North Valley Quality Care LLC

Based on record review and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for two of two residents sampled who received medication administration services. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a signed medication order prescribed on July 23, 2024 to include Digoxin 125 MG once a day, Metoprolol 50 MG every 12 hours, Travatanz 0,004 solution at bedtime, Trazodone 50 MG at bedtime, Quetiapine 50 MG twice a day, and Sennoside S 8.6 MG once a day. 2. A review of R1's medication administration record (MARs) sheet for September revealed Metoprolol, Travatanz, Trazodone, Quetiapine, and Lactobacillus were not documented as being administered for the evening dose on September 11, 2024. Digoxin, Metoprolol, Quetiapine, and Sennoside were not documented as being administered on the morning of September 12, 2024. 3. A review of R2's medical record revealed a signed medication order prescribed on July 23, 2024 to include Seroquel 50 MG twice a day, Trazodone 50 MG at bedtime, Amlodipine 5 MG once a day, Metoprolol 50 MG twice a day, and Sennoside 8.6 MG twice a day. 4. A review of R2's medication administration record (MARs) sheet for September revealed Seroquel, Trazodone, and Sennoside were not documented as being administered for the evening dose on September 11, 2024. Seroquel, Amlodipine, and Sennoside were not documented as being administered on the morning of September 12, 2024. 5. In an interview, E1 reported all residents receive medication administration. 6. In an interview, E1 reported R1 and R2 were administered the medications as prescribed; however, E1 forgot to document administration of the medications on the MARs for R1 and R2. 7. In an interview, E1 acknowledged that they failed to ensure a medication administered to a resident was documented in the resident's medical record.

Based on documentation review and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to meet the needs of residents. Findings include: 1. A review of facility documentation revealed a policy covering how a caregiver's skills and knowledge would be verified and documented was not available for review at time of the inspection. 2. In an interview, E1 acknowledged a policy covering how a caregiver's skills and knowledge would be verified and documented was not available for review at time of the inspection.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. Review of the facility's policy and procedure revealed a policy titled "Safety of Wandering Residents". This policy stated, "If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security." 3. During the environmental inspection of the facility, the Compliance Officers observed an alert on the backdoor; however, the alert was not activated. 4. In an interview, E1 reported that the alert was disabled to minimize the noise during the daytime; however, it is activated at night. E1 and acknowledged that the means of exiting the facility was not controlled or alerted.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of two sampled residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed documentation indicating whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant; however, it was dated five days after R2's time of acceptance. 2. In an interview, E1 acknowledged R2's documentation was not submitted before or at the time of acceptance.