All Valley Assisted Living Home, LLC

Based on record review, documentation review, and interview, the manager failed to ensure caregivers were only assigned to provide the assisted living services the caregiver had the documented skills and knowledge to perform, for two of two caregivers sampled. The deficient practice posed a risk if the caregivers were unable to meet a resident's needs. Findings include: 1. Review of R3’s medical record revealed two incident reports dated June 11, 2025, and June 22, 2025. On June 11, 2025, the incident was for “pain bladder (Possible UTI)” and on June 22, 2025, the incident was for a “Possible UTI”. 2. Review of R3’s medical record revealed a current service plan dated April 4, 2025, which indicated R3 had a catheter. The service plan also revealed a checked box, which stated, “Caregiver does daily care”. 3. Review of R3’s medical record revealed a June 2025 activities of daily living (ADL) log. This ADL log stated, “Drain Catheter Bag” which had been checked off on the days R3 was in the facility. 4. Review of E2’s and E3’s personnel records revealed no documentation showing E2's and E3's had the skill and knowledge to perform catheter care. 5. Review of the facility’s policies and procedures revealed a policy titled, "Urinary Catheter” which stated, “To care for the catheter, caregivers on shift are to clean the area where the catheter exits the body and the catheter itself with soap and water every day. Also clean the area after every bowel movement to prevent infection.” 6. In an interview, E2 reported continuing education was not offered for catheter care. 7. In an interview, E2 acknowledged E2 and E3 provided catheter care and did not have the documented skills and knowledge. In an exit interview, the findings were reviewed with [employee(s)] and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. The Compliance Officers observed an ambulatory resident. 2. The Compliance Officers observed a basket in a R1's and R3's room which contained an Albuterol Sulfate inhaler and Fluticasone Propionate nasal spray 50 mcg. 3. The Compliance Officers observed a closet in R1's and R3's bedroom. The closet had a plank of wood that was placed on the sliding door to the closet to keep it from opening. However, the plank of wood was not in place and Compliance Officers were able to open the sliding door without any physical exertion. The following medications were observed in the closet: Nasal Spray Oxymetazoline HCI .05%; Vitamins A&D Ointment ; Analgesic Creme with Aloe; Aspercreme; Proctozone-HC 2.5%; Triple Antibiotic ointment; Diclofenac Sodium 1% topical gel; and Triamcinolone Acetonide Cream USP .1% 4. The Compliance Officers observed in a common area a drawer that contained the following: Sterile Otic Suspension; Ciprofloxacin .3% and Dexamethasone .1% Otic Suspension; A&D Ointment; Naproxen 500 MG; Fluconzole 100 MG; Gabapentin 100 MG; and Diclofenac Sodium Topical Gel 1%; and One medication organizer with medications inside 5. In an interview, E2 acknowledged medications were not stored in the locked medication cabinet.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials were maintained in labeled containers in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of department documentation revealed the facility was licensed at the directed level of care. 2. The Compliance Officers observed an ambulatory resident. 3. The Compliance Officers observed a clear plastic 1-gallon container filled with a purple liquid in a common area. The container had a label which read “Aqua Hydrate”. However, the liquid in the container smelled like a cleaning material. 4. The Compliance Officers observed a container of Lysol Power Clinging Gel in R1's and R3's bathroom. 5. The Compliance Officers observed an unlocked kitchen cabinet sink that contained the following: A bottle of Easy Off Cleaner Degreaser; A can of Comet with bleach powder; and A spray can of Easy Off heavy duty oven cleaner 6. Review of the facility policies and procedures revealed a policy titled, “Emergency, Safety and Environmental Standards” which stated, “Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas.” 7. In an interview, E2 reported that the 1-gallon container was a cleaning material and acknowledged poisonous or toxic materials were not maintained in labeled containers in a locked area and inaccessible to residents.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for a resident who received personal care services. Findings include: 1. A review of R2's medical record revealed a service plan for personal care services dated January 23, 2023. No additional service plan was available for review. 2. In an interview, E1 reviewed R2's service plan. E1 confirmed that R2's January 23, 2023, service plan was the current service plan found in R2's medical record. E1 acknowledged the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for a resident who received personal care services.

Based on observation, documentation review, observation, and interview, the manager failed to ensure a caregiver or assistant caregiver provided a resident with the assisted living services in the resident's service plan. Findings include: 1. The compliance officer observed R1 in bed with R1's morning medications in a cup on the stand. 2. A review of R1's medical record revealed a document titled, "Service Plan," dated April 3, 2023, which identified R1 as personal level of care. The document listed the following services was to be provided to R1; " Medication Administration, repositioning every 2-3 hours and check pressure area's daily." 3. A review of R1's medical record revealed no documentation R1 was repositioned every 2-3 hours and check pressure areas daily as identified. 4. In an interview, E1 reported E1 repositions R1 however does not reposition R1 every 2-3 hours as identified on the service plan. In an interview, R1 acknowledged R1's service plan identified R1 required Medication Administration. E1 acknowledged E1 provides R1's medications in a cup and leaves the medication cup with R1 to take at R1's leisure. E1 acknowledged R1 is not provided medication administration as identified in R1's service plan.

Based on documentation review, record review, observation, and interview, the manager accepted and retained a resident who were confined to a bed or chair because of an inability to ambulate even with assistance, without a determination from a medical practitioner which stated that the resident's needs could be met by the facility. Findings include: 1. A review of R2's medical record revealed a service plan dated January 23, 2023. The service plan revealed R2 required assistance with ambulation. 2. A review of R2's medical record revealed documentation signed January 13, 2023, signed by a medical practitioner examined R2, reviewed the assisted living facility's scope of services, and signed and dated a determination stating R2's needs could be met by the assisted living facility. No additional documentation was available for review to reflect determination was documented every six months. 3. In an interview, E1 reported R2 was bedbound. E1 reported having overlooked completing the required documentation every six months. E1 acknowledged no current documentation was included whether R2's primary care provider or other medical practitioner examined R2, reviewed the assisted living facility's scope of services, and signed and dated a determination stating R2's needs could be met by the assisted living facility was available for review. This is a repeat deficiency from the complaint inspection conducted on April 20, 2021.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the compliance officers observed a patio door that led to an outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the backyard did have a means of alerting employees of the egress of residents to the outside area. However, the alarm was not turned on or working. 3. During an interview, E1 acknowledged the patio door exiting to the outside area did not have a working means of controlling or alerting employees to egress. E1 acknowledged the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility.

Based on observation, documentation review, and interview, the administrator failed to ensure a resident bedroom was not used as a passageway to a common area, another sleeping area, or common bathroom before October 1, 2013 unless written consent was obtained from the resident or the resident's representative. Findings include: 1. During a tour of the facility with E1, the Compliance Officer observed R1's bedroom, bathroom, and closet. The compliance officer observed O1 in R1's closet sleeping on a bed. The compliance officer observed O1's personal belongings in the closet. 2. During an interview, O1 reported O1 stayed at the facility at times and was sleeping in the closet. 3. During an interview, E1 acknowledged O1 slept in R1's closet and a resident bedroom was used as a passageway to another sleeping area.