Valley House Assisted Living

A revisit survey was completed on 3/11/25 for previous deficiencies cited on 12/5/24. The agency is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A certification complaint, prompted by #CO38439 and #CO38576, was completed on 12/5/24. Deficiencies were cited. Based on record review and interview the residence failed to comply with Colorado Adult Protective Services (CAPS) Data System and ensure mitigation procedures were used if the Provider Agency becomes aware of information that indicates a staff member or volunteer could who provided direct care to at-risk members (residents) for one of one sample staff (#1), affecting 20 current residents.Findings include:1. Residence PolicyThe residence' s Background Check and Adult Protective Services Policy, dated 12/1/20, read in part: " all applicants must undergo a Colorado Adult Protective Services (CAPS) check prior to employment. If any concerning information arises from a (CAPS) check, the HR department will conduct a thorough review of the findings ... the employee will not work alone particularly during the initial period of employment ... staff will conduct regular check-ins and observations during each shift the employee works ... management is responsible for ensuring guidelines are followed and all staff are trained on the importance of these safety protocols."2. ObservationOn 12/5/24 from 7:30 a.m. to 4:00 p.m. Staff #1 provided care and services to residents. 2. Record ReviewThe personnel file for Staff #1 revealed she was a qualified medication administration person (QMAP), hired on 7/21/21. The personnel file revealed a Colorado Adult Protective.. Based on record review and staff interview, the facility failed to identify and investigate incidents of suspected or actual mistreatment, abuse, neglect and exploitation (MANE) for two of four members (residents) (#1, #2) and one former resident (#5).Findings include:1. Residence PolicyThe residence' s Investigations of Abuse and Neglect policy, dated July 2015, read in part that the residence investigated all allegations of abuse and neglect and ensured all incidents were reported to the administrator within 24 hours. The administrator reported founded allegations of abuse and neglect to APS.However, the policy failed to include that any allegations of abuse and neglect would be reported to APS.2. Record ReviewResident #2 was admitted to the residence on 9/25/21 with a diagnosis of Alzheimer' s Disease.A progress note for Resident #2, dated 11/7/24, read Former Resident #5 hit Resident #2 on the top of the head with a disposable plastic cup. Resident #2 sustained a bruise on her head and a scratch.The residence' s investigation, dated 11/7/24, read Former Resident #5 knocked on the door of Resident #2' s room and hit her on the head with a plastic cup. Both powers of attorney (POA) and law enforcement were notified. Former Resident #5 was reassessed, found to have increased confusion, and was admitted to a secure environment on 11/13/24. An occurren..

A licensure complaint, prompted by #CO38438 and #CO38574, was completed on 12/5/24. Deficiencies were cited. Based on interview and record review, the residence failed to ensure that residence personnel engaged in the care of at-risk persons reported suspected abuse or neglect to law enforcement within 24 hours of observation or discovery, affecting 20 current residents.Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residencies, part 2.12, defines caretaker neglect as neglect that occurred when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a c.. Based on interviews and record review, the residence failed to ensure its written policy included that all allegations of abuse and neglect be reported to Adult Protection Services (APS), and failed to report to the assisted living residence administrator an allegation of neglect, affecting two of four sample residents (#1, #2) and one former resident (#5).Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.1, defines abuse as "any of the following acts or omissions: (A) The non-accidental infliction of bodily injury, serious bodily injury or death."b. Chapter VII regulations governing assisted living residences, part 2.12, defines "Caretaker Neglect" as neglect that occurred when adequate food, clothing, shelter, psychological care, physical car.. Based on observation, record review, and interview, the residence failed to implement policies and procedures regarding the continued service of any staff member whose adult protective service records did not reveal good, moral, and responsible character that could pose a risk to the health, safety, and welfare of the residents, affecting 20 current residents.Findings include:1. Residence PolicyThe residence' s Background Check and Adult Protective Services Policy, dated 12/1/20, read in part: "All applicants must undergo a Colorado Adult Protective Services (CAPS) check prior to employment. If any concerning information arises from a (CAPS) check, the HR (human resources) department will conduct a thorough review of the findings ... the employee will not work alone particularly d.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.10 Each resident care plan shall: (D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs; (E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence' s visitation policy as required by Part 9.2, along with care coordination arrangements.18.9 The face sheet shall be updated at least annually and contain the following information: (E) Date of admission and readmission, if applicable; (F) Name, contact information, and maili..