Moon Valley Assisted Living II, LLC

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 two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1 . In an interview, E1 reported the residents received medication administration. 2 . A review of R1's medical record revealed a signed medication order list for the following: -Gabapentin 100 MG capsule once daily; -Fluticasone 50 MCG nasal spray 2 sprays per nostril once daily; -Hydroxyzine HCL 25 MG tablet three times daily; -Acetaminophen 500 MG tablet two times daily; -Aspirin 81 MG tablet once daily; -Fluoxetine HCL 20 MG capsule once daily; -Gabapentin 300 MG capsule once daily; -Melatonin 10 MG tablet once daily; and -Trazadone 50 MG tablet once daily. However, a review of R1's medication administration record (MAR) sheet for December 2025 revealed the above medications were not documented as administered on December 9, 2025. 3 . A review of R2's medical record revealed a signed medication order list for the following: -Zoloft 100 MG tablet once a day; -Senna Plus 8.6 MG/50 MG tablet once a day; -Guaifenesin 100 MG/ 5ML 20 ML three times daily; -Ipratropium-Albuterol 0.5 MG-3 MG 1 unit dose via SVN two times daily; -Tylenol 500 MG 2 tablets twice a day; -Senna Plus 8.6 MG/50 MG 2 tablets once daily; -Olanzapine 10 MG tablet once daily; -Aspirin 81 MG tablet once daily; and -Trazadone 100 MG tablet once daily. However, a review of R2's medication administration record (MAR) sheet for December 2025 revealed the above medications were not documented as administered on December 9, 2025. 4 . In an exit interview, the findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked cabinet. The deficient practice posed a risk to residents who were unable to self-administer medications. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet in the kitchen that had a magnetic lock. However, the magnetic lock was disengaged, and the caregiver was able to open the cabinet, which contained medication stored by the assisted living facility. 2 . In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officer observed a cabinet in a common hallways bathroom with a locked door. However, the Compliance Officer was able to open the door wide enough to be able to pull out a bottle of "Clorox" bleach and a bottle of "Windex" glass cleaner. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.