Serene Valley Assisted Living Home, LLC

Based on record review, observation, and interview, the manager did not ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom used by a resident receiving directed care services. Findings include: 1. A review of R2's medical record revealed a service plan from October 2025. The Service plan revealed R2 was expected to receive directed level of services. 2. During an environmental inspection, the Compliance Officer observed no bell, intercom, or other mechanical means to alert employees to R2's or R3's needs were available in R2's or R3's bedrooms. 3. In an interview, E5 reported R3 was directed level of care. E5 acknowledged R2's and R3's bedrooms did not contain a bell, intercom, or other mechanical means to alert employees to R2's or R3's needs or emergencies.

Based on record review, and interview, for one resident reviewed, whose service plan documented personal care services, the manager failed to ensure a written service plan was reviewed and updated at least once every six months. The deficient practice posed a health and safety risk to residents if the service plans were not updated to include services to be provided for the resident to address the resident's current condition. Findings include: 1. In record review, R3's medical record (received personal care services), included a service plan dated June 7, 2023. R3's medical record did not include documentation the service plan was reviewed and updated every six months. 2. During an interview, E1 reported R3's service plan was completed in December 2023; however, E1 was unable to locate the service plan. E1 acknowledged R3's record did not include an updated service plan since June 7, 2023.

Based on observation, record review, and interview, and record review, for one of two residents observed, the manager failed to ensure a resident was not subjected to a restraint. The deficient practice posed a health and safety risk to a resident should a restraint result in harm to a resident. Findings include: 1. During an environmental inspection, the compliance officer observed R4 in the common area, sitting in a Geri Chair, with a bed sheet wrapped around the waist and tied in the back. In R4's bedroom, R4's bed was pushed up against the wall, and the side of the bed that was open to the room, was observed to have two 1/2 bed rails (in the down position). 2. During an interview, E3 reported R4 was in the Geri Chair with the sheet wrapped around the waist to prevent R4 from falling. E3 reported that R4 would try to get out of the Geri Chair and would fall, thus the bed sheet was tied around R4's waist to prevent R4 from getting out of the chair. 3. In record review, the medical record for R4 included documentation in the admission orders (signed by the medical practitioner) that indicated the resident did not require restraints. 4. During an interview, E1 acknowledged R4 was in a Geri Chair with a sheet tied around R4's waist.

Based on observation, and interview, for one of four residents observed, the manager failed to ensure the premises was free from a situation that may cause a resident harm. The deficient practice posed a health and safety risk to a resident should the use of a bedrail result in harm to a resident. Findings include: 1. During an environmental inspection. R3 was observed in bed with a raised 1/2 bed rail. 2. During an interview, E3 reported R3 had a bed rail also to prevent R3 from falling from the bed. E3 reported R3 could not lower the bed rail by [R3's] self. 3. In record review, the medical record for R3 included documentation in the admission orders (signed by the medical practitioner) that indicated the residents did not require restraints. 4. During an interview, E1 reported R3 had the bed rail up because it had a water bottle attached and held R3's water bottle. 5. This is a repeat deficiency from the compliance inspection conducted on May 2, 2023.

Based on record review and interview, for one of three residents reviewed, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure, to residents and staff. Findings include: 1. In record review, R3's record (received personal care services) did not include documentation of freedom from TB. Based on R3's acceptance date, this documentation was required. 2. During an interview, E1 reported having requested the documentation of freedom from TB from R3's family; however, the family did not provide the documentation to the facility. E1 acknowledged documentation of freedom from TB is required.

Based on record review and interview, for one of three residents reviewed, the manager failed to ensure a resident's medical record contained a copy of a resident's health care power of attorney (POA). The deficient practice posed a risk if the facility did not have the required legal documentation of a resident's responsible party. Findings include: 1. In record review, R2's medical record (received directed care services) did not include a copy of R2's health care POA. R2's residency agreement was signed by O1. 2. During an interview, E1 reported O1 was R2's POA, and acknowledged the POA document for R2 was not in R2's medical record, and was not available for review during the inspection. 3. This is a repeat deficiency from the compliance inspection conducted on May 3, 2022.

Based on observation and interview, the manager failed to ensure a smoke detector, installed in a bedroom, was in working order. The deficient practice posed a health and safety risk if a smoke detector was not working during an emergency. Findings include: 1. During an environmental inspection with E3, the compliance officer observed a "caregiver" bedroom had a non-working smoke detector. The smoke detector did not have a battery. 2. During an interview, E1 and E3 acknowledged the caregiver room did not have a working smoke detector.

Based on observation, and interview, for three of nine residents observed, the manager failed to ensure the premises was free from a situation that may cause a resident harm. The deficient practice posed a health and safety risk to a resident should the use of a bedrail result in harm to a resident. Findings include: 1. During an environmental inspection with E3, the compliance officer observed five resident's beds had full bedrails or two half bedrails attached to the beds. The beds for R2 (received directed care services), R3 (received personal care services), R5 (received directed care services), R6 (received directed care services), and R7 (received personal care services), had bedrails. 2. During an interview, E3 reported the bedrails were used in the up position for R2, R5, and R6 because the residents were at risk for falling from the bed. E3 reported the residents were unable to put the bedrails down on their own. 3. During an interview, the findings were reviewed with E1, who reported the Hospice agency supplied the beds with the bedrails, and acknowledged the use of bedrails could pose a risk to a resident.

Based on observation, and interview, for three of 10 bedrooms observed, the manager failed to ensure a resident's sleeping area had a window or door that could be used for direct egress to outside the building. The deficient practice posed a safety risk to a resident who would not be able to exit to the outside of the building in the event of an emergency, and an inability to exit the window. Findings include: 1. During an environmental inspection with E3, the compliance officer observed the bedrooms for R3 (received personal care services), R4 (received directed care services) and R5 (received directed care services) had a window; however, the window had furniture blocking direct egress from the window. All bedrooms had a bed in front of the window. 2. In an interview, the findings were reviewed with E1, who acknowledged a resident's sleeping area is required to have a window or door that can be used for direct egress to outside the building. 3. Technical assistance was provided during the prior compliance inspection conducted on May 3, 2022.

Based on observation and interview, for three of 10 resident bedrooms, the manager failed to ensure that each sleeping area had linen, including a mattress pad. Findings include: 1. During an environmental inspection with E3, the compliance officer observed the beds for R1, R3, and R8, did not have a mattress pad. 2. During an interview, E3 reported the beds were provided by the facility. E1 and E3 acknowledged the residents' beds were required to have a mattress pad.