Pleasant Valley Adult Care Home, LLC.

“Based on record review and interview, the manager failed to ensure a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse stating whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two sampled residents accepted by the assisted living facility on or after April 2024.   Findings include;   1. A review of R1’s medical record revealed a document titled “Admission Order Form,” which was completed by the physician. However, the document did not indicate if continuous medical services, continuous or intermittent nursing services, behavioral health services, or restraints, including the use of bedrails, were required.   2. In an interview, E3 acknowledged R1 had not provided complete documentation signed by a medical practitioner or a registered nurse stating whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints.”

“Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The toxicology guide available for use by personnel members was the “Mosby’s Nursing Assistant Drug Reference” Toxicology Guide, published in 2022. 2. A review of the publisher's website revealed the "Mosby’s Nursing Assistant Drug Reference” toxicology guide published 2024 was the most recent edition. 3. During an interview, E3 acknowledged that a current toxicology reference guide was not available for use by personnel members.”

“Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1. During the environmental tour of the facility, the Compliance Officers observed a cupboard in the kitchen that had a magnetic lock.  However, the magnetic lock was not in working order; the Compliance Officers were able to open the cupboard without the magnetic device, and there were non-medical items stored in the cupboard with medications: ·        Body lotions ·        Q tips ·        Vaseline ·        Toothpaste ·        Medi sets ·        Polyethylene Glycol 3350 2. In an interview, E3 acknowledged that the magnetic lock was not functioning properly and that there were non-medical items stored in the cupboard with medications.”

“Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During a tour of the facility, the Compliance Officers observed two unsecured oxygen tanks stored upright in the closet of a resident room.  2. In an interview, E3 acknowledged there were unsecured oxygen tanks stored in a resident room.”