Letis at Valencia Mdsl 2

Based on record review and interview, the manager failed to ensure that a resident had a service plan that was established, documented, and implemented, which was completed no later than 14 calendar days after the resident's date of acceptance, for one of three residents sampled. Findings include: 1 . A review of R3's medical record revealed that documentation of a completed service plan was not available for review at the time of inspection. Based on R3's date of acceptance and date of termination, a service plan should have been completed. 2 . In an interview, E3 reported E3 did not complete R3's service plan. 3 . In an exit interview, the findings were reported to E3, and no additional information was added.

Based on record review and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of three residents. Findings include: 1 . In an interview, E4 reported that the facility provided medication administration. 2 . A review of R2's medical record revealed a signed medication order. The order included Memantine 10 milligrams (mg) 1 tablet twice a day and Nortriptyline 50 mg 1 capsule once a day. However, a review of R2's Medication Administration Record (MAR) sheet for July 2025 revealed Memantine 10 mg was not documented as administered on July 8, 2025 at 8 PM, and Nortriptyline 50 mg was not documented as administered on July 8, 2025 and July 20, 2025. 3 . In an interview, R1 and R2 reported they received their medications daily. 4 . In an exit interview, the findings were discussed with E3 and no additional information was added.

Based on record review and interview, the manager failed to ensure care instructions provided to the facility by a home health agency or hospice service were documented in a resident's service plan, for one of one sampled resident receiving services from a home health agency. Findings include: 1. In an interview, E1 reported R1’s home health wound specialist instructed the caregivers to apply hydrocellular foam dressing, Sorbalgon Ag Silver, and Petrolatum dressing 4in x 4in. 10 cm x 10 cm. E1 reported that the instructions are required to be completed every other day and as needed. 2. A review of R2’s service plan revealed that there were no care instructions provided by a home health agency documented on a R2’s service plan. 3. In an interview, E1 acknowledged R2’s service plan did not include care instructions provided by a home health agency.

Based on documentation review, observation, record review, and interview, the manager failed to ensure a complete personnel record was maintained for one of five sampled personnel members. Findings include: 1. A.A.C. R9-10-101(165) states: "Personnel member" means, "except as defined in specific articles in this Chapter and excluding a medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services to a patient." 2. Upon arrival at the facility, the surveyor observed E3 on the premises interacting with the residents. 3. A review of E3's personnel record revealed no documentation of E3's starting date of employment, date of birth, contact telephone number, and completed orientation. 4. In an interview, E1 acknowledged E3 did not have a complete personnel record with the required documents, and reported E3 was a live-in volunteer.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance, one of two sampled residents accepted by the facility on or after October 1, 2013 who were expected to receive assisted living services, submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints. Findings include: 1. A review of R1's medical record revealed no documentation to indicate whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 2. A review of R3's medical record revealed there was no documentation indicating whether R3 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. 3. In an interview, E1 acknowledged R1's and R3's medical records did not include documentation to indicate whether R1 and R3 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on observation and interview, the manager failed to ensure that medications stored by the facility were stored in a locked area, which posed a health and safety risk to residents. Findings include: 1. During a facility tour, the compliance officer observed Tylenol on a nightstand accessible inside E1's unlocked bedroom. 2. In an interview, E4 acknowledged that the medication was left unsecured and accessible.

Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented, for four of four current residents sampled. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed there was no documentation of the residents' orientation to the assisted living facility's evacuation plan, and the route to be used was available for review. 2. In an interview, E4 reviewed the above resident records and acknowledged E4 failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. Findings Include: 1. During a tour of the facility, the compliance officer observed paint and hair dye accessible inside the facility's common bathroom. 2. In an interview, E1 acknowledged poisonous or toxic materials were found in an unlocked area and accessible to the residents.

Based on documentation review and interview, the manager failed to provide written notification to the Department of a resident's unexpected death within one working day after the resident's death. The deficient practice posed a risk as the Department was unable to assess potential dangers to other residents at the facility in a timely manner. Findings include: 1. A review of Department documentation revealed no written notice of R1's death submitted by the facility. 2. A review of facility documentation revealed a document titled "Incident Report" which described the following incident: "Description of Incident: While performing routine care duties, the caregiver noticed [R1] appearing pale despite the continued operation of the oxygen on the ventilator. The caregiver promptly took action by contacting the on-call nurse and notifying the manager/owner. Simultaneously, the manager informed the family members. Upon consulting the doctor, the manager received instructions to administer Lantus at 8 pm, based on the sugar reading obtained at 4:30 pm. Subsequently, the nurse arrived and assessed the resident's pulse, recommending an immediate call to 911 due to the [R1's] lack of heart beat signs. Actions Taken: Notification: On-call nurse, manager/owner, and [R1's] family were promptly informed. Medical Intervention: - Doctor's consultation for Lantus administration. Emergency Response: - Nurse assessed [R1's] pulse and advised calling 911. Services arrived around 6 pm and confirmed the [R1] passing. Family Arrival: - Family members arrived between 6:50 pm and 7 pm. Body Pickup: Emergency services picked up the resident's body around 12 am." 3. In an interview, E1 reported R1 was not on hospice and acknowledged the Department was not notified of R1's death.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services provided to the resident, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a current written service plan dated April 13, 2023 for personal care services. The service plan stated the following service was required: "Dressing...1-2 person assist...dependent...assist in selecting clothes...assist in putting on clothes...assist in removing clothes." However, the service plan did not include the frequency of the service to be provided. 2. In an interview, E1 acknowledged R1's service plan did not include the frequency of the service being provided.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or the resident's representative, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a current written service plan dated April 13, 2023 for personal care services. However, the service plan was not signed and dated by R1's representative. 2. In an interview, E1 reported R1 had a representative. E1 reported E1 has been unable to reach R1's representative. E1 acknowledged R1's service plan was not signed and dated by R1's representative.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as services provided were unable to be verified and the required documentation was not provided during the inspection. Findings include: 1. A review of R1's medical record revealed a current written service plan dated April 13, 2023 for personal care services. The service plan stated "Incontinent checks Q 2-4 hr" and "Bowel...monitor daily bowel pattern." 2. A review of R1's medical record revealed an activities of daily living (ADL) document for June 2023. The ADL document included "incontinence care" and "bowel movement". However, the ADL did not include documentation of the caregivers providing "Incontinent checks Q 2-4 hr" and "monitor daily bowel pattern.". 3. In an interview, E1 reported the aforementioned services on R1's ADL are the corresponding services in R1's service plan. 4. In an interview, E1 reported R1 is independent for the aforementioned services, and R1's service plan needed to be updated. E1 acknowledged the aforementioned services were not documented on R1's ADL as provided.

Based on documentation review and interview, the administrator failed to ensure the facility's disaster plan was reviewed at least once every 12 months. Findings include: 1. A review of facility policies and procedures revealed an undated policy titled "DISASTER PLAN". The policy included the requirements listed in R9-10-818(A)(1). However, the policy did not include a review date. 2. In an interview, E1 reported the facility reviews the disaster plan once a year. E1 acknowledged documentation of the facility's disaster plan review at least once every 12 months was not available for review.