablet by mouth one time a day related to hypertension Hold for SBP<110
DBP<60 pulse <60( the medication was held due to blood pressure was not within the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
675305
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
parameters) scheduled for 7:30am, Aspirin EC tablet delayed release 81mg, give 1 tablet by mouth one
time a day scheduled for 7:30 am, Citalopram Hydrobromide tablet 20mg, 1 tablet by mouth one time a day
for depression scheduled for 7:30am, Ferrous sulfate tablet 325 mg (65 fe), give 1 tablet by mouth one time
a day for supplementation scheduled for 7:30am, Folic acid tablet 1 mg, give 1 tablet by mouth one time a
day related to vitamin deficiency scheduled for 7:30 am , Keppra tablet 500 mg, give 2 tablet by mouth two
times a day related to other seizure scheduled for 7:30am, Vimpat tablet 150 mg give 1 tablet by mouth two
times a day related to other seizures, scheduled at 7:30 am, Gabapentin capsule 400 mg give 1 capsule by
mouth three times a day related to pain scheduled at 0900, 1300, 1700, Multiple Vitamin tablet give 1 tablet
by mouth one time a day for supplementation scheduled at 06 am -11am.
During an observation on 01/17/23, at 9:58 a.m. revealed MA C prepared, dispensed, and administered to
Resident #31 the following medications; Aspirin 81 mg enteric coated 1 tablet, Citalopram 20 mg 1 tablet,
Iron tablet 325 mg 1 tablet, Folic acid 1 mg 1 tablet, Levetraceta 500 mg 2 tablet, Vimpat 150 mg 1 capsule.
In an interview on 01/18/23 at 10:34 am with MA C regarding the medications not being administer at the
scheduled time, she stated she was running behind and since she was assigned two halls, it was hard to
finish giving the medications on time. She stated if the medications were scheduled to be administered at a
particular time, she was supposed to administer the medications 1 hour before or 1 hour after. If she
administered the medication beyond the 1 hour after the scheduled time they were considered late. She
stated giving medications not at the scheduled time could lead to the medication not being effective, like the
Protonix that normally should be given before meals. She also stated she had to follow the five rights of
medication administration.
In an interview on 01/19/23 at 03:11 pm with the DON, she stated, per the facility's policy, the staff were to
administer medications 1 hour before and 1 hour after the scheduled time. The DON stated the medications
were considered late if they were administered after the 1-hour window from the scheduled time. She
stated medications were to be administered timely for them to be effective and to follow the primary
physician orders. She stated the facility followed the liberalized medication pass time but some medications
were scheduled at a specific time.
Review of the facility policy not dated and titled Liberalized medications pass times reflected, It is the policy
of this facility to administer medication in a home like atmosphere to enhance patient well being while
recognizing the resident's rights and choice for receiving medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal
laws, all drugs and biologicals were stored in locked compartments for two of ten residents (Resident #4
and #37) reviewed for storage of medication.
1. Facility failed to securely store Resident #4's medication; Resident #4 had two bottles of eye drops
(Resitasis) at the bedside table.
2. Facility failed to securely store Resident #37 medication; Resident #37 had a bottle of Calcium carbonate
600mg with vitamin D3 on her bed side table
These failures could place residents at risk of consuming unsafe medications.
Findings included:
Record review of Resident #4's face sheet, dated 01/19/23, revealed the resident was a [AGE] year-old
female with an initial admission date of 07/05/21. Resident #4's had diagnoses which included hypertension
(high blood pressure), Dementia, anxiety disorder, chronic obstructive pulmonary disease (Obstruction of
airflow to the lungs), and cognitive communication deficit.
Record review of Resident #4's MDS (Minimum Data Set) assessment, dated 12/8/22, revealed the
resident had a BIMS (Brief Interview for Mental Status) score of 11, which indicated the resident cognition
was moderately impaired.
Record review of Resident #4's care plan undated reflected, dependent on staff for activities, cognitive
stimulation, social interaction r/t cognitive deficits, physical limitations
Record review of Resident #4's physician order, dated 07/05/21, revealed he had an order for Systane
solution 0.4-0.3%, instill 1 drop in both eyes every 12 hours as needed for dry eyes.
Observation and interview on 01/17/23 at 10:45 am revealed Resident #4 was in the room and she was
sitting at the edge of her bed. There were three bottles of Restasis eyes drops on the bed side table and
one bottle was empty. In an interview with the resident, she stated she knew she had the eye drops in her
room and she used the medications couple times per day because she had dry eyes. She stated her
daughter had bought her the medication.
In an interview with RN D on 01/17/23 at 10:55 am, she confirmed the resident had the medications in the
room. She stated she was not aware Resident #4 had the medications although they were on the bedside
table, and she stated she was in the resident's room early this morning. She stated the resident was not
supposed to have the medications at her bedside because she had not been assessed to self-administer
medications. She stated there could be medications interactions with other medications when the primary
care provider was not aware of self-administering the medications.
Record review of Resident #37's face sheet, dated 01/19/23, revealed the resident was a [AGE] year-old
female with an initial admission date of 03/03/21. Resident #37 had diagnosis which included:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
bipolar disorder, muscle weakness, dysphagia (difficult swallowing and eating), pain, major depressive
disorder, hypertension (High blood pressure), and spinal stenosis (spinal narrowing).
Review of Resident #37's MDS quarterly assessment, dated 12/07/22, reflected had a BIMS score of 15,
which revealed the resident did not have cognitive impairment.
Residents Affected - Some
Review of Resident #37's physician orders, dated 01/19/23, reflected no order for Calcium carbonate
600mg with vitamin D3.
An observation on 01/17/23 at 11:30am revealed the resident was in bed and she was asleep. A bottle of
Calcium carbonate 600mg with vitamin D3 was noted on the bedside table near the entrance of the door.
In an interview on 01/17/23 at 11:18 am with LVN B, she confirmed the medication, and she stated she was
not aware whose medication it was because the other resident was not in the room. She stated she will find
out. Follow up interview with LVN B she stated she asked Resident #37, after she woke up, and the resident
stated it was her medication and she ordered the medication online. She stated the resident was not
supposed to have the medication in the room, because she did not self-administer medications. The staff
stated she was not aware of the medication being in the room, even though it was on the bedside and was
easily visible.
In an interview on 01/19/23 at 12:35pm with the DON and Administrator, they stated the issue of the
resident having medications in the rooms had been identified. They identified at the start of the year, and
they sent out information to the family members not to bring the medications to the residents. The DON
stated medication was to be left with the charge nurse. The DON stated the residents were not to have
medications in their room and administer the medications to themselves because the doctor needed to be
aware of the medication to prevent medication interactions.
Review of the facility policy, revised 11/22, and titled Medication Access and Storage reflected, It is the
policy of this facility to store all drugs and biological in locked compartments under proper temperature
controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or
staff members lawfully authorized to administer medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and
serve food in accordance with professional standards for food safety in the facility's only kitchen where all
facility food is prepared.
The facility failed to ensure that food was labeled, dated, sealed and not expired in their kitchen.
These failures could place residents at risk for food contamination and food-borne illness.
Findings included:
An observation on 1/17/23 at 9:49 AM revealed in the walk-in refrigerator, 1 gallon of Caesar dressing
expired on 10/20/22.
An observation on 1/17/23 at 9:50 AM revealed in the walk-in refrigerator, a container of peeled garlic
expired on 11/27/22.
An observation on 1/17/23 at 9:51 AM revealed in the walk-in refrigerator, a container of ketchup with no
expiration date.
An observation on 1/17/23 at 9:51 AM revealed in the walk-in refrigerator, a container of ranch dressing
with no expiration date.
An observation on 1/17/23 at 9:52 AM revealed in the walk-in freezer, a bag of 22 hamburger patties
undated, unlabeled, and unsealed on the bottom shelf in the freezer.
An interview with the AM [NAME] on 1/17/23 at 9:55 AM revealed, leftover food should be wrapped in
plastic paper and close in a bag. The AM [NAME] stated the cooks are responsible for checking for expired
food in the freezer. The AM [NAME] stated expired food should be checked for daily and thrown out. The
AM [NAME] revealed expired food could make resident's sick. The AM [NAME] revealed food left open in
the freezer can get contaminated and dry.
An interview with the Dietary Manager on 1/17/23 at 9:57 AM revealed the PM [NAME] just started and he
was still learning policy and procedures for the kitchen. The Dietary Manger revealed, the cooks are
responsible for checking labels and expiration dates by the end of every shift. The Dietary Manager stated
by not labeling and sealing food, cross contamination and bacteria could develop and make the residents
sick. The Dietary Manager stated expired food could cause residents to have diarrhea and other adverse
side effects.
Record review of facility policy (revised October 2022) titled Infection control Policy/Procedure revealed: k.
leftovers must be dated, labeled, covered .
Record review revealed in-service on 01/17/23 on Check for expiration date and how we missed it, label
and date, close product and burger patties left open.
Record review revealed of FDA Food Code dated 2017 section 3-501.18 (A) A FOOD specified in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
3-501.17(A) or (B) shall be discarded if it: (2) Is in a container or PACKAGE that does not bear a date or
day
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an Infection prevention and control
program designed to provide a safe, sanitary, and comfortable environment and to help prevent the
development and transmission of communicable disease and infection for 1 of 5 residents (Resident #37)
reviewed for infection control, in that:
Residents Affected - Few
The facility failed to ensure CNA A followed proper hand hygiene before and after perineal care of Resident
#37.
The facility failed to ensure LVN B follow proper hand hygiene during perineal care of Resident #37
These deficient practices could place residents at risk for infection.
Findings included:
Review of the face sheet, dated 01/19/23, reflected Resident #37 was admitted to the facility on [DATE].
Admitting diagnosis included; bipolar disorder, fracture of lower end of right humerus (upper arm), muscle
weakness, pain, and type 2 diabetes.
Review of the care plan not dated reflected Resident #37 had bowel or bladder incontinence related to
activity intolerance, impaired mobility, physical limitations.
Observation on 01/18/23 at 1:45 PM revealed CNA A and LVN B were assisting Resident #37 in bed and
then provided perineal care. Observation revealed both staff completed hand hygiene and then gloved, and
then the staff assisted the resident get in bed with a sliding board. The resident's pants were wet from urine.
After transferring the resident in bed, they positioned the resident, took off the resident's wet pants and
proceeded to take off the soiled brief. After taking the resident's dirty brief they took off the dirty pants, they
provided perineal care. After providing care, the staff did not complete any form of hand hygiene, they
proceed to apply the resident's clean brief, then aide applied cream on the resident's bottom area and then
fastened the resident's brief with the same gloves. Both staff then positioned the resident, applied pillow
and the aide placed the resident's bed remote and call light within reach. After taking care of the resident,
the nurse washed hands, but the aide took off her gloves, left the room and proceeded to the cart that was
on the hallway with clean linens and took out trash bags.
In an interview with CNA A on 01/18/23 at 2:16 PM, she stated she did not complete hand hygiene
because she forgot. She stated she was supposed to change gloves and wash her hands after cleaning the
resident. She stated she was supposed to change gloves and wash hands to prevent infection because the
dirty gloves were considered contaminated. She stated she was not supposed to touch the resident's
belongings with the dirty gloves. She also stated she was supposed to complete hand hygiene after
assisting the resident and before leaving the resident's room. CNA A stated she had been in-serviced on
infection control about a week ago.
In an interview with LVN B on 01/18/23 at 2:23 PM, she stated she might have forgotten to complete hand
hygiene during resident care. She stated she was supposed to wash hands after cleaning the resident
before applying the clean brief. She stated failure to complete hand hygiene between care could
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675305
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pleasant Valley Healthcare and Rehabilitation Cent
1525 Pleasant Valley Rd
Garland, TX 75040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
cause spread of infections from the contaminated gloves. She stated she had been in-serviced on infection
control.
In an interview with the DON on 01/19/23 at 3:26 PM, she stated she was made aware of the issue with
perineal care. She stated the staff were supposed to complete hand hygiene after cleaning the resident
before putting on the clean brief to prevent the spread of infection. She stated the staff had been
in-serviced on infection control and verbally reminded almost every week. DON stated failure of the staff
completing hand hygiene could lead to spreading of infection.
Review of the facility's policy, dated 8/29/17, titled Hand Hygiene reflected, This facility considers hand
hygiene the primary means to prevent the spread of infections.4. Use an alcohol-based hands rub
containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the
following situations.h. Before moving from contaminated body site to a clean body site during resident care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675305
If continuation sheet
Page 8 of 8
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the January 19, 2023 survey of PLEASANT VALLEY HEALTHCARE AND REHABILITATION CENT?
This was a inspection survey of PLEASANT VALLEY HEALTHCARE AND REHABILITATION CENT on January 19, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PLEASANT VALLEY HEALTHCARE AND REHABILITATION CENT on January 19, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure medication error rates are not 5 percent or greater."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.