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.”